'• 


0'nsiu.y 


A 


SYSTEM 


BY 

AMERICAN    AUTHORS. 

\ 

EDITED    BY 

WILLIAM   PEPPER,  M.D.,  LL.D., 

PROVOST  AND   PROFESSOR  OF  THE    THKORY   AND    PRACTICE    OB'    MEDICINE   AND    OF    CLINICAL 
MEDICINE   IN  THE    UNIVERSITY    OF  PENNSYLVANIA. 

ASSISTED   BY 

LOUIS    STABR,   M.D., 

CLINICAL   PROFESSOR  OF  DISEASES  OF  CHILDREN    IN   THE   HOSPITAL  OF  THE  UNIVERSITY 
OF  PENNSYLVANIA. 


VOLUME    I. 
PATHOLOGY  AND  GENERAL  DISEASES. 


PHILADELPHIA : 
LEA   BROTHERS   &  CO. 

'    1885. 


WBIOO 


Entered  according  to  Act  of  Congres?,  in  the  year  2885,  by 

LEA   BROTHERS   &   CO., 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


WESTCOTT  &  THOMSON,  WILLIAM  J.  DORNAN, 

Stereotypers  and  Electrotypers,  Philada.  Printer.  Philada. 


PREFACE. 


THE  present  work  has  been  undertaken  in  the  belief  that  by  obtain 
ing  the  co-operation  of  a  considerable  number  of  physicians  of  ackuow 
ledged  authority,  who  should  treat  subjects  selected  by  themselves,  thert 
could  be  secured  an  amount  of  practical  information  and  teaching 
not  otherwise  accessible.  It  was  determined  to  restrict  the  selection  of 
authors  to  those  of  this  country — including  Canada — not  from  any  want 
of  recognition  of  the  importance  of  the  studies  of  certain  special  sub- 
jects by  European  investigators,  but  because  it  was  felt  that  the  proper 
time  had  arrived  for  the  presentation  of  the  whole  field  of  medi- 
cine as  it  is  actually  taught  and  practised  by  its  best  representatives  in 
America. 

It  is  a  matter  of  importance  also  that  a  comprehensive  study  shall  be 
made  of  the  various  forms  of  disease  as  occurring  among  our  highly 
composite  population  and  under  our  varied  and  peculiar  climatic  influ- 
ences. Of  course,  in  the  present  work  comparative  studies  of  this  kind 
must  occupy  a  subordinate  position ;  yet  it  cannot  fail  to  enhance  both 
its  interest  and  its  value  to  have  the  various  forms  of  disease  as  they 
occur  in  this  country  discussed  by  those  among  us  who  are  confessedly 
the  most  competent  and  experienced. 

The  force  of  these  observations  must  have  been  felt  by  the  distin- 
guished men  to  whom  I  made  application,  for  with  scarcely  an  exception 
they  joined  cordially  in  the  laborious  undertaking.  I  take  the  greatest 
pleasure  in  testifying  to  the  courtesy  which  has  marked  all  our  relations, 
and  which  has  lessened  materially  the  labor  and  strain  inevitable  in 
the  production  of  such  a  work. 

To  ensure  greater  accuracy  in  the  revision  of  the  large  amount  of  proof- 
sheets,  as  well  as  to  relieve  me  of  some  of  the  details  connected  with  the 
editorial  work,  I  associated  with  myself  Dr.  THOMAS  HOLMES  CATII- 
CART,  and,  after  sudden  illness  had  cut  short  his  very  promising  career, 
I  was  fortunate  in  securing  the  assistance  of  Dr.  Louis  STARR  for  the 
same  purpose. 

In  order  to  render  the  work-  as  valuable  as  possible  to  the  general 

3 


4  PREFACE. 

practitioner,  its  scope  has  been  made  as  comprehensive  as  could  be  done 
without  exceeding  the  limits  prescribed  by  the  nature  of  the  under- 
taking. This  will  be  particularly  noted  in  the  section  on  Gynaecology, 
where  is  presented  a  series  of  articles  by  eminent  specialists  upon  the 
subjects  of  chief  importance  to  the  general  practitioner,  written  with 
special  reference  to  their  constitutional  relations  and  their  bearings  on 
associated  morbid  conditions,  while,  among  the  general  diseases,  a  full 
article  on  puerperal  fever  has  properly  been  included.  Important  arti- 
cles will  also  be  found  on  Tracheotomy,  the  Diseases  of  the  Rectum  and 
the  Anus,  and  those  of  the  Bladder  and  the  male  sexual  organs.  Com- 
prehensive sections  have  further  been  provided,  from  the  pens  of  distin- 
guished specialists,  upon  medical  ophthalmology,  medical  otology,  and 
on  skin  diseases,  presenting  these  large  and  complicated  subjects  in  a 
clear  and  practical  light  and  with  special  reference  to  their  relations  to 
general  medical  practice.  In  the  presentation  of  such  subjects  as  hydro- 
phobia, glanders,  and  anthrax  care  has  been  taken  to  ensure  the  full 
discussion  of  these  affections,  not  only  as  occurring  in  man,  but  also  in 
the  lower  animals,  since  it  is  highly  important  to  provide  the  physician 
with  authoritative  information  on  at  least  such  points  of  Veterinary  Sci- 
ence as  have  a  direct  practical  bearing  on  morbid  processes  in  man. 

In  view  of  the  intimate  relations  of  all  questions  of  hygiene  to  the 
causation  and  prevention  of  disease,  in  regard  to  which  medical  men 
are  constantly  consulted,  and  are,  indeed,  often  obliged  to  assume 
weighty  responsibilities,  interesting  articles  on  Drainage  and  Hygiene 
have  been  provided. 

In  order  to  avoid  repetition  and  confusion,  and  at  the  same  time  to 
secure  a  comprehensive  presentation  of  the  subjects  of  General  Pathology 
and  of  General  Etiology,  Symptomatology,  and  Diagnosis,  considerable 
space  has  been  devoted  to  their  full  discussion.  The  chapter  on  General 
Morbid  Processes  will  be  found  to  convey  distinct  and  conservative 
teaching  on  all  points  included  under  that  comprehensive  title,  and 
will  thus  supply  a  solid  basis  for  the  subsequent  discussions  of  special 
morbid  conditions.  In  any  work  on  General  Medicine  at  the  present 
day  frequent  allusion  must  be  made  to  the  relations  of  various  low 
organisms  to  morbid  processes.  This  question — or  rather  the  series 
of  questions  which  arise  in  connection  with  this  subject,  and  which  at 
present  form  the  most  fruitful  topic  of  discussion  and  of  investigation 
— will  be  found  treated  by  different  authors  in  various  places  and  from 
various  standpoints.  No  attempt  has  been  made  to  secure  uniformity  of 
views  upon  a  matter  which  is  still  sub  judice,  and  which  demands 
much  more  skilful  and  critical  investigation  before  its  true  scien- 
tific position  has  been  finally  determined.  It  has  even  been  felt  to  be 
desirable  to  allow  a  certain  amount  of  repetition,  which  has  naturally 


PREFACE.  5 

resulted  from  the  introduction  of  this  discussion,  not  only  in  the  chapter 
on  General  Etiology,  but  in  connection  with  the  causation  of  scarlatina, 
diphtheria,  hydrophobia,  pyaemia,  puerperal  fever,  and  phthisis. 

Throughout  the  work  the  chief  purpose  of  the  editor  and  of  his  collab- 
orators, to  furnish  a  concise  and  thoroughly  practical  system  of  medi- 
cine, has  compelled  the  omission  of  bibliographical  lists,  of  numerous  ref- 
erences, and  of  extended  discussions  of  theoretical  views  or  of  contro- 
verted questions,  in  order  that  more  space  might  be  devoted  to  clear 
descriptions  of  disease  and  to  a  full  presentation  of  the  subjects  of  diag- 
nosis and  treatment.  If  it  should  seem,  in  consequence,  that  inadequate 
recognition  has  been  made  of  the  labors  of  others,  it  must  be  borne  in 
mind  that  ample  quotations  and  numerous  references  were  inadmissible 
in  such  a  work  as  the  present. 

The  classification  and  nomenclature  which  have  been  adopted  are  those 
recommended  by  the  Royal  College  of  Physicians  of  England  and  by  the 
American  Medical  Association.  Charts  and  tables  have  been  inserted 
wherever  they  were  needed  to  elucidate  the  text,  but  after  mature  reflec- 
tion it  was  felt  necessary  to  omit  all  illustrations  that  were  not  impera- 
tively required,  although  many  original  drawings  and  paintings  of  high 
value  were  offered  with  the  articles. 

THE  EDITOR. 

OCTOBER,  1884. 


CONTENTS  OF  VOL.  I. 


PAGE 

PEEFACE.  .  ...       3 


GENERAL  PATHOLOGY  AND  SANITARY  SCIENCE. 

GENERAL  MORBID  PROCESSES.     By  REGINALD  H.  FITZ,  M.  D 35 

GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS.  AND  PROGNOSIS.     By 

HENRY  HAKTSIIORNE,  M.  D.,  LL.D 125 

HYGIENE.     By  JOHNS.  BILLINGS,  A.M.,  M.D.,  LL.D.  (Edin.) 173 

DRAINAGE  AND  SEWERAGE  IN  THEIR  HYGIENIC  RELATIONS.    By 

GEORGE  E.  WARING,  JR.,  M.  Inst.  C.  E 213 

GENERAL  DISEASES. 

SIMPLE  CONTINUED  FEVER.    By  JAMES  H.  HUTCHINSON,  M.  D 231 

TYPHOID  FEVER.    By  JAMES  II.  HUTCHINSON,  M.  D 237 

TYPHUS  FEVER.    By  JAMES  H.  HUTCHINSON,  M.  D 338 

RELAPSING  FEVER.     By  WILLIAM  PEPPER,  M.  D.,  LL.D 369 

VARIOLA.    By  JAMES  NEYINS  HYDE,  M.  D 434 

VACCINIA.     By  FRANK  P.  FOSTER,  M.  D 455 

VARICELLA.     By  JAMES  NEYINS  HYDE,  M.  D 481 

SCARLET  FEVER.     By  J.  LEWIS  SMITH,  M.  D 486 

RUBEOLA.     By  W.  A.  HARDAWAY,  A.  M.,  M.  D 557 

ROTHELN.     By  W.  A.  HARDAWAY,  A.  M.,  M.  D 582 

MALARIAL  FEVERS.     By  SAMUEL  M.  BEMISS,  M.  D 589 

PAROTITIS.     By  JOHN  M.  KEATING,  M.  D 620 

ERYSIPELAS.     By  JAMES  NEVINS  HYDE,  M.  D 629 

YELLOW  FEVER.     By  SAMUEL  M.  BEMISS,  M.  D 64C 

7 


8  CONTEXTS  OF  VOL.  I. 

PAGl 

DIPHTHERIA.     By  ABRAHAM  JACOBI,  M.D 656 

CHOLERA.     By  ALFRED  STILL*,  M.  D.,  LL.D 715 

PLAGUE.    By  JAMES  C.  WILSON,  A.  M.,  M.  D 771 

LEPROSY.     By  JAMES  C.  WHITE,  M.  D 785 

EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.    By  A.  STILLE,  M.  D.,  LL.D.  795 

PERTUSSIS.     By  JOHN  M.  KEATING,  M.  D 836 

INFLUENZA.    By  JAMES  C.  WILSON,  A.  M.,  M.  D 851 

DENGUE.     By  II.  D.  SCHMIDT,  M.  D 879 

RABIES  AND  HYDROPHOBIA.     By  JAMES  LAW-,  F.  R.  C.  V.  S 886 

GLANDERS  AND  FARCY.     By  JAMES  LAW,  F.  R.  C.  Y.  S 909 

ANTHRAX  (MALIGNANT  PUSTULE).     By  JAMES  LAW,  F.  R.  C.  V.  S.    .    .  926 

PYAEMIA  AND  SEPTICAEMIA.     By  B.  A.  WATSON,  A.  M.,  M.  D 945 

PUERPERAL  FEVER.     By  WILLIAM  T.  LUSK,  M.  D 984 

BERIBERI.     By  DUANE  B.  SIMMONS,  M.  D 1038 

INDEX  .   .   .  f 1045 


CONTRIBUTORS  TO  VOL.  I. 


BEMISS,  SAMUEL  M.,  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine  in  the  Univer- 
sity of  Louisiana,  New  Orleans. 

BILLINGS,  JOHN  S.,  A.  M.,  M.  D.,  LL.D.  (Edin.), 
'     Surgeon  U.  S.  Army,  Washington. 

FITZ,  REGINALD  II.,  M.  D., 

Shattuck  Professor  of  Pathological  Anatomy  in  Harvard  University,  Boston. 

FOSTER,  FRANK  P.,  M.  D., 
New  York. 

HARDAWAY,  W.  A.,  A.  M.,  M.  D., 

Professor  of  Diseases  of  the  Skin  in  the  St.  Louis  Post-Graduate  School  of  Medicine 
and  in  the  Missouri  Medical  College,  St.  Louis ;  President  of  the  American  Der- 
matological  Association. 

IIARTSHORNE,  HENRY,  M.  D.,  LL.D., 

Late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  Philadelphia. 

IIUTCHINSON,  JAMES  H.,  M.  D., 

Physician  to  the  Pennsylvania  Hospital  and  to  the  Children's  Hospital,  Philadelphia. 

HYDE,  JAMES  NEVINS,  M.  D., 

Professor  of  Skin  and  Venereal  Diseases  in  the  Ensh  Medical  College,  Chicago. 

JACOBI,  ABRAHAM,  M.  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  College  of  Physicians  and  Surgeons, 
New  York,  etc. 

KEATING,  JOHN  M.,  M.D., 

Visiting  Obstetrician  and  Lecturer  on  Diseases  of  Women  and  Children  to  the  Phil- 
adelphia (Blockley)  Hospital ;  Surgeon  to  the  Maternity  Hospital ;  Physician  to 
St.  Joseph's  Hospital,  Philadelphia. 

LAW,  JAMES,  F.  R.  C.  V.  S., 

Professor  of  Veterinary  Science  in  Cornell  University,  Ithaca,  N.  Y. 

LUSK,  WILLIAM  T.,  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  Bellevne  Hos- 
pital Medical  College,  New  York. 

9 


10  CONTRIBUTORS  TO    VOL.  I. 

PEPPER,  WILLIAM,  M.  D.,  LL.D., 

Provost  and  Professor  of  the  Theory  and  Practice  of  Medicine  and  of  Clinical  Medi- 
cine in  the  University  of  Pennsylvania,  Philadelphia. 

SCHMIDT,  II.  D.,  M.D., 

Pathologist  to  the  Charity  Hospital,  New  Orleans. 

SIMMONS,  DUANE  B.,  M.  D.,  Yokohama,  Japan, 

Late  Director,  Physician,  and  Surgeon-in-Chief  of  the  Government  Hospital,  also 
Consulting  Surgeon  to  Prison  and  Police  Hospitals  at  Yokohama,  Japan. 

SMITH,  J.  LEWIS,  M.  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College 
New  York. 

STILLE,  ALFRED,  M.  D.,  LL.D., 

Emeritus  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penn- 
sylvania, Philadelphia. 

WARING,  GEORGE  E.,  JR.,  M.  Inst.  C.  E., 

Engineer  of  Sanitary  Drainage,  Newport,  E.  I. 

WATSON,  B.  A.,  A.  M.,  M.  D., 

Surgeon  to  the  Jersey  City  Charity,  St.  Francis,  and  Christ  Hospitals,  Jersey  City, 
.      N.  J. 

WHITE,  JAMES  C.,  M.  D., 

Professor  of  Dermatology  in  Harvard  University,  Boston. 

WILSON,  JAMES  C.,  A.  M.,  M.  D., 

Physician  to  the  Jefferson  Medical  College  Hospital  and  to  the  Philadelphia  Hospital, 
Philadelphia. 


ILLUSTRATIONS. 


FIGURE  PACK 

1.  MICKOCOCCI 142 

2.  BACTERIA 142 

3.  BACILLUS  MALARIA 4 143 

4.  BACTERIA  FROM  GELATIN  SOLUTION 143 

5.  VIBRIOS  IN  GELATIN  CULTURE-FLUID ]44 

6.  PROTOCOCCUS  FROM  SLIDES  EXPOSED  OVER  SWAMP-MUD 144 

7.  BACILLI  FROM   SWAMP-MUD 145 

8.  BACILLI  FROM  SEPTIC.&MIC  RABBIT 145 

9.  BACILLI  FROM  HUMAN  SALIVA 146 

10.  BACILLUS  ANTHRACIS 146 

11.  BACILLUS  TUBERCULOSIS 147 

12.  CHART  OF  TYPICAL  RANGE  OF  TEMPERATURE  IN  TYPHOID  FEVER,  AFTER 

WUNDERLICH 282 

13.  CHART  SHOWING  RECRUDESCENCE  OF  FEVER  FROM  INDISCRETION  OF  DIET.  283 

14.  CHART  SHOWING  FALL  OF  TEMPERATURE  FROM  INTESTINAL  HEMORRHAGE 

IN  TYPHOID  FEVER 284 

15.  PULSE-TRACING  IN  RELAPSES  OF  TYPHOID  FEVER 304 

16.  CHART  OF  TEMPERATURE  IN  TYPHOID  FEVER  WITH   RELAPSE.— ORIGINAL 

ATTACK 306 

17.  CHART  OF  TEMPERATURE  IN  TYPHOID  FEVER  WITH  RELAPSE. — RELAPSE.  306 

18.  TEMPERATURE  CHART  OF  TYPHOID  FEVER. — ABORTIVE  ATTACK,  FOLLOWED 

BY  TYPICAL  ATTACK 308 

19.  SPIRILLUM  FROM  THE  BLOOD  IN  A  CASE  OF  RELAPSING  FEVER 374 

20.  TEMPERATURE  CHART  OF  TYPICAL  CASE  OF  RELAPSING  FEVER,  WITH  THREE 

RELAPSES  TERMINATING  IN  RECOVERY 379 

21.  TEMPERATURE  CHART  OF  TYPICAL  CASE  OF  RELAPSING  FEVER,  TERMINAT- 

ING IN  RECOVERY 380 

22.  TEMPERATURE  CHART  FROM  A  CASE  OF  THE  BILIOUS  TYPHOID  OR  GRAVE 

SUBINTRANT  FORM  OF  RELAPSING  FEVER 397 

23.  TEMPERATURE  CHART  SHOWING  THE  LAPSE  OF  A  REMITTENT  FEVER  INTO 

AN  INTERMITTENT 600 

24.  CHARTS  SHOWING  THE  TEMPERATURE  CURVE  IN  TYPHO-MALARIAL  FEVER: 

PART  I.,  SHOWING  PREDOMINANCE  OF  TYPHOIDAL  ELEMENT  ;  PART  II., 

SHOWING   PREDOMINANCE   OF   MALARIAL   ELEMENT '     '     .     .  617 

11 


GENERAL  PATHOLOGY. 


GENERAL  MORBID  PROCESSES. 
GENERAL  ETIOLOGY. 
HYGIENE  AND  QUARANTINE. 

DRAINAGE  AND  SEWERAGE  IN  RELATION  TO  THE  PREVENTION 
OF  DISEASE. 


VOL.  I.— 3 


GENERAL  MORBID  PROCESSES.1 

INFLAMMATION;  THROMBOSIS  AND  EMBOLISM;  EFFUSIONS; 
DEGENERATIONS;  TUBERCULOSIS;  MORBID  GROWTHS. 

BY  REGINALD  H.  FITZ,  M.  D. 


GENERAL  MOKBID  PROCESSES. 

DISEASE  is  to  be  regarded  as  representing  the  result  of  a  series  of  pro- 
cesses called  morbid  or  pathological,  from  the  fact  that  they  are  man- 
ifested by  disturbances  in  the  organism. 

The  processes  concerned  are  the  same  in  kind  as  those  essential  to 
health,  but  they  are  modified  in  time,  place,  or  quantity. 

Morbid  processes,  therefore,  are  to  be  considered  as  modified  physio- 
logical processes  tending  to  cause  disease. 

All  physiological  processes  are  subject  to  certain  variations  which 
tend  to  produce  disturbances  in  the  functions  of  the  body  In  the 
healthy  organism  this  tendency  is  checked  by  the  automatic  regulators 
of  the  functional  activity  of  the  various  organs,  to  the  importance  of 
which  Virchow2  long  ago  called  attention.  By  their  action  the  influ- 
ence of  external  agents  is  controlled  within  certain  limits.  The  lids 
close  and  prevent  injury  to  the  eye.  Sneezing,  coughing,  and  vomit- 
ing bring  about  the  expulsion  of  noxious  irritants.  Sweating  aids  in 
neutralizing  the  injurious  effects  of  exposure  to  high  temperatures. 
Rapid  respiration  permits  a  sufficient  cleansing  of  the  blood  in  rarefied 
atmospheres.  When  the  limits,  within  which  the  regulation  of  physio- 
logical processes  is  possible,  are  exceeded,  such  processes  become  patho- 
logical and  disease  begins.  A  morbid  process,  therefore,  is  usually  inca- 
pable of  recognition  till  disease  is  present.  It  may  exist  and  disease  be 
unsuspected  and  denied.  A  diminished  blood-supply  may  be  one  link  in 
the  process  which  eventually  leads  to  the  production  of  disturbances. 

1  In  the  ^reparation  of  this  subject  full  and  free  use  has  been  made  of  the  following  works: 
Die  Cellular  Patholoyie,  Virchow,  4te  Auilage,  Berlin,  1871 ;  Hnndbuck  tier  Altyemeinen 
Pathologie,  Uhle  und  Wagner,  7te  Auflage,  Leipzig,  1876;  Handbuch  der  Al/yemeincn 
Pathologic  als  Patltologische  Physiologic,  Samuel,  Stuttgart,  1879;  Vorlesimyen  iiber  AUye- 
meine  Pathologic,  Cohnheim,  2te  Auilage,  Berlin,  1882 ;  Lehrbitch  der  Pathologischen  Anato- 
mie,  Birch-Hirschfeld,  2te  Auflage,  ler  Band,  Leipzig,  1882;  Lehrbncli  der  Allf/emeinen  un<l 
Speciellen  Pathologixchcn  Anatomie,  Ziegler,  ler  und  2er  Theil,  Jena,  1882  and  1883. 

1  Handbuch  der  Spcciellen  PaLholoyie  und  Tkerapie,  Virchow,  ler  Band,  p.  15,  Erlangen, 
1854. 

35 


36  GESEEAL  MORBID  PROCESSES. 

Another  link  is  to  be  found  in  tlie  fatty  degeneration  resulting  from  this 
luck  of  blood. 

Such  a  degeneration  may  have  long  existed  in  the  walls  of  a  blood- 
vessel, and  yet  the  individual  appear  in  the  best  of  health.  The  sudden 
rupture  of  the  weakened  wall  results  in  death  or  disease.  With  the 
manifestation  of  the  disturbances  which  render  the  condition  of  the 
vessel  obvious  the  individual  is  said  to  be  diseased. 

In  •  most  instances,  however,  the  morbid  process  makes  itself  early  ap- 
parent. Disturbances  of  nutrition,  formation,  or  function  soon  become 
sufficient  in  quantity  to  attract  attention  from  the  resulting  discomfort, 
and  the  presence  of  disease  is  then  recognized.  The  latter  is  thus  essen- 
tially a  conventional  term,  and  begins  when  the  morbid  processes  occasion 
a  sufficient  degree  of  inconvenience. 

The  process  is  never  at  a  standstill.  It  cither  tends  toward  a  return  to  the 
physiological  conditions,  or  its  course  LS  in  the  direction  of  their  destruc- 
tion. As  physiological  processes  are  absolutely  dependent  upon  the  vital- 
ity of  the  elements  of  the  tissues,  so  those  which  have  become"  pathological 
cease  to  exist  with  the  death  of  such  elements.  In  the  dead  body  there  is 
no  disease,  although  its  results  remain,  and  furnish  the  most  efficient  means 
of  identifying  the  processes  which  occasioned  them. 

In  the  study  of  morbid  processes,  therefore,  one  must  appreciate  the 
normal  conditions  and  manifestations  of  life  in  the  individual.  Phys- 
iological laws  govern  pathological  phenomena,  and  the  latter  must  always 
be  submitted  to  the  tests  furnished  by  the  former. 

Just  as  little,  however,  as  the  study  of  anatomy  familiarizes  the 
student  with  the  anatomical  changes  resulting  from  diseased  processes, 
does  the  study  of  physiology  accustom  the  student  to  the  features  of 
disease.  Pathological  processes  must  be  studied  by  themselves  and  for 
themselves,  although  the  means  which  are  employed  may  be  the  same 
as  those  used  in  physiological  research. 

It  is  evident  that  the  exactness  of  method  which  is  the  demand  of 
the  physiological  investigator  cannot  be  secured  by  the  pathologist.  The 
material  of  the  latter  lies  farther,  beyond  his  control.  Nevertheless,  much 
of  the  ground  to  be  gone  over  is  common,  and  the  object  sought  for  is 
essentially  the  same — the  knowledge  of  the  conditions  necessary  to  main- 
tain life. 

In  an  introduction  to  the  study  of  disease  there  are  certain  processes 
which  deserve  early  recognition.  They  are  both  the  cause  and  the  result 
of  disease,  and  may  occur  in  various  diseases,  either  limited  to  one  organ 
or  present  in  a  series  of  organs.  Their  treatment  at -present  obviates  the 
necessity  of  repetition,  and  prepares  the  reader  for  the  special  consideration 
of  their  occurrence  in  the  various  structures  and  systems  of  the  body. 

These  processes  are  named  in  virtue  of  some  prominent  characteristic, 
and  each  is  made  up  of  a  complex  series  of  conditions  and  disturbances. 
In  part,  they  represent  modifications  in  the  circulation  of  blood  and 
lymph ;  in  part,  they  consist  of  nutritive  derangements,  whose  conse- 
quences appear  as  the  various  degenerations,  or  as  the  additions  to  the 
body,  the  new  formations. 

The  processes  and  groups  of  processes  in  question  are  those  included 
under  the  following  heads:  inflammation;  thrombosis  and  embolism; 
effusions;  degenerations;  tuberculosis;  and  morbid  growths. 


INFLAMMATION.  37 


Inflammation. 

Inflammation  is  characterized  now,  as  in  the  time  of  Galen,  by  the 
presence  of  redness,  heat,  swelling,  and  pain.  The  disturbance  of  func- 
tion, added  to  modern  definitions,  is  to  be  regarded  either  as  a  result  or 
a  cause,  or  both,  of  the  variously  modified  physiological  processes  whose 
sum  is  the  inflammation. 

The  redness  of  inflammation  is  obviously  dependent  upon  the  presence 
of  an  increased  quantity  of  blood.  This  is  readily  apparent  in  the  direct 
observation  of  the  blood-vessels  of  an  inflamed,  transparent  part  of  the 
body,  as  the  mesentery  of  the  frog  or  rabbit,  or  the  tongue  and  webbed 
foot  of  the  former  animal.  The  redness  of  inflammation  consequently 
demands  the  presence  of  blood-vessels  in  the  affected  region,  and  becomes 
all  the  greater  the  more  vascular  the  part — i.  e.  the  richer  it  is  in  such 
vessels. 

Redness  does  not  suffice  for  the  existence  of  inflammation,  for  it  may 
be  found  in  the  absence  of  other  evidence  of  the  latter.  The  diffused  red- 
ness, often  extensive,  of  birth-marks,  that  from  venous  obstruction  or 
temporary  congestions,  from  vaso-motor  disturbances — the  section  of  the 
sympathetic  furnishing  a  well-known  instance — are  examples  of  non-in- 
flammatory redness.  Inflammation  may  even  be  present  without  redness, 
as  may  be  constantly  observed  in  the  occurrence  of  parenchymatous  in- 
flammation and  of  the  chronic  interstitial  varieties. 

The  heat  of  inflammation  is  one  of  the  most  important  clinical  features, 
yet  not  indispensable,  as  appears  from  its  absence  in  chronic  interstitial 
forms  of  inflammation.  In  the  acute  varieties  of  inflammation  an  ele- 
vated temperature  is  constant,  and  its  observation  and  record  furnish  a 
most  valuable  means  of  determining  the  beginning  and  progress  of  an  in- 
flammation, which,  for  a  time,  may  furnish  but  little  additional  evidence. 

The  heat  of  inflammation  is  the  prominent  characteristic  of  inflam- 
matory fever,  and  it  is  the  study  of  this  variety  of  fever  of  late  years 
which  has  resulted  in  an  intelligible  and  relatively  satisfactory  theory 
concerning  fevers  in  general.  Information  of  much  value  is  to  be  found 
in  the  recent  work  of  Wood,1  which  contains  abundant  historical  informa- 
tion, as  well  as  extensive  original  observations  and  conclusions. 

Inflammatory  fevers  are  distinguished  from  idiopathic  forma.  The 
latter  variety  includes  the  occurrence  of  fever  as  an  attribute  of  the 
disease  concerned,  the  more  characteristic  symptoms  of  which  follow  the 
febrile  outbreak.  Local  inflammatory  processes  may  take  place  during 
the  progress  of  the  disease  with  its  fever,  but  such  processes  are  co-effects 
of  the  cause  of  the  latter,  rather  than  its  cause.  Most  of  those  diseases 
in  which  fever  occurs  as  one  of  the  joint  effects  of  the  cause  of  the  disease, 
are  included  among  the  infective  or  zymotic  classes. 

The  inflammatory  fevers  are  those  attending  an  acute  inflammatory 
process,  and  are  secondary  to,  and  occasioned  by,  the  latter.  The  type 
of  this  variety  is  seen  in  the  fever  occurring  during  the  progress  of  a 
wound,  whether  its  course  is  towrard  healing  or  extension.  Such  trau- 

1  Fever:  A  Study  in  Morbid  and  Normal  Physiology,  H.  C.  Wood,  A.  M.,  M.  D.,  Phila- 
delphia, 1880.  (Keprint  from  the  Smithsonian  Contributions  to  Knowledge,  No.  357.) 


38  GENERAL  MORBID  PROCESSES. 

malic  fevers  are  characterized  as  septic  or  aseptic ;  the  former  including 
the  conditions  of  septicaemia  and  pyaemia.  The  aseptic  traumatic  fevers, 
as  described  by  Volkmann,1  are  those  which  pursue  their  course  with  an 
elevated  temperature,  but  without  most  of  the  other  febrile  phenomena. 

Fever  in  general  is  characterized  by  a  combination  of  disturbances  in 
the  physiological  processes  of  the  body.  Such  processes  are  those  con- 
cerned in  the  production  and  dissipation  of  heat,  in  respiration  and  circu- 
lation, digestion  and  secretion,  and  in  mental,  motor,  and  other  sensorial 
action.  Such  disturbances  are  manifested  by  a  persistent  elevation  of 
temperature,  an  increased  destruction  of  tissue,  a  quickened  and  modified 
pulse,  accelerated  breathing,  increased  thirst,  diminished  appetite,  and 
diminished  quantity  and  altered  quality  of  the  secretions.  The  sensorial 
disturbances  include  wakefulness  and  stupor,  headache,  delirium,  twitch- 
ings,  cramps,  and  other  symptoms  indicative  of  functional  impairment  of 
the  nervous  system. 

Of  all  these  manifold  evidences  of  fever,  the  elevation  of  temperature 
is  the  one  whose  cause,  range,  and  results  have  been  most  carefully  and 
critically  investigated.  No  record  of  a  case  in  which  fever  is  present  is 
regarded  as  complete  without  the  chart  of  the  daily  variations  in  temper- 
ature, respiration,  and  circulation.  The  practical  value  of  such  records 
is  thus  admitted,  and  in  the  experiments  relating  to  the  origin  of  animal 
heat  the  observations  of  temperature  are  as  essential  as  the  chemical 
analyses,  each  of  which  supplements  the  other. 

The  more  accurate  determination  of  the  heat  produced  in  the  body  is 
obtained  either  by  the  use  of  the  calorimeter  (an  apparatus  for  measuring 
the  collected  heat  liberated  from  the  body)  or  by  estimating  the  quantity 
of  heat  produced  in  the  destruction  of  the  constituents  of  the  body  from 
quantitative  analyses  of  the  discharged  carbonic  acid  and  urea.  The 
results  of  such  investigations  are  regarded  by  Rosenthal2  as  possessing 
only  a  relative  value,  but  justify  the  conclusion  that  most  of  the  heat 
produced  in  the  organism  results  from  the  oxidation  of  its  constituents. 

For  the  preservation  of  health  it  is  essential  that  this  heat  should  be 
removed  from  the  body  in  such  qTiautity  that  the  temperature  of  the 
latter  shall  not  vary  to  any  considerable  extent,  for  any  considerable  time, 
from  37.2°  C.  (98.4°  F.)."  The  removal  of  the  heat  is  mainly  accom- 
plished by  its  radiation  or  conduction  into  a  surrounding  cooler  medium, 
and  by  the  evaporation  of  moisture  from  the  surface  of  the  body.  Too 
great  a  removal  of  heat  results  in  death  from  freezing,  while  too  great  an 
accumulation  of  heat  terminates  fatally  from  the  effects  of  an  unduly 
elevated  temperature.  To  ensure  the  normal  range  of  temperature,  con- 
stantly changing  relations  must  exist  between  the  production  of  heat  and 
its  dissipation.  The  cooler  the  surroundings,  the  more  must  heat  be 
produced,  or  the  less  must  heat  be  evolved  from  the  body. 

An  increased  production  of  heat  is  obvious  under  conditions  of  climate 
demanding  prolonged  exposure  to  low  temperature.  An  abundantly  fatty 
diet  promotes  the  formation  of  hont,  while  suitable  clothing  checks  its 
dissipation.  Although  it  is  claimed  by  Liebermeister  that  sudden 
exposure  to  cold  stimulates  heat-production,  Rosenthal3  disputes  this 

1  Beitrage  zur  Chirurgie,  Leipzig,  1875,  p.  24;  Sammlung  KliniscJier  Vortrage,  No.  121, 
Genzmer  und  Volkmann. 

1  .Hermann's  Handbuch  der  Physiologic,  Leipzig,  18S2,  iv.  2,  375.  !  Op.  cit.t  413. 


INFLAMMATION.  39 

statement,  and  maintains  that  it  is  still  to  be  regarded  as  doubtful 
whether  the  production  of  heat  can  be  varied  to  suit  the  demands  of 
sudden  and  temporary  changes  of  temperature.  With  the  admission  of 
this  doubt,  the  regulation  of  the  temperature  of  the  body,  under  the 
circumstances  just  referred  to,  is  mainly  accomplished  through  the 
influence  of  agencies  favoring  or  checking  the  loss  of  heat.  Since  heat 
is  largely  brought  to  the  surfaces  of  the  body  by  the  circulating  blood, 
modifications  in  the  fulness  and  rapidity  of  this  superficial  current  pro- 
duce corresponding  differences  in  the  amount  of  heat  and  moisture  pre- 
sented. Such  variations  are  considered  to  be  accomplished  through  the 
action  of  the  vaso-motor  nervous  system,  whose  differing  effects  are 
apparent  in  the  pale,  cool  skin  and  the  flushed,  warm  surface. 

The  search  for  the  regulation  of  such  vaso-motor  action  has  led  to  the 
view  that  the  production  of  heat,  as  well  as  its  dissipation,  may  be 
influenced  from  a  nervous  centre.  Wood1  claims  that  the  result  of 
experiments  made  by  him  proves  the  existence  of  such  a  heat-centre  in 
or  above  the  pons.  Although  admitting  the  possibility  of  its  being  a 
muscular  vaso-motor  centre,  he  regards  it  rather  as  an  inhibitory  heat- 
centre,  which  acts,  as  suggested  by  Tscheschichin,  by  repressing  the  chem- 
ical changes  in  the  constituents  of  the  body  through  which  heat  is  pro- 
duced. 

This  view  is  objected  to  by  Rosenthal,2  on  the  ground  that  the  facts 
are  not  universally  agreed  upon,  and  their  interpretation  is  somewhat 
vague.  Even  the  increased  production  of  heat  as  determined  by  Wood, 
if  admitted,  may  be  regarded  as  the  result  of  a  modified  circulation. 

The  preservation  of  a  normal  range  of  temperattire  in  general  is  to  be 
recognized  as  the  result  of  variations  in  the  relation  of  heat-production 
to  heat-dissipation.  The  causes  which  influence  this  relation  may  act 
from  without  or  from  within,  and  are  regarded  as  producing  their  effect 
by  means  of  the  vaso-motor  nervous  system.  The  causes  which  act  from 
within  are  those  concerned  in  the  febrile  elevation  of  temperature. 
Whether  the  latter  is  associated  with,  or  independent  of,  inflammatory 
processes,  the  question  of  first  importance  relates  to  the  modification  of 
physiological  conditions.  The  causes  of  the  physiological  production  of 
heat  and  its  dissipation  have  already  been  referred  to,  and  the  same 
elements  demand  consideration  in  the  pathological  range  of  temperature 
so  striking  in  fever. 

Relatively  accurate  inductions  with  regard  to  the  origin  of  febrile  heat 
were  first  rendered  possible  by  the  experiments  of  Billroth  and  Weber. 
These  observers  found  that  the  introduction  of  putrid  material  into  the 
circulation  of  animals  produced  fever.  It  was  afterward  shown  that 
various  substances,  not  necessarily  of  a  putrid  character,  might  produce 
the  same  result. 

From  measurements  with  the  calorimeter  of  the  heat  produced,  it  was 
concluded  by  Wood3  that  in  the  fever  of  pyremic  dogs  more  heat  was 
produced  than  in  healthy,  fasting  dogs,  although  less  than  in  high-fed, 
healthy  dogs.  An  increased  production  of  heat  in  the  fevered  animal  is 
thus  obvious,  as  his  capacity  to  receive  and  assimilate  food  is  considerably 
less  than  that  of  a  high-fed,  healthy  dog.  The  calculations  of  Sanderson, 
referred  to  by  Wood,4  based  upon  the  analyses  of  eliminated  carbonic 
1  Op.  cit.,  254.  *  Op.  cit.,  442.  3  Op.  cit.  236.  4  Op.  cit.  239. 


40  GENERAL  MORBID  PROCESSES. 

acid  and  urea,  show  that  the  febrile  human  subject  produces  very  much 
more  heat  than  the  fasting,  though  less  than  the  fully-fed,  healthy,  man. 

An  increased  production  of  heat  in  fever  is  generally  admitted,  although 
it  alone  is  not  to  be  regarded  as  the  essential  feature  in  the  elevated  range 
of  the  temperature.  The  fasting  man  or  animal  under  ordinary  circum- 
stances is  not  febrile,  and  an  increased  production  of  heat  from  full  feeding 
in  health,  equal  to  that  observed  in  fever,  not  being  associated  with  fever, 
it  is  apparent  that  the  retention  of  the  produced  heat  is  of  importance  for 
the  existence  of  fever.  Although  it  has  been  shown  by  various  observers 
that  more  heat  is  dissipated  during  fever  than  in  health,  this  increased 
loss  is  not  in  proportion  to  the  increased  production  of  heat.  A  persistent 
elevation  of  temperature  is  the  necessary  result.  This  elevation  is  subject 
to  daily  and  hourly  differences,  as  is  the  temperature  of  the  healthy 
individual.  These  variations  in  the  range  of  the  febrile  temperature  are 
apparently  due  to  an  agency  like  that  which  dominates  the  course  of 
normal  temperatures — viz.  a  varying  action  of  the  vaso-motor  nervous 
apparatus,  as  well  as  of  that  controlling  the  secretion  of  sweat,  now  per- 
mitting, now  checking,  the  dissipation  of  the  produced  heat. 

For  the  existence  of  the  elevated  temperature  of  fever,  therefore,  there 
is  demanded  the  presence  of  an  agent  within  the  body  which,  as  stated  by 
"\Vood,1  shall  act  "  upon  the  nervous  system  which  regulates  the  produc- 
tion and  dissipation  of  animal  heat — a  system  composed  of  diverse  parts 
so  accustomed  to  act  continually  in  unison  in  health  that  they  become,  as 
it  were,  one  system  and  suifer  in  disease  together."  It  may  be  that  there 
exists,  as  claimed  by  Wood  and  Tscheschichiu,  a  heat-centre  independent 
of  the  vaso-motor  and  other  centres,  through  which  heat  is  dissipated,  or 
it  may  be,  as  maintained  by  Rosenthal,  that  the  vaso-motor  system  alone 
is  concerned  in  the  regulation  of  temperature.  Such  action  may  be 
inhibitor}7  or  excitant,  according  to  the  views  of  the  one  or  the  other 
author,  without  aifecting  the  main  question  as  above  stated. 

The  elevation  of  temperature  suffices  to  explain  for  the  most  part 
certain  of  the  other  phenomena  of  fever,  as  thirst,  digestive  disturbances, 
increased  respiration,  and  emaciation.  A  coincident  affection  of  various 
cerebro-spinal  centres  is  demanded  to  explain  the  altered  action  of  the 
heart  and  the  numerous  nervous  symptoms  which  are  to  be  found  in 
fever.  The  agent  producing  such  manifold  effects  is  obviously  no  unit. 
It  may  be  introduced  from  without  or  it  may  arise  within  the  body,  and 
its  transfer  to  the  nervous  centres  is  undoubtedly  accomplished  through 
the  circulation. 

Among  those  agents  which  act  from  without  are  to  be  included  the 
specific  causes  of  infective  diseases.  It  is  probable  that  these  produce 
the  fever,  as  they  occasion  other  symptoms  of  the  disease,  and  their 
action  may  be  regarded  as  direct,  or  indirect  through  the  secondary 
products  of  their  own  vital  changes.  In  the  light  of  the  existing  facts 
the  products  of  minute  organisms  developed  outside  the  human  body  may 
give  rise  to  fever  when  introduced,  without  the  organism,  into  the  body. 
The  history  of  septicaemia  contains  numerous  illustrations  of  the  pyro- 
genetic  properties  of  material  produced  in  connection  with  wounded 
surfaces  of  the  body  exposed  to  the  action  of  minute  organisms.  The 
introduction  of  blood  of  the  same,  or  of  a  different  animal,  into  the  cir- 

1  Op.  cit.  255. 


INFLAMMATION.  41 

dilation  of  a  given  animal  is  followed  by  fever,  as  is  the  injection  of 
considerable  quantities  of  water  into  the  blood-vessels.  The  same  is 
true  of  various  chemical  substances. 

It  is  further  obvious  that  the  agents  producing  fever  may  arise  within 
the  body.  The  fever  resulting  from  the  deprivation  of  water,  and  from 
the  destruction  of  tissues,  are  instances  of  the  probable  origin  of  pyro- 
genetic  substances  from  the  rapid  metamorphosis  of  tissues. 

It  is  suggested  by  Samuel [  that  under  given  circumstances  the  fever 
may  be  sanatory.  This  view  is  based  upon  the  probability  that  certain 
parasitic  organisms  are  destroyed  at  such  temperatures  as  may  be  produced 
within  the  body.  The  growth  of 'the  bacillus  of  malignant  pustule  takes 
place  most  vigorously  at  a  temperature  of  30.5°  C.  (95°  F.),  while  its 
development  is  feeble  at  40°  C.  (104°  F.).  The  bacillus  of  tuberculosis, 
as  shown  by  Koch,  thrives  at  temperatures  between  37°  C.  (98.6°  F.)  and 
38°  C.  (100.4°  F.),  but  its  growth  ceases  at  temperatures  above  41°  C. 
(105.8°  F.).  The  spiral  fibre  of  relapsing  fever,  which  is  present  in  the 
blood  in  great  abundance  at  the  beginning  of  the  febrile  onset,  disappears 
at  the  close,  the  temperature  being  42°  C.  (107.6°  F.).  It  is  not  to  be 
found  in  the  intervals  between  the  febrile  paroxysms,  but  reappears  a  few 
hours  before  the  recurrence  of  the  fever.  The  history  of  intermittent 
fever  suggests  a  similar  relation  between  its  cause  and  the  febrile  periods. 

The  value  of  pain  as  evidence  of  inflammation  is  merely  relative.  Its 
existence  depends  upon  the  presence  of  sensitive  nerves,  and  those  inflam- 
mations are  the  least  painful  which  occur  in  parts  where  such  nerves  are 
fewest. 

The  pain  of  inflammation  is  attributable  to  the  pressure  upon  the  nerves 
of  that  product  of  the  inflammation  known  as  the  exudation.  This  pres- 
sure becomes  all  the  greater  the  more  abundant  the  exudation,  or  the  greater 
the  obstruction  offered  to  its  diffusion  throughout  the  inflamed  part.  The 
intense  pain  resulting  from  inflammation  of  the  fascia  or  of  the  periosteum 
is  thus  explained,  while  an  inflammation  of  the  loose  connective  tissue 
may  be  diffused  over  a  wide  area  with  little  or  no  pain.  In  the  chronic 
varieties  of  inflammation,  where  the  exudation  is  but  scanty,  and  its  ac- 
cumulation extended  over  a  long  period  of  time,  there  may  be  no  pain 
during  the  entire  course  of  the  inflammation. 

Swelling  remains  for  consideration  as  the  most  important  of  the  four 
cardinal  symptoms.  Like  the  others,  its  presence  is  not  absolutely  essen- 
tial. It  may  exist  at  one  time  in  the  course  of  the  inflammation,  and  may 
be  absent  at  another.  Even  a  diminution  in  the  size  of  an  organ  may 
suggest  the  existence  of  an  inflammation,  for  the  yellow  and  cirrhotic 
atrophies  of  the  liver  give  evidence,  respectively,  of  an>  acute  and  chronic 
inflammation  of  this  organ. 

The  swelling  of  an  inflamed  part  is  due  to  the  presence  of  an  increased 
quantity  of  blood,  and  lymph,  and  to  the  exudation.  These  constituents 
of  the  swelling  are  not  of  equal  importance.  Although  the  quantity  of 
blood  in  the  part  is  increased,  no  considerable  swelling  is  produced,  pro- 
vided the  flow  of  blood  and  lymph  from  the  part  be  unobstructed.  The 
current  of  lymph  through  the  larger  lymphatics  may  be  greatly  increased, 
yet  a  decided  swelling  be  absent,  unless  there  is  an  obstruction  to  the 
passage  of  lymph  from  the  inflamed  region. 

1  Op.  dt.  155. 


42  GENERAL  MORBID  PROCESSES. 

The  exudation  is  the  most  essential  element  of  the  swelling,  and  our 
knowledge  of  its  origin  and  fate  includes  the  most  important  features  of 
the  general  pathology  of  the  processes  concerned. 

The  inflammatory  exudation  is  represented  by  the  accumulation,  outside 
the  blood-vessels,  of  material  previously  within  them.  The  prevailing 
views  concerning  the  manner  of  origin  of  this  exudation,  and  its  relation 
to  inflammatory  processes,  are  essentially  due  to  the  rediscovery  by  Cohn- 
heim  of  the  forgotten  observation  of  Addison,  that  white  blood-corpuscles 
pass  through  the  apparently  intact  walls  of  the  blood-vessels. 

In  the  observation  of  the  mesentery  or  other  transparent  part  of  a  suit- 
able animal,  the  changes  taking  place  in  inflammation  are,  at  the  outset, 
limited  to  the  blood-vessels  and  their  immediate  vicinity.  The  vessels 
become  dilated  and  the  rapidity  of  the  flow  within  them  is  soon  dimin- 
ished. In  the  veins  particularly  the  white  blood-corpuscles  separate  in 
considerable  numbers  from  the  general  current  and  line  the  wall  in  con- 
stantly-increasing numbers,  while  the  red  corpuscles  are  borne  along  the 
middle  of  the  stream.  The  white  corpuscles  stagnate,  stick  to  the  wall 
for  a  longer  or  shorter  time,  and  often  change  their  place,  while  the  red 
corpuscles  are  in  constant  and  progresssive  motion.  In  the  capillaries  a 
considerable  number  of  white  corpuscles  are  found  in  contact  with  the 
wall,  but  numbers  of  red  corpuscles  are  associated  with  them.  The  for- 
mation of  the  exudation  noAV  begins  by  the  passage  of  white  corpuscles 
through  the  apparently  intact  wall  of  the  veins  and  capillaries,  especially 
of  the  former.  Limited  numbers,  under  ordinary  circumstances,  of  red 
corpuscles  also  make  their  way  through  the  walls  of  the  capillaries.  This 
is  the  phenomenon  of  emigration,  and  is  associated  with  the  amoeboid 
movements  of  the  white  corpuscles. 

With  the  passage  outward  of  the  white  and  red  corpuscles  there  is  also 
the  effusion  of  liquid  material.  Both  the  liquid  and  solid  constituents 
continually  escape  and  spread  in  all  directions  beyond  the  wall,  following 
the  course  of  the  least  resistance.  It  is  probable  that  this  course  is  de- 
nned by  the  pre-existing  spaces  within  the  tissues  of  the  part,  the  lymph- 
spaces.  The  exudation  is  more  abundant  in  parts  richly  provided  with 
blood-vessels  and  in  those  containing  the  larger  spaces ;  it  is  diminished 
where  the  vessels  are  less  numerous  or  the  surrounding  parts  more  resist- 
ant, with  smaller  and  fewer  lymph-spaces.  The  resulting  swelling  is  the 
less  when  .ready  opportunities  for  the  diffusion  and  removal  of  the  exuda- 
tion by  lymphatics  and  veins  are  presented,  and  when  the  material  appears 
upon  surfaces  over  which  it  may  flow  away. 

The  liquid  portion  of  the  exudation  represents  something  more  than 
the  transuded  blot)d-serum,  and  a  certain  practical  importance  results 
from  the  distinction  drawn  between  an  exudation  and  a  transudatiou. 
Such  a  distinction  is  especially  called  for  when  the  inflammatory  or  non- 
inflammatory origin  of  considerable  quantities  of  fluid  in  the  larger  cav- 
ities of  the  body  is  concerned.  From  a  recent  contribution  to  our  know- 
ledge of  this  subject  by  Eeuss1  the  following  information  is  derived  :  The 
percentage  of  albumen  is  always  greater  in  exudations  than  in  trans- 
udations,  and  is  more  constant  in  the  former  than  in  the  latter.  It  in- 
creases with  the  severity  of  the  inflammation,  being  highest  in  the  ichorous 
forms,  less  in  the  purulent,  and  least  in  the  serous  exudations.  When  an 
1  Deutscfies  Archivfiir  Klinische  Aledicin,  1879,  xiiv.  5S3. 


INFLAMMATION.  43 

inflammatory  exudation  is  found  to  contain  less  albumen  than  usual,  the 
existence  of  a  transudation  with  secondary  inflammation  is  suggested,  or 
the  exudation  may  have  taken  place  in  a  hydnemic  individual.  A  suf- 
ficient number  of  exceptions  are  met  with,  however,  to  interfere  with  the 
absolute  nature  of  this  test. 

The  coagulation  of  an  inflammatory  exudation  apparently  depends 
upon  the  contained  white  blood -corpuscles ;  the  more  numerous  (within 
certain  limits)  these  are  in  a  serous  exudation,  the  more  abundant  is  the 
formation  of  fibrin.  The  cellular  element  likewise  is  that  which  in  abun- 
dant liquid  exudations  characterizes  them  as  purulent.  Although  it  is 
generally  agreed  that  most  of  the  corpuscles  of  pus  are  emigrated  white 
blood-corpuscles,  it  is  not  necessary  to  admit  that  all  are  of  this  nature. 
The  cells  present  in  an  inflamed  part  include  those  pre-existing,  as  well  as 
those  which  escape  from  the  vessels.  The  former  are  the  wandering  cells 
of  the  connective  tissues,  as  well  as  the  fixed  variety,  the  epithelial  cells 
of  the  surface  of  a  mucous  membrane  in  addition  to  the  subjacent  con- 
nect ive-tissTie  cells.  Amoeboid  cells  outside  the  blood-vessels  have  been 
seen  to  divide,  and  it  is  possible  that  such  duplication  may  serve  as  the 
method  of  formation  of  a  certain  number  of  pus-corpiiscles.  The  state- 
ments concerning  the  proliferation  of  the  fixed  connective-tissue  cells  and 
of  epithelium  are  derived  from  appearances,  and  are  interpretations  of 
these  appearances,  not  observations  of  a*  process. 

The  changes  taking  place  along  the  walls  of  the  blood-vessels  being  the 
feature  of  prime  importance  in  the  observation  of  the  progress  of  an  in- 
flammation, numerous  investigators  have  directed  their  attention  to  the 
determination  of  the  nature  of  the  changes  in  the  vessel  wall  by  means  of 
which  the  escape  of  the  corpuscles  is  permitted.  Arnold  represents  the 
most  strenuous  advocates  of  the  stomata  theory,  according  to  which  the 
leucocytes  pass  through  canals  normally  existing  in  the  wall.  By  means 
of  the  silver  method  of  staining,  and  by  injections  of  various  insoluble  pig- 
ments into  the  blood-current,  certain  results  are  met  with,  which  give  color 
to  the  view  that  pores  and  canals  are  present  upon  and  in  the  walls  of  the 
vessels,  analogous  to  those  found  in  the  diaphragm.  As  the  latter  have 
been  shown  to  be  in  direct  communication  with  the  lymphatic  system  of 
tubes  and  spaces,  so  the  walls  of  the  blood-vessels  have  been  assumed  to 
present  similar  channels  of  communication. 

The  prevailing  views  at  the  present  time  are  in  favor  of  the  artificial 
nature  of  the  stomata  and  pores  in  the  walls  of  the  blood-vessels.  An  in- 
creased porosity  of  the  vascular  wall  in  inflammation  is  necessary  for  the 
occurrence  of  the  exudation,  but  such  porosity  is  regarded  rather  as  a 
physical  condition  permitting  an  observable  filtration,  and  a  filtration  of 
solids  as  well  as  liquids. 

In  this  connection  reference  should  be  made  to  the  observation  of 
AViniwarter,  who  has  demonstrated  that  colloid  material,  a  solution  of 
gelatin,  passes  through  the  vascular  wall  in  inflammation  more  readily 
— i.  e.  under  less  pressure — than  through  the  normal  wall  of  the  blood- 
vessel. 

The  causes  of  inflammation  are  to  be  regarded  as  those  which  produce 
an  increased  porosity  of  the  vessel  wall  without  causing  its  death,  for  no 
exudation  escapes  from  a  dead  vessel,  its  contents  becoming  clotted. 

These  causes  may  act  from  without  or  from  within,  primarily  affecting 


44  GENERAL  MORBID  PROCESSES. 

the  tissues  outside  the  vessels,  or  exerting  their  action,  at  the  outset,  upon 
the  wall  itself.  The  usual  histological  relation  of  vessels  and  surrounding 
tissues  is  such  that  both  arc  simultaneously  affected.  The  occurrence  of  an 
inflammation  in  non-vascular  parts,  however,  as  the  cornea,  from  irritation 
of  its  centre,  the  part  farthest  removed  from  the  surrounding  blood-vessels, 
shows  that  the  affection  of  the  vessels  may  be  indirect  as  well  as  direct. 
This  indirect  action  is  to  be  regarded  as  taking  place  through  the  agency 
of  nerves  or  through  that  of  the  nutritive  currents.  That  nervous  influ- 
ence alone  does  not  suffice  to  transmit  the  effect  of  an  applied  cause  is 
apparent  from  the  absence  of  inflammation  of  the  cornea  which  has  become 
anesthetized  by  section  of  the  trigeminus  nerve.  With  the  protection  of 
the  cornea  from  external  irritation  there  is  an  absence  of  inflammation. 

The  consideration  of  the  final  symptom  of  inflammation,  the  disturb- 
ance of  function,  which  has  been  added  in  recent  times,  belongs  to  special 
rather  than  general  pathology.  It  varies  according  to  the  seat  of  the 
inflammation,  the  disturbed  function  of  the  brain  or  heart  differing  from 
that  of  the  liver  or  kidney.  The  clinical  importance  of  this  symptom 
of  inflammation  is  greater  than  of  all  the  rest,  as  it  is  the  one  whose 
presence  is  constant  and  indispensable. 

An  inflammation  may  exist,  as  already  stated,  without  heat,  redness,  or 
pain.  The  swelling  may  escape  observation  from  the  limited  quantity  of 
the  exudation  and  other  causative  agents,  or  from  the  inaccessibility  of 
the  inflamed  part  to  physical  examination.  The  disturbance  of  function, 
however,  becomes  early  apparent,  and  is  present  throughout  the  course 
of  the  inflammation.  A  knowledge  of  its  nature  enables  the  seat  of  the 
latter  to  be  recognized,  and  its  variations  furnish  a  desired  test  of  the 
efficiency  of  therapeutic  agents. 

The  causes  of  inflammation  may  be  divided  into  the  traumatic,  toxic, 
parasitic,  infectious,  dyscrasic  or  constitutional,  and  trophic. 

The  traumatic  causes  are  those  which  act  mechanically,  producing  an 
injury  to  tissues  by  pressure,  crushing,  tearing,  stretching,  and  the  like. 
Others  represent  modifications  in  temperature,  thermic  agencies,  and 
include  extremes  of  cold  as  well  as  of  heat.  The  chemicals  whose 
action  is  direct,  as  caustic,  include  a  third  variety  of  the  traumatic 
causes.  Such  chemicals  are  applied  to  surfaces,  cutaneous  or  mucous, 
and  comprise  the  active  element  producing  the  perforating  ulcer  of  the 
stomach  and  duodenum,  as  well  as  such  substances  as  potash  or  sulphuric 
acid  which  may  have  been  swallowed  intentionally  or  accidentally. 

The  toxic  group  of  causes  is  closely  allied  to  the  chemical  variety  of 
the  traumatic  agencies.  It  includes  chemicals  whose  action  is  indirect, 
through  absorption  in  a  diluted  form  rather  than  from  direct  application 
in  a  concentrated  condition.  Such  chemicals  are  derived  from  without, 
as  arsenic,  phosphorus,  and  antimony;  or  may  be  formed  within  the 
body,  and  the  latter  include  the  chemical  products  of  putrefactive  changes 
— in  the  urine,  for  instance — and,  with  considerable  probability,  certain 
of  the  active  agents  of  blood-poisoning  in  septic  diseases.  It  is  not 
unlikely  that  some  of  the  inflammatory  affections  met  with  among  the 
so-called  constitutional  diseases,  as  rheumatism  and  gout,  may  owe  their 
origin  to  the  production  of  chemical  substances  within  the  body,  excessive 
in  quantity  if  not  changed  in  quality. 


INFLAMMATION.  45 

The  parasitic  causes  of  inflammation  are  both  animal  and  vegetable, 
and  act  upon  the  surfaces  of  the  body  or  within  its  deeply-seated  parts. 
Some  of  the  animal  parasites  act  locally  at  their  place  of  entrance,  while 
others  produce  but  slight  disturbances  in  this  region,  their  eifects  usually 
resulting  from  the  transfer  of  their  offspring  to  remote  parts  of  the  body. 
The  vegetable  parasites  are  for  the  most  part  the  various  fungi,  which 
act  locally  upon  the  skin  or  on  those  transitional  surfaces  lying  between 
skin  and  mucous  membrane.  The  resulting  parasitic  inflammations  are 
known  as  favus,  sycosis,  ringworm,  thrush,  etc.  The  border-line  between 
such  parasitic  diseases  and  those  included  among  the  infective  diseases  is 
somewhat  arbitrarily  drawn.  Parasites  in  the  limited  sense  act  chiefly  as 
foreign  bodies,  while  the  effect  of  minute  vegetable  organisms  is  rather 
that  of  ferments,  in  virtue  of  their  products.  Such  a  distinction  is  of 
relative  value  merely,  as  the  micrococci  and  bacteria  are  capable  of  acting 
in  other  ways  than  by  the  production  of  septic  material. 

The  infectious  causes  of  inflammation  are  for  the  most  part  parasitic  in 
their  nature,  although  the  discovery  and  identification  of  the  parasite  are 
in  most,  of  these  inflammations  assumed  rather  than  demonstrated.  The 
relation  of  the  anthrax  bacillus  to  malignant  pustule  no  longer  admits  of 
a  doubt,  mainly  in  consequence  of  the  researches  of  Koch.  This  investi- 
gator has  been  enabled  to  establish  a  definite  etiological  relation  between 
the  septicaemia  of  certain  animals  and  accompanying  minute  vegetable 
organisms.  His  recent  discovery  of  the  bacillus  of  tuberculosis  definitely 
removes  the  tubercular  process  from  the  group  of  dyscrasic  or  constitu- 
tional affections  to  that  of  the  infective  diseases.  The  constant  presence 
of  minute  organisms  in  relapsing  fever,  leprosy,  malaria,  typhoid  fever, 
diphtheria,  erysipelas,  and  numerous  other  affections  associated  with,  if 
not  characterized  by,  inflammatory  conditions,  renders  extremely  probable 
the  closest  pathological  relation  between  such  diseases  and  a  microscopic 
organism.  That  an  inflammatory  process  may  be  regarded  of  infectious 
origin,  it  is  necessary,  according  to  Koch,1  that  a  characteristic  organism 
should  be  found  in  all  cases  of  the  disease,  and  in  such  numbers  and  dis- 
tribution as  to  account  for  all  the  phenomena  of  the  disease  in  question. 

These  organisms  may  act  in  virtue  of  their  growth  and  the  consequent 
demand  for  oxygen,  as  seems  probable  in  certain  cases  of  malignant  pus- 
tule, where  the  affected  individual  dies  with  symptoms  of  asphyxia.  Their 
operation  may  also  be  like  that  of  ferments,  which  produce  chemical  ma- 
terial whose  effect  may  be  remote  from  the  immediate  presence  of  the 
minute  organism.  They  may  likewise,  in  connection  with  their  coloniza- 
tion in  various  parts  of  the  body,  act  more  immediately  upon  the  walls 
of  the  blood-vessels,  and  produce  that  increased  porosity  which  is  so  essen- 
tial a  factor  in  inflammation. 

The  discovery  of  the  immediate  cause  of  the  various  infective  diseases, 
as  measles,  scarlatina,  variola,  cholera,  dysentery,  mumps,  whooping 
cough,  cerebro-spinal  meningitis,  and  numerous  other  epidemic  and  en- 
demic affections,  still  remains  a  question  for  the  future.  The  constant 
association  of  microbia  with  any  or  all  of  such  diseases  is  but  one  fact  in 
connection  with  them,  and  such  a  discovery  is  to  be  regarded  merely  as 
a  step  forward,  to  be  followed  by  others,  each  of  which  represents  not 
only  an  advance,  but  confirms  the  position  attained. 

1  Untersuchunr/en  uber  die  Aetiologie  der  Wundinfectioiiskrankheilen,  1878,  27. 


46  GENERAL  MORBID  PROCESSES. 

The  dyscrasic  or  constitutional  causes  of  inflammation  are  those  which, 
though  long  established,  appear  less  demanded  as  our  knowlege  advances. 
Regarded  as  the  result  of  an  alteration  in  the  composition  of  the  blood,  it 
is  obvious  that  such  changes  may  arise  from  the  introduction,  from  with- 
out, of  wholly  foreign  material.  The  dyscrasia  may  also  represent  mod- 
ifications in  the  relative  proportion  of  the  normal  constituents  of  the 
blood.  In  the  former  series  are  included  what,  for  the  most  part,  have 
already  been  referred  to  under  the  toxic  and  infectious  causes  of  inflam- 
mation. The  dyscrasiae  from  lead,  alcohol,  and  the  like  belong  to  this 
series.  Still  more  -important  are  the  poisons,  the  virus  of  tuberculosis  and 
scrofula,  of  leprosy  and  syphilis.  The  dyscrasiae  known  as  anaemia,  leu- 
caemia, uraemia,  icterus,  and  diabetes  are  to  be  regarded  less  as  inflamma- 
tory causes  than  as  predisposing  conditions  which  favor  the  action  of  other 
groups  of  causes. 

The  trophic  causes  of  inflammation  are  those  whose  action  is  supposed 
to  take  place  through  the  influence  of  nerves.  Although,  as  has  already 
been  stated,  a  faulty  iunervation  of  tissues  is  an  important  element  in 
favoring  the  action  of  various  inflammatory  causes,  there  remain  certain 
forms  of  inflammation  where  the  disturbance  of  nervous  action  seems  to 
be  the  essential  feature.  The  occurrence  of  an  acute  peripheral  gangrene 
soon  after  certain  traumatic  or  inflammatory  lesions  of  the  brain  or  spinal 
cord,  of  articular  inflammation  following  chronic  affections  of  the  cerebro- 
spiual  axis,  are  instances  in  point.  The  origin  and  distribution  of  herpes 
zoster,  the  occurrence  of  sympathetic  ophthalmia  and  symmetrical  gangrene, 
suggest  a  predominant  disturbance  of  innervation  as  the  exciting  cause. 
At  the  same  time,  it  is  desirable  to  call  attention  to  the  recent  observations 
of  MacGillavray,  Leber,  and  others,1  which  suggest  that  a  sympathetic 
ophthalmia  is  due  to  the  extension  of  a  septic  choroiditis  along  the  lymph- 
spaces  of  the  optic  nerve.  It  is  further  apparent  that  in  certain  so-called 
trophic  inflammations,  as  the  pneumonia  after  section  of  the  pneumogastric, 
and  the  inflammation  of  the  eye  following  paralysis  of  the  trigeminus,  the 
paralysis  of  the  nerve  is  a  remote,  rather  than  an  immediate  cause,  of  the 
inflammation.  There  still  remain,  however,  a  number  of  localized  inflam- 
mations whose  origin  is  so  intimately  connected  writh  nervous  disturbances 
as  to  demand,  for  the  present  at  least,  a  corresponding  Classification. 

The  course  of  an  inflammation  is  often  indicated  by  the  predominance 
of  certain  symptoms,  which,  for  the  most  part,  indicate  a  condition  of  the 
individual  acted  upon  rather  than  a  peculiarity  of  the  cause.  The  sthenic 
inflammations  take  place  in  robust  individuals  with  powerful  hearts  and 
an  abundant  supply  of  blood.  In  such  persons  a  strong  pulse,  high  fever, 
and  an  injection  of  the  superficial  blood-vessels  suggested,  in  former  times, 
the  necessity  of  bloodletting  as  the  essential  therapeutic  agent.  The 
sthenic  form  of  inflammation  was  most  commonly  associated  with  pneu- 
monia, where  the  obstruction  to  the  passage  of  blood  through  the 
lungs  wras  an  important  cause  of  the  superficial  injection  of  the  blood- 
vessels. 

The  asthenic  inflammations,  on  the  contraiy,  are  those  occurring  in 
feeble  individuals,  debilitated  in  consequence  of  pre-existing  disease, 
exposure,  or  habits.  A  weak  heart,  low  febrile  temperature,  and  super- 

1  Wadsworth's  "  Report  of  Recent  Progress  in  Ophthalmology,"  Boston  Medical  and 
Surgical  Journal,  1882,  cvi.  517. 


INFLAMMATION.  47 

ficial  pallor,  characterize  tlje  asthenic  inflammations,  which  show  a  fre- 
quent tendency  to  become  localized  in  the  more  dependent  parts  of  the 
body,  the  force  of  the  circulation  being  too  feeble  to  overcome  the  effect 
of  gravitation. 

In  the  typhoidal  inflammations  are  associated  those  symptoms  which 
are  so  prominent  in  the  severe  varieties  of  typhoid  fever.  These  are  the 
predominant  symptoms  :  hebetude  or  low,  muttering  delirium,  picking  at 
the  bed-clothes,  involuntary  evacuations,  stertor,  and  the  like.  The  ner- 
vous disturbances  are  associated  with  a  feeble  pulse  and  a  dusky  hue  of 
the  skin. 

The  constituents  of  an  inflammatory  exudation  are  frequently  used  as 
a  basis  of  classification,  and  characterize  the  inflammation  from  the  ana- 
tomical point  of  view.  As  the  exudation  is  complex  in  its  composition, 
the  predominant  element  is  made  use  of  to  designate  the  variety,  and  in 
doubtful  cases  a  combined  adjective  indicates  the  presence  of  the  two  most 
abundant  constituents.  As  the  exudation  is  directly  derived  from  the 
blood  and  contains  serum  in  addition  to  white  and  red  corpuscles,  the 
serous,  purulent,  and  hemorrhagic  varieties  of  exudation  naturally  arise. 
The  fibrinous  and  diphtheritic  inflammations  relate  to  the  presence  of 
membranes  or  false  membranes.  Finally,  there  are  the  productive  inflam- 
mations, resulting  in  the  new  formation  of  tissue,  and  the  destructive 
inflammations,  where  losses  of  substance  occur. 

Serous  inflammations  are  most  frequent  in  those  parts  of  the  body 
where  the  structure  contains  the  largest  lymph-spaces.  The  so-called 
serous  cavities  of  the  body  offer  the  most  favorable  opportunities  for  the 
accumulation,  as  well  as  for  the  exudation,  of  the  inflammatory  product ; 
then  follow  the  regions  of  the  larger  lymph-spaces,  according  to  the  size 
and  number  of  the  latter. 

The  serous  inflammations  may  also  arise  from  the  epithelial  coverings 
of  the  body,  as  the  cutaneous,  alimentary,  and  respiratory  surfaces.  The 
serous  exudations  of  the  skin  are  those  present  in  vesicles,  blisters,  or 
bullse,  which  owe  their  limitation  to  the  resistance  offered  to  the  spreading 
of  the  liquid  inflammatory  product  by  the  coherent  epidermis.  Serous 
inflammations  of  the  alimentary  canal  may  assume  a  vesicular  character, 
although,  from  the  structure  of  its  mucous  membrane  and  the  macerating 
influence  of  its  contents,  the  vesicles  are  apt  to  be  of  an  extremely  tran- 
sitory character. 

The  more  important  serous  inflammations  of  the  intestines  are  those 
manifested  by  profuse  watery  evacuations,  the  extreme  form  of  which  is 
to  be  found  in  cholera. 

Serous  inflammation  of  the  lungs  accompanies  the  more  severe  forms, 
and  usually  represents  but  a  limited  and  circumscribed  affection,  asso- 
ciated with  .more  abundant  cellular  and  fibrinous  products. 

Serous  inflammations  of  the  peritoneum,  pleura,  pericardium,  tunica 
vaginalis,  and  central  ventricles  often  give  rise  to  the  presence  of  enor- 
mous quantities  of  fluid,  whose  partial  removal  from  many  of  the  cavities 
concerned  by  operative  measures  frequently  represents  a  most  beneficial 
result  of  treatment. 

The  smaller  lymph-spaces  of  the  connective  tissue  in  various  parts  of 
the  body  are  the  frequent  seat  of  the  inflammatory  oedema,  so  called, 
whose  presence  is  an  important  indication  of  the  direction  assumed  by  a 


48  GENERAL  MORBID  PROCESSES. 

spreading  inflammation,  as  well  as  a  suggestion  of  the  frequent  virulence 
of  its  cause. 

In  general,  the  serous  inflammations  are  to  be  regarded  as  less  severe 
than  other  varieties,  or  as  representing  an  early  stage  of  what  later  may 
be  otherwise  characterized  by  a  change  in  the  nature  of  the  products. 

The  purulent  variety  of  inflammation  is  present  when  the  exudation  is 
abundantly  cellular.  As  has  already  been  stated,  such  cells  are,  for  the 
most  part,  white  blood-corpuscles.  The  purulent  exudation,  like  the 
serous  variety,  may  appear  either  on  surfaces,  when  the  term  secretion  is 
applied,  or  within  the  lymph-spaces  of  the  connective  tissue  over  a  con- 
siderable space,  when  the  pus  is  said  to  be  infiltrated.  When  the  infil- 
tration is  more  circumscribed  and  the  walls  of  the  affected  lymph-spaces 
are  destroyed,  so  that  adjoining  cavities  are  thrown  into  larger  holes, 
an  abscess  is  present,  from  whose  wall  pus  is  constantly  derived,  while 
the  inflammation  is  progressive. 

The  attention  of  the  surgeon,  in  particular,  has  been  directed  to  the 
isolation  of  the  immediate  cause  of  suppurative  inflammation,  and  the 
modern,  antiseptic,  treatment  of  wounds  is  essentially  based  upon  the  view 
of  the  infectious  origin  of  pus.  The  frequent  presence  of  microbia  in 
purulent  exudation  where  no  precautions  are  taken  to  exclude  their 
admission,  and  their  frequent  absence  or  presence  in  minute  quantities 
where  such  precautions  are  taken,  have  suggested  that  through  their 
influence  an  inflammatory  exudation  is  likely,  if  not  actually  compelled, 
to  become  purulent. 

Whether  the  microbia  or  their  products  are  the  cause  of  most  suppura- 
tive inflammations  may  be  regarded  as  an  open  question.  It  is  generally 
admitted,  however,  that,  as  a  rule,  an  inflammation  becomes  purulent  in 
consequence  of  the  presence  of  an  infective  agent ;  in  other  words,  that 
most  pus  is  of  an  infectious  origin  and  possesses  infectious  attributes^ 
The  labors  of  Lister  in  insisting  upon  the  exclusion  of  all  possible  putre- 
factive agencies  in  the  treatment  of  wounds  have  met  with  universal 
approval,  and  the  basis  of  his  treatment  remains  fixed,  although  different 
methods  have  been  devised  for  its  enforcement.  His  researches,  and 
those  stimulated  by  his  work,  have  resulted  in  the  establishment  of  prin- 
ciples which  affect  the  whole  field  of  theoretical  as  well  as  practical 
medicine. 

Although  most  pus  may  be  considered  as  due  to  the  action  of  a  virus 
introduced  from  without,  and  capable  of  indefinite  progressive  increase 
within  the  body,  all  pus  is  not  to  be  regarded  as  of  infectious  origin. 
There  are  pyrogcuetic  agencies,  like  petroleum,  turpentine,  and  croton 
oil,  which,  introduced  into  the  body,  produce  suppurative  inflammation 
without  the  association  of  microbia. 

A  bland  pus  is  usually  in  a  state  of  beginning  putrescence,  so  that  it 
is  only  relatively  bland,  and  acquires  extreme  virulence  when  long 
exposed  to  putrefactive  agencies.  It  is  possible  that  those  agencies 
producing  an  ichorous  pus  are  the  same  or  different  from  those  present 
in  bland  pus.  The  iehorous  exudation  contains  less  corpuscles  than 
bland  pus,  is  more  fluid,  less  opaque,  strongly  alkaline,  of  a  greenish 
color,  and  of  offensive  odor. 

In  hemorrhagic  inflammation  the  exudation  contains  large  numbers  of 
red  blood-corpuscles.  The  occurrence  of  this  form  is  sometimes  associated 


INFLAMMATION.  49 

with  peculiarities  of  the  cause,  as  is  obvious  from  the  epidemics  of  hem- 
orrhagic  small-pox,  measles,  scarlatina,  and  cerebro-spiual  meningitis.  It 
is  also  associated  with  peculiarities  of  the  individual,  as  in  such  epidemics 
all  cases  are  not  equally  hemorrhagic,  and  in  scurvy  the  hemorrhages 
are  attributable  to  the  abnormal  conditions  to  which  the  sufferers  are 
exposed.  Hemorrhagic  exudations  are  also  met  with  in  those  inflamma- 
tions of  serous  surfaces  accompanying  the  outcropping  of  tubercular  and 
cancerous  or  sarcomatous  growths.  In  all  cases  a  hemorrhagic  exuda- 
tion represents  a  grave  complication,  and  when  found  in  serous  cavities 
has  a  certain  diagnostic,  as  well  as  prognostic,  importance. 

Fibrinous  inflammations  are  characterized  by  the  presence  in  the  exu- 
dation of  considerable  quantities  of  fibrin.  As  the  prevailing  theory  of 
the  formation  of  fibrin  demands  fibrino-plastic  as  well  as  fibrinogenous 
material,  both  are  to  be  sought  for  in  the  exudation.  The  latter  is  present 
in  the  liquid  portion  of  the  exudation ;  the  existence  of  the  former,  as 
well  as  that  of  the  ferment,  is  dependent  upon  the  presence  of  the  white 
blood-corpuscles.  The  more  numerous  these,  within  certain  limits,  the 
more  abundant  the  formation  of  fibrin.  As  their  death  appears  essential 
for  the  fibrinous  coagulation,  the  latter  is  most  constantly  met  with  in 
those  parts  of  the  body  where  the  white  blood-corpuscles  are  quickest 
separated  from  influences  favoring  their  life.  The  farther  removed  they 
are  from  the  blood-vessels,  the  more  likely  is  their  early  death.  Fibrinous 
exudations  are  therefore  frequent  and  abundant  in  cellular  and  serous 
(sero-cellular)  inflammation  of  the  great  serous  cavities  of  the  body. 
The  clotted  fibrin  appears  as  false  membrane  lying  upon  the  serous 
surface,  either  smooth  or  rough,  tripe-like,  or  as  villosities  projecting 
above  the  surface,  and  again  as  bands,  fibrinous  adhesions,  stretching 
across  the  cavity  and  uniting  opposed  surfaces. 

The  frequent  occurrence  of  fibrinous  exudations  on  the  mucous  mem- 
branes of  the  larynx  and  trachea,  accompanied  by  the  suffocative  symp- 
toms known  as  croup,  has  led  to  the  use  of  the  term  croupous  inflam- 
mation as  synonymous  with  fibrinous  inflammation,  and  it&  application 
to  various  parts  of  the  body  where  croupous — i.  e.  suffocative — symptoms 
are  not  in  question.  Croupous  inflammation,  when  used,  is  to  be 
considered  as  an  anatomical  term,  indicating  merely  the  production  of 
fibrin,  and,  for  the  avoidance  of  confusion,  it  is  preferable  to  substitute 
fibrinous  for  croupous  when  such  inflammations  are  described. 

The  disease,  croup,  it  is  well  known,  may  exist  without  a  croup- 
ous— that  is,  fibrinous — inflammation,  as  is  familiarly  recognized  in  the 
constant  use  of  the  terms  spasmodic,  membranous,  and  diphtheritic 
croup. 

Fibrinous  inflammation  of  the  mucous  membrane  of  the  larger  air- 
passages  is  much  more  frequently  met  with  than  that  of  mucous  mem- 
branes elsewhere,  as  of  the  intestines,  uterus,  and  bladder.  The  psnedo- 
membranous  inflammations  of  the  latter  tracts  are  more  commonly  the 
result  of  the  catarrhal  and  diphtheritic  varieties  than  of  the  fibrinous 
form.  Fibrinous  exudations  on  mucous  surfaces,  according  to  Weigert, 
can  only  take  place  when  the  epithelium  is  destroyed.  Hence  those 
causes  which  give  rise  to  the  destruction  or  detachment  of  the  epithelium 
are  alone  capable  of  producing  a  fibrinous  inflammation  of  mucous  mem- 
branes, and  a  fibrinous  laryngitis,  trachitis,  and  bronchitis  may  result  from 
VOL.  I.— 4 


50  GENERAL  MORBID  PROCESSES. 

the  local  application  of  such  irritants  as  steam  or  ammonia,  as  well  as 
occur  in  the  diseases  croup  and  diphtheria. 

Fibrinous  exudations  may  also  be  present  within  tissues,  especially  in 
those  whose  meshes  are  wide,  provided  the  essential  elements  of  coagula- 
tion are  present.  The  coagulative  necrosis  of  various  organs,  to  be  more 
fully  mentioned  hereafter,  is  closely  allied  to  fibrinous  clotting,  the 
fi  brine-plastic  element  being  derived  from  the  death  of  the  pareuchy- 
matous  cells  of  the  part. 

In  the  existence  of  a  fibrinous  pneumonia  the  conditions  are  somewhat 
analogous  to  those  present  in  the  fibrinous  inflammation  of  serous  surfaces 
and  of  the  areolar  connective  tissue.  There  is  present  an  abundantly 
cellular  exudation,  held  in  the  place  of  its  origin,  the  cells  undergoing 
rapid  death  and  surrounded  by  a  wall  whose  superficial  cells  resemble  in 
structure,  if  not  in  origin,  the  endothelial  cells  lining  the  smaller  lymph- 
spaces  of  connective  tissue,  as  well  as  the  larger  cavities  within  the  same, 
known  as  serous  cavities. 

The  diphtheritic  inflammation  is  no  more  to  be  confounded  with  the 
disease  diphtheria  than  is  the  fibrinous  inflammation  with  the  disease 
croup.  Although  diphtheria  owes  its  name  to  the  frequent  presence  of 
an  apparent  membrane,  it  may  be  said  that  the  latter  is  not  essential  to 
the  existence  of  the  former.  Diphtheria,  like  croup,  is  an  affection  in 
which  various  exudations  may  be  present,  and  the  anatomical  product 
alone  does  not  suffice  in  all  instances  for  the  recognition  of  the  disease. 
In  croup  there  may  be  a  swollen  mucous  membrane,  with  a  slight  super- 
ficial mucous  exudation,  or  a  more  abundant  exudation  of  desquamated 
epithelium  and  mucus,  as  well  as  a  fibrinous  false  membrane.  In  diph- 
theria the  same  varieties  of  exudation  may  occur,  and  in  addition  the 
diphtheritic  exudation  may  also  be  present.  The  latter,  however,  is  not 
limited  to  the  disease  diphtheria,  for  its  presence  is  apparent  in  other 
mucous  membranes  than  that  of  the  air-passages,  and  in  the  pharyngeal 
mucous  membrane  in  other  diseases  than  diphtheria.  A  diphtheritic 
conjunctivitis,  enteritis,  cystitis,  and  endometritis  are  recognized.  The 
cutaneous  surfaces  of  the  body  may  also  furnish  a  diphtheritic  exudation. 
The  diphtheritic  inflammations  of  wounds  and  of  variolous  eruptions  are 
instances  in  point. 

The  characteristics  of  a  diphtheritic  inflammation  are  the  presence 
within  the  tissues  of  a  clotted  exudation,  which  is  associated  with  a 
defined  swelling  and  death  of  the  part.  The  exudation  contains  not  only 
dead  leucocytes  and  interlacing  fibres,  but  is  also  provided  with  abundant 
granular  material,  much  of  which  presents  the  well-known  peculiarities 
of  microscopic  organisms.  The  apparent  false  membrane  is  thus  dead, 
infiltrated  tissue,  which  may  be  torn  away  from  the  continuous  unaffected 
tissue,  leaving  a  raw,  rough  surface,  but  not  peeled  from  a  comparatively 
smooth  surface,  as  in  other  forms  of  pseudo-membranous  inflammation. 

The  frequent  association  of  a  superficial  false  membrane,  corresponding 
in  area  with  that  of  the  deeper-seated  changes,  in  which  cells  and  fibres 
may  be  present,  is  to  be  recognized.  The  diphtheritic  process,  however, 
is  localized  within,  and  not  upon,  the  tissues  affected.  The  diphtheritic 
exudation  represents  a  local  death,  a  necrosis,  of  the  part  concerned,  and 
the  mult  has  frequently  been  compared  with  the  death  consequent  upon 
the  action  of  a  caustic.  » 


INFLAMMATION.  51 

The  immediate  cause  of  a  diphtheritic  inflammation  is  now  generally 
attributed  to  the  action  of  microbia  which  enter  the  tissue  from  without, 
and  in  their  growth  beneath  the  surface  produce  not  only  the  local,  but 
also  the  remote,  constitutional  disturbances  which  are  associated  with  a 
diphtheritic  inflammation.  The  investigations  of  Wood  and  Formad l 
point  to  ordinary  putrefactive  organisms  as  a  sufficient  cause  for  the 
diphtheritic  inflammation  of  diphtheria,  while  other  observers  demand  a 
specific  organism  as  the  exciting  cause.  The  occurrence  of  diphtheritic 
inflammations  in  various  parts  of  the  body,  in  regions,  as  the  intestine, 
where  putrefactive  processes  are  constantly  present,  and  in  the  bladder 
and  uterus,  where  the  phenomena  of  putrefaction  are  often  associated 
with  diphtheritic  inflammation,  suggest  the  efficacy  of  ordinary  putre- 
factive agencies  in  producing  the  latter.  As  all  microbia  found  in  putre- 
faction are  not  alike,  and  as  the  properties  of  certain,  differ  from  those  of 
others,  and  as  our  knowledge  of  the  effects  of  all  is  but  fragmentary,  the 
characteristics  of  specific  germs  for  a  diphtheritic  inflammation  of  one 
part  of  the  body,  or  of  all  parts  of  the  same,  must  still  be  regarded  as  not 
proven. 

Productive  inflammations  are  those  which  result  in  the  new  formation 
of  tissues.  One  of  the  frequent  products  of  inflammation  is  fibrous 
tissue,  which,  at  first  abundantly  cellular,  later  becomes  more  vascular, 
and  is  finally  transformed  into  a  tissue  whose  fibres  predominate  over 
its  cells.  This  formation  of  a  cicatricial  tissue  demands  further  recogni- 
tion when  the  termination  of  inflammation  is  considered. 

In  a  more  limited  sense  certain  inflammations  are  called  productive 
when  multiple  circumscribed  new  formations,  as  cancer,  sarcoma,  tubercle, 
and  the  like,  arise  in  connection  with  the  ordinary  products  of  inflam- 
mation. Such  new  formations  are  of  frequent  occurrence  in  serous  mem- 
branes, and  a  tuberculous  pericarditis  or  a  cancerous  peritonitis,  indicates 
that  a  growth  of  tubercles  or  cancerous  nodules  has  taken  place,  in  addition 
to  a  more  or  less  abundant  exudation  with  various  proportions  of  serum 
fibrin  and  cells.  This  association  of  ordinary  and  transitory  inflammatory 
products  with  the  formation  of  more  permanent  tissues  may  be  found 
within  organs  as  well  as  upon  surfaces.  A  tubercular  arachnitis  or  lepto- 
meniugitis  presents  the  various  products  of  an  inflammation  of  the  pia  mater 
with  an  abundant  formation  of  tubercles.  In  like  manner,  a  tubercular 
pneumonia,  or  a  tubercular  nephritis  suggests  an  association  of  neoplastic 
growth  and  inflammation,  in  the  lung  and  kidney.  Such  a  relation  offers 
a  basis  for  the  theory  in  favor  of  the  inflammatory  origin  of  tumors,  and 
is,  in  part  at  least,  a  cause  for  the  frequent  consideration  of  tubercles  as 
mere  inflammatory  products,  wholly  cellular  or  cellular  and  fibrous, 
subject  to  the  same  modifications  as  take  place  during  the  course  of 
ordinary  inflammations. 

Even  if  tuberculous  and  scrofulous  inflammations  are  regarded  as 
inflammatory  processes,  modified  by  a  specific  cause  and  by  peculiarities 
of  the  individual,  the  cancerous  and  sarcomatous  inflammations  are  still 
to  be  considered  as  representing  an  association  of  inflammatory  disturb- 
ances and  specific  new  formations,  the  cause  of  the  latter  not  being  the 
cause  of  the  former.  As  ordinary  inflammations  of  the  regions  con- 
cerned may  take  place  in  the  absence  of  the  neoplasms,  so  may  the 
1  Research  on  Diphtheria  for  the  National  Hoard  of  Health,  1880,  Supplement  No.  7. 


52  GENERAL  MORBID  "PROCESSES. 

specific  growth  appear  in  the  same  regions  without  anatomical  or  clinical 
evidence  of  inflammation. 

The  classification  of  inflammation  as  to  its  products  is  supplemented 
by  distinctions  drawn  with  reference  to  the  scat.  The  exudations  may 
be  superficial  or  deep-seated  ;  they  may  lie  within  the  cells,  parenchyma, 
of  an  organ,  or  within  the  interstitial  tissue  of  the  same. 

The  product  of  superficial  inflammations  may  lie  on  the  surface,  as  in 
the  case  of  inflamed  mucous  membranes,  or  immediately  below  the  surface, 
as  in  numerous  cutaneous  inflammations,  of  which  erysipelas  may  serve 
as  the  type.  The  term  catarrhal,  applied  to  superficial  inflammations, 
carries  with  it  the  idea  of  displacement,  flowing,  of  the  exudation.  The 
product  of  a  catarrhal  inflammation  must  be  largely  liquid,  that  such  a 
displacement  may  readily  take  place,  and  the  catarrhal  exudation  is  chiefly 
composed  of  an  excess  of  those  elements  which  are  present  in  the  normal, 
physiological  secretion  from  the  membrane  concerned.  Mucus  therefore 
represents  a  frequent  constituent  of  the  catarrhal  exudation,  and  mucous 
as  well  as  muco-purulent  catarrhs  of  the  gastro-intestiual,  bronchial, 
genito-urinary,  and  other  mucous  membranes  are  recognized.  The 
catarrhal  inflammation  of  the  respective  membranes  usually  represents 
the  mildest  form,  as  it  demands  an  intact  epithelium,  and  a  ready  removal 
of  the  inflammatory  product. 

As  the  cause  of  a  catarrhal  inflammation  may  occasion  a  destruction 
of  the  epithelium  or  a  necrosis  of  the  mucous  membrane,  the  frequent 
association  of  catarrhal  with  fibrinous  or  diphtheritic  inflammations  is 
obvious.  In  such  cases  the  clinical  importance  of  the  latter  varieties 
gives  them  the  precedence  in  the  designation  of  the  inflammation.  The 
retention  of  the  catarrhal  products  is  the  frequent  cause  of  permanent  dis- 
turbances of  a  more  or  less  serious  nature.  These  result  in  part  from 
the  mechanical  obstruction  oifered  to  the  function  of  parts  beyond  the 
seat  of  obstruction,  as  pulmonary  atelectasis;  and  in  part  from  the  changes 
taking  place  in  the  retained  product.  Purulent  otitis  media  writh  its 
dangerous  or  fatal  results,  and  gangrene  of  the  lung  terminating  in  septic 
pleurisy,  are  not  infrequent  instances  of  severe  disturbances  from  putre- 
faction of  the  retained  products  of  a  primarily  catarrhal  inflammation.  A 
cheesy  degeneration  of  the  catarrhal  cells  leads  to  a  surrounding  fibrous, 
or  destructive,  inflammation,  with  a  corresponding  diminution  in  the 
function  of  the  organ  affected. 

Of  the  deep-seated  varieties  of  inflammation,  that  requiring  special 
mention  is  the  phlegmonous  form.  This  runs  its  course  within  the  less 
dense  fibrous  tissue  known  as  the  areolar  or  cellular  tissue.  The  term 
cellulitis  is  usually  employed  by  English  writers  to  indicate  the  seat  and 
nature  of  the  process,  and  although  the  use  of  the  term  cellular  tissue 
is  rapidly  becoming  obsolete,  the  convenience  of  cellulitis  favors  the  reten- 
tion of  the  latter  name. 

The  exudation  lies  within  the  larger  lymph-spaces,  and  is  therefore 
sometimes  designated  as  the  result  of  a  lymphangitis,  the  deep-seated, 
wider  lymph-spaces  being  concerned  rather  than  those  more  superficial. 
Certain  forms  of  phlegmonous  inflammation  are  of  decidedly  infectious 
origin,  and,  when  seated  subcutaneously,  are  known  as  phlegmonous 
erysipelas,  being  thus  distinguished  from  the  simple  erysipelas,  whose 
seat  is  denned  by  the  small  superficial  lymph-spaces  of  the  skin. 


INFLAMMATION.  53 

Infective  forms  of  cellulitis  are  also  frequently  met  with  in  the  loose, 
sub-peritoneal  tissue  of  the  pelvis.  The  infectious  element  usually  pro- 
ceeds from  the  uterus,  and  excites  the  malignant  oedema  of  the  broad 
ligament,  the  septic  parametritis,  or  the  pelvic  cellulitis,  according  as  the 
lymph-spaces  inflamed  lie  nearer  the  fundus  or  cervix,  and  as  the  direction 
of  the  current  is  upward  toward  the  spine,  or  outward  toward  the  sub- 
peritoneal  lymphatics  of  the  pelvic  wall. 

Parenchymatous  inflammation  is  present  when  the  exudation  is  taken 
into  the  cells  of  an  organ,  or  when  the  changes  dependent  upon  inflam- 
mation of  an  organ  take  place  within  its  functionally  important  cells. 
Virchow  originally  used  the  term  pareuchymatous  inflammation  in  con- 
tradistinction to  secretory  inflammation,  the  changes  in  the  former  occur- 
ring within  the  elements  of  the  tissues,  while  in  the  latter  the  exudation 
made  its  appearance  on  the  surface  of  the  organ. 

Parenchymatous  inflammation  is  manifested  by  a  degeneration  of  the 
cells  affected.  This  may  terminate  in  their  destruction  through  the  con- 
version of  their  protoplasm  into  fat-drops,  fatty  degeneration ;  although 
more  frequently  a  simple  accumulation  of  albuminoid  granules  (granular 
degeneration)  occurs.  The  latter  represents  a  transitory  condition,  from 
which  a  return  to  the  normal  state  readily  takes  place.  This  form  of 
inflammation  is  met  with  in  those  organs  which  present  a  sharply-defined 
contrast  between  the  functionally  important  cells  and  the  connective  tissue 
which  surrounds  them.  The  liver,  kidneys,  heart,  spleen,  pancreas,  and 
glands  in  general,  are  consequently  the  most  frequent  seat  of  pareuchy- 
matous inflammation. 

Opposed  to  this  variety  is  the  interstitial  inflammation.  The  exuda- 
tion of  the  latter  remains  within  the  connective-tissue  framework  of  the 
organ.  It  is  essentially  cellular  in  character,  and  the  number  of  cells  is 
comparatively  small.  With  their  presence  and  the  possibility  of  their 
nutrition  a  permanent  increase  in  the  quantity  of  the  fibrous  tissue  of  the 
organ  is  permitted.  This  becomes  relatively  greater  in  the  course  of 
time,  and  the  parenchymatous  cells  become  degenerated  and  absorbed. 
Interstitial  inflammations  are  likely  to  become  chronic  in  character,  and, 
from  the  outset,  are  usually  associated  with  parenchymatous  changes. 

An  important  clinical  distinction  is  drawn  with  reference  to  the  dura- 
tion of  an  inflammation.  Acute  inflammations  are  those  whose  course  is 
rapid,  whose  progress  is  associated  with  graver  disturbances  of  function, 
and  with  a  greater  prominence  of  the  cardinal  symptoms.  The  chronic 
forms  occupy  more  time  in  their  progress,  the  functional  disturbances, 
though  severe,  are  injurious  more  from  their  protracted  persistence,  than 
their  temporary  violence,  while  redness,  swelling,  heat,  and  pain  are 
symptoms  of  trifling  prominence. 

The  exudation  in  acute  inflammation,  if  recovery  takes  place,  is  rap- 
idly removed  from  the  place  of  its  origin,  Avhile  in  the  chronic  variety 
it  tends  to  become  a  part  of  the  region  in  which  it  lies,  or,  if  removed, 
slowly  disappears,  and  may  be  constantly  replaced.  Acute  inflamma- 
tions may  become  chronic,  and  the  chronic  variety  is  liable  to  acute 
exacerbations. 

The  distinction  between  acute  and  chronic  inflammations  is  essentially 
one  of  convenience,  and,  when  considered  from  the  anatomical  point  of 
view,  relates  rather  to  the  persistence  of  the  results.  These  may  be  pres- 


54  GENERAL  MORBID  PROCESSES. 

ent  as  a  variously  modified  exudation  or  as  a  degenerated  condition  of  the 
parenchyma  of  the  organ  or  tissue  affected. 

Inflammation  terminates  in  resolution,  production,  or  destruction. 

For  resolution  to  occur  it  is  necessary  that  the  causes  of  inflammation 
cease  to  act,  either  by  their  removal  or  their  isolation,  and  that  their  re- 
sults be  removed.  With  the  removal  of  the  results  there  is  often  asso- 
ciated the  removal  of  the  cause.  That  such  may  take  place  it  is  necessary 
that  the  function  of  the  vessel  walls  be  so  restored  that  the  exudation  ceases 
to  escape.  Inflammatory  products  already  outside  the  vessels,  if  present 
on  surfaces  with  external  outlets,  are  carried  along  in  the  course  of  the 
excretions.  If  they  lie  within  the  cavities  of  the  body  not  opening  ex- 
ternally, their  removal  is  accomplished  through  the  medium  of  the  circu- 
lating lymph  and  blood,  by  absorption.  The  liquid  portion  of  the  exuda- 
tion becomes  a  part  of  the  circulating  fluids  of  the  body.  The  fibrin  is 
converted  into  a  granular  detritus,  which  eventually  disappears  from  the 
place  of  its  formation.  The  leucocytes  may  return  to  the  blood-vessels 
or  enter  the  lymphatics ;  the  latter  course  probably  being  the  one  taken  by 
the  larger  number  of  the  corpuscles.  Many  undergo  a  fatty  degeneration, 
and  as  they  lie  in  lymph-spaces  their  conversion  into  an  emulsion  permits 
a  removal  of  the  mechanical  obstruction  to  the  flow  of  lymph  through  the 
spaces  in  which  they  were  accumulated.  The  red  blood-corpuscles  are 
destroyed,  their  pigment  being  dissolved  by  the  surrounding  fluid  and 
removed  in  the  course  of  the  circulation  and  excretions,  or  it  becomes 
transformed  into  granules  or  crystals,  which  may  remain  in  the  place  of 
their  formation,  or  be  transferred,  within  amoeboid  cells,  to  remote  parts 
of  the  body. 

When  the  exudation  is  abundant,  as  in  the  great  lymph-sacs  of  the 
body — the  several  serous  cavities — and  especially  when  the  openings  in 
the  walls  of  these  sacs  are  obstructed  or  the  currents  within  them  are 
feeble,  absorption  takes  place  with  great  difficulty,  and  demands  a  long 
interval  of  time.  The  fibrinous  and  cellular  portion  of  such  an  exudation 
frequently  becomes  converted  into  a  caseous  mass,  from  a  partial  fatty  de- 
generation and  inspissatiou.  This  mass  becomes  isolated  from  the  cavity 
in  which  it  lies,  usually  at  the  most  dependent  portion,  by  the  formation 
of  a  capsule  of  connective  tissue.  It  may  subsequently  become  infiltrated 
with  lime  salts,  calcified,  and  thus  remain  comparatively  inert  throughout 
the  life  of  the  individual. 

The  productive  termination  of  inflammation  is  manifested  by  the  new 
formation  of  connective  tissue.  This  tissue  is  variously  designated,  as 
the  inflammatory  process  is  limited  to  the  surfaces  of  the  body  exposed  to 
the  air,  or  the  surfaces  of  cavities  and  organs,  or  as  it  lies  within  organs 
or  the  deep-seated  parts  of  the  body.  In  numerous  instances  it  becomes 
a  permanent  constituent  of  the  body,  and,  as  time  is  usually  essential  for 
its  formation,  its  occurrence  is  indicative  of  a  chronic,  rather  than  an  acute 
inflammation.  Certain  chronic  inflammations  are  progressive  in  charac- 
ter, the  production  of  connective  tissue  being  continuous,  with  perhaps 
occasional  intermissions,  as  in  the  chronic  interstitial  inflammations  of 
organs  and  tissues.  The  new-formed  tissue,  which  at  the  outset  is  rich  in 
cells,  becomes  in  time  more  fibrous,  and  associated  with  this  change  in 
structure  is  a  physical  modification,  manifested  by  its  shrinkage.  This 
new  formation  may  fill  a  gap  resulting  from  the  destruction  of  tissue  in 


INFLAMMATION.  55 

the  progress  of  an  inflammation,  when  it  is  present  as  cicatricial  tissue — 
the  scar  which  is  usually  met  with  upon  the  surfaces  of  the  body  or  of 
certain  of  its  organs.  When  opposed  surfaces  are  united  by  the  new- 
formed  tissue,  the  term  adhesion  is  applied ;  the  adhesions  being  pres- 
ent as  fibrous  bauds,  cords,  or  membranes.  The  pericardial  milk-spots 
and  thickenings,  the  tendinous  or  semi-cartilaginous,  indurated  patches 
of  serous  membranes  and  of  the  intirna  of  arteries,  are  all  regarded  as 
manifestations  of  a  chronic  inflammation  of  these  tissues.  With  the  local- 
ization of  the  inflammation  in  the  outer  walls  of  the  bronchi  and  blood- 
vessels a  thickening  of  the  external  sheath  results,  called  a  peri-bronchitis, 
arteritis,  or  phlebitis,  as  the  case  may  be. 

The  new  formation  of  blood-vessels  is  essential  for  the  production  and 
preservation  of  this  connective  tissue,  and  both  arise  from  pre-existing 
tissues.  Pus-corpuscles  represent  the  simple  cellular  product  of  an  in- 
flammation, and  their  existence  is  but  transitory.  With  the  new  forma- 
tion of  blood-vessels  imbedded  in  abundant  cells  there  exists  a  granulation- 
tissue,  likewise  transitory,  but  out  of  which  arises  the  permanent  fibrous 
tissue.  The  question  is  still  mooted  as  to  the  part  played  by  exuded 
white  blood-corpuscles  in  the  production  of  the  permanent  results  of 
inflammation.  It  is  generally  conceded,  especially  since  the  observations 
of  Ziegler,  that  they  are  capable  of  transformation  into  lasting  constituents 
of  tissue,  into  blood-vessels  as  well  as  into  cells  and  fibres.  Whether  all 
the  resulting  permanent  products  of  inflammation  are  dependent  upon 
their  activity,  or  whether  the  pre-existing  fixed  elements  participate,  is 
still  to  be  considered  undecided. 

What,  at  present,  appears  most  probable  is,  that  from  exuded  leucocytes 
there  arise,  in  the  course  of  several  days,  larger  cells — epithelioid  or  endo- 
thelioid — which  are  eventually  associated  with  still  larger  cells,  more 
irregular  in  shape,  and  provided  with  projecting  filaments,  giant-cells. 
Both  varieties  may  result  from  the  enlargement  of  leucocytes  by  fusion 
or  by  the  assimilation  of  nutriment.  The  epithelioid  cells  eventually 
become  fusiform  or  stellate,  and  their  projections,  as  well  as  those  of  many 
of  the  giant-cells,  become  fibrillated.  The  fibrils  of  adjoining  cells,  be- 
coming united,  are  thus  transformed  into  a  mesh  work  of  fibrous  bundles 
enclosing  irregular  spaces,  while  the  nuclei  of  the  cells,  with  the  imme- 
diately surrounding  protoplasm,  remain  upon  these  bundles  as  the  per- 
manent cells  of  the  new-formed  tissue.  The  blood-vessels  arise  from  pre- 
existing vessels,  chiefly  capillaries,  and  probably  are  also  formed  from  the 
cells  present  in  the  exudation.  The  former  method  is  indicated  by  the 
projection  of  solid  sprouts  from  the  wall  of  a  capillary,  which  may  unite, 
forming  arches,  and  communicate  with  sprouts  from  neighboring  capil- 
laries, thus  forming  bridges.  Both  arches  and  bridges  then  become  hol- 
lowed and  admit  the  circulating  blood.  Ziegler  maintains  that  the  pro- 
jections of  the  larger  epithelioid  cells  and  giant-cells  become  elongated, 
and  eventually  fused  with  capillaries,  or  the  projections  from  capillaries. 
When  this  fusion  is  accomplished  the  cells  become  hollowed,  their  cavities 
communicating  with  those  of  the  blood-vessels.  These  epithelioid  cells, 
whose  formation  and  transformation  are  of  such  importance  in  the  history 
of  productive  inflammation,  are  designated  by  Ziegler  as  formative  cells, 
and  are  frequently  derived  from  the  exuded  white  blood-corpuscles,  though 
not  identical  with  them. 


56  GENERAL  MORBID  PROCESSES. 

The  inflammations  not  terminating  in  resolution  or  production,  end  in 
the  destruction  of  the  part.  This  result  occurs  when  the  nutrition  of  the 
inflamed  territory  is  so  diminished,  by  the  changes  in  and  around  the 
vessels,  as  to  become  insufficient  for  its  preservation.  As  the  nutriment 
is  derived  through  the  blood-vessels,  the  more  complete  and  the  more 
permanent  the  stagnation  in  them  the  more  likely  is  death  to  result. 
This  event  also  depends  upon  the  quantity  and  quality  of  the  exudation. 
The  more  abundantly  cellular  the  latter,  the  more  likely  is  an  abscess  or 
ulcer  to  result. 

As  most  abundantly  cellular  exudations  are  considered  to  be  dependent 
upon  the  presence  of  putrefactive  agencies,  those  inflammations  of  a  pre- 
dominant putrid  character  (gangrenous  inflammations)  are  those  termi- 
nating in  destruction.  The  dead  product  is  present  as  a  slough  or  seques- 
trum, when  dead  soft  or  hard  tissues  are  detached,  entire  or  in  part,  from 
the  living ;  or  as  a  granular  detritus  contained  in  a  more  or  less  abundant 
liquid.  The  inflammatory  process  producing  the  slough  and  sequestrum 
is  characterized  as  a  gangrenous  inflammation  of  soft  parts  or  a  caries  of 
bone,  while  the  process  resulting  in  the  formation  of  the  granular  detritus, 
and  which  has  no  necessary  connection  with  putrefactive  agencies,  is  called 
a  softening,  from  the  physical  condition  of  its  result. 


Thrombosis  and  Embolism. 

A  blood-clot  formed  within  a  blood-vessel  during  life  is  called  a 
thrombus.  The  entire  process  of  which  the  thrombus  is  the  essential 
element  is  designated  thrombosis. 

These  terms  were  introduced  by  "Virchow1  to  avoid  the  confusion  which 
resulted  from  regarding  the  process  and  result  as  synonymous  with  in- 
flammation of  the  vessel.  All  writers,  even  at  present,  do  not  adhere  to 
this  strictness  of  meaning.  For  a  thrombus  of  the  vulva  indicates  a  clot 
of  extravasated  blood  within  the  connective  tissue  of  the  labium ;  in  like 
manner,  a  vaginal  thrombus  is  the  effused  and  clotted  blood  in  the  loose 
connective  tissue  surrounding  the  vagina.  These  exceptions  are  gradually 
disappearing,  and  the  word  hsematoma,  tumor  composed  of  clotted  blood, 
is  being  substituted  in  both  instances.  A  cancerous  thrombus  represents 
a  mass  of  cancerous  tissue  whose  growth  is  extended  along  the  course  of 
a  vessel,  its  wall  having  been  penetrated.  In  general,  however,  the  term 
thrombus,  unless  otherwise  qualified,  is  used  as  first  stated. 

Although  thrombosis  is  commonly  a  morbid  process,  it  is  not  uni- 
formly so.  Its  physiological  significance  is  illustrated  by  the  part  it 
takes  in  the  closure  of  the  umbilical  and  uterine  vessels,  after  childbirth. 
The  surgeon  makes  use  of  it  in  his  efforts  to  overcome  certain  of  the  ill 
effects  of  amputation,  and  to  accomplish  a  cure  of  such  local  diseases  as 
aneurism,  where  it  is  deemed  important  to  diminish  the  supply  of  blood. 

The  thrombus  being  a  blood-clot,  it  is  composed,  like  the  latter,  of 
fibrin  and  blood-corpuscles.  It  is  presumable  that  the  fibrinous  part  of  a 
thrombus  owes  its  origin  to  the  same  conditions  which  determine  the 
presence  of  fibrin  in  blood  removed  from  the  vessels  during  life  or  in  that 
within  the  vessels  after  death. 

1  Handbuch  der  Sptciellen  Pathologic  und  Tkerapie,  Erlangen,  1854,  i.  159. 


THROMBOSIS  AND  EMBOLISM.  57 

According  to  A.  Schmidt,1  the  blood  and  other  fluids,  in  which  clotted 
fibrin  makes  its  appearance,  contain  two  generators,  called  fibrino-plastic 
and  fibrinogenous.  The  former  is  considered  to  be  paraglobulin,  a  sub- 
stance contained  mainly  in  the  white  blood-corpuscles,  while  the  fibrinog- 
enous  generator  is  held  in  solution  in  the  plasma  of  the  blood.  When 
these  materials  are  acted  upon  by  a  third,  the  fibrin  ferment,  clotting 
takes  place  and  fibrin  is  formed.  It  is  thought  that  the  ferment  is  inti- 
mately connected  with  the  white  blood-corpuscles,  for  with  the  microscope 
coagulation  is  seen  to  advance  as  these  become  destroyed,  and  where  the 
leucocytes  are  most  abundant,  there  coagulation  advances  most  rapidly. 
The  elements  of  clotted  fibrin  are  always  present  in  circulating  blood, 
but  Briicke  has  shown  that  blood  remains  fluid,  under  ordinary  circum- 
stances, because  of  its  constant  contact  with  the  normal  vascular  wall. 

The  general  causes  of  thrombosis  are  those  which  produce  an  abnormal 
condition  of  the  endothelium,  a  rapid  destruction  of  the  white  blood- 
corpuscles,  or  a  stagnation  of  the  blood.  With  the  presence  of  one  of 
these  causes  there  is  often  conjoined  another,  and  the  conditions  under 
which  they  are  present  are  conveniently  used  in  the  classification  of 
thrombi. 

Although  stagnation  of  the  blood  is  often  an  important  immediate 
cause  of  its  coagulation,  it  is  apparent,  from  the  investigations  of  Duraute2 
and  others,  that  stagnant  blood  clots  in  the  living  vessels  only  Avhen  their 
eudothelium  is  in  an  abnormal  condition.  With  the  co-existence  of 
abnormal  endothelium  and  stagnant  blood,  thrombi  form  with  greater 
frequency  and  become  more,  voluminous  in  a  given  interval  of  time. 

The  importance  of  the  death  of  white  blood-corpuscles  in  the  formation 
of  thrombi  is  generally  admitted,  and  is  especially  insisted  upon  by 
Weigert.  According  to  the  observations  of  Zahn,  the  nucleus  of  certain 
thrombi  is  the  result  of  the  death  of  these  leucocytes  and  their  accumu- 
lation upon  an  altered  intima.  The  experiments  of  Naunyn,  Kohlcr,  and 
others  show  that  a  thrombus  may  be  rapidly  produced  by  the  injection 
into  the  blood  of  fibriuo-plastic  substances,  and  of  those  through  which 
free  haemoglobin  is  admitted  into  the  circulation.  The  former  may  be 
expressed  from  a  fresh  blood-clot;  the  latter  may  be  obtained  by  thawing 
frozen  blood,  or  by  injecting  such  material  (bile-acids,  for  instance)  into  the 
circulating  blood  as  rapidly  destroys  the  red  blood-corpuscles.  Although 
Weigert  lays  special  stress  upon  the  destruction  of  white  blood-corpuscles 
in  the  formation  of  the  thrombus,  it  appears,  from  the  experiments  above 
referred  to,  that  indirectly  the  destruction  of  the  red  corpuscles  is  also  of 
importance. 

Although  largely  made  up  of  fibrin,  a  thrombus  also  contains  blood- 
corpuscles,  both  red  and  white,  and  the  appearance  of  the  mass  is 
modified  according  to  the  variations  in  the  relative  proportions  of  these 
constituents. 

Zahn3  divides  thrombi,  according  to  their  color,  into  red,  white  or 
colorless,  and  mixed  varieties.  The  red  owes  its  color  to  a  large  number 
of  red  blood-corpuscles,  while  the  white  and  mixed  forms  contain  various 
proportions  of  white  blood-corpuscles  and  fibrin  and  a  diminished  number 

1  Rollett,  Hermann's  ITanrfbuch  der  Physiologic,  Leipzig,  1880,  iv.  1,  114. 

2  Wiener  Medizinische  Jahrbuclier,  1871,  321. 
5  Virchow's  Archiv,  1875,  Ixxii.  85. 


58  GENERAL  MORBID  PROCESSES. 

of  red  corpuscles.  The  cause  of  this  difference  in  the  color  of  thrombi  is 
to  be  sought  for  in  their  method  of  origin.  When  blood  clots  slowly  in 
a  dish,  the  heavier  red  corpuscles  settle  to  the  bottom,  and  the  lighter 
white  corpuscles  form  a  superficial  layer.  Stagnant  blood  clotting  rapidly 
furnishes  a  uniformly  red  mass.  The  red  thrombus,  like  the  red  clot,  is 
the  result  of  the  rapid  coagulation  of  stagnant  blood.  The  white 
thrombus,  on  the  contrary,  largely  composed  of  white  blood-corpuscles, 
reprasents  a  constantly  increasing  deposition  of  these  from  flowing  blood. 
The  mixed  thrombi  arise  from  a  combination  of  both  conditions,  and  are 
usually  white  at  the  outset.  Thrombi  formed  in  the  heart  and  larger 
arteries  are  usually  white,  those  in  the  auricular  appendages  and  on 
venous  valves  are  mixed,  while  red  thrombi  are  more  common  in 
arteries  and  veins,  since  the  conditions  favoring  their  origin  are  more 
frequently  met  in  such  vessels. 

Thrombi  are  frequently  stratified,  in  consequence  of  the  successive 
deposition  of  new  layers  of  blood-corpuscles  and  fibrin  upon  a  pre-existing 
thrombus.  Circulating  blood  is  therefore  necessary  for  the  stratification, 
and  such  thrombi  are  likely  to  be  mixed  in  color.  Unstratified  thrombi 
are  usually  white  or  red,  the  former  largely  composed  of  agglomerated 
white  blood-corpuscles  so  moulded  and  situated  as  to  prevent  a  stagnation 
of  blood  in  their  vicinity,  while  the  red  thrombus  is  rarely  stratified,  since 
its  formation  demands  a  stoppage  of  the  blood-current.  Stratification  is 
intimately  connected  with  the  enlargement  or  growth  of  the  thrombus, 
which  takes  place  from  the  surface  exposed  to  the  flowing  blood,  and 
which  is  greater  or  less  according  to  the  seat  of  the  thrombus. 

Thrombi  are  usually  divided  into  those  from  compression,  dilatation, 
traumatism,  and  marasmus ;  in  all  of  which  groups  an  abnormal  condition 
of  the  eudothelium  is  to  be  met  with. 

Thrombi  from  compression  are  frequently  formed  in  veins,  in  the 
vicinity  of  growing  tumors.  Their  presence  is  most  constant  when  the 
vein  is  compressed  between  a  resistant  surface,  especially  bone,  and  the 
tumor.  A  compression  of  the  smaller  blood-vessels  within  an  organ,  as 
the  liver  or  kidney,  may  take  place  in  consequence  of  chronic  interstitial 
inflammation,  or  the  growth  of  cancerous  or  other  malignant  tumors  in 
such  organs.  The  production  of  this  form  of  thrombus  is  sought  for  in 
the  treatment  of  certain  aneurisms  by  direct  pressure,  the  resulting 
stagnation  of  blood  being  followed  by  a  coagulation  within  the  aneuris- 
mal  sac. 

Thrombi  from  dilatation  are  met  with  both  in  dilated  arteries  and  veins. 
In  aneurism  and  varix  a  slowing  of  the  blood-current  is  present,  and  the 
intima  of  the  diseased  region  is  frequently  in  such  an  abnormal  condition 
that  a  slotting  of  the  blood  readily  takes  place.  The  shape  and  situation 
of  the  dilatation  are  of  importance  in  promoting  the  formation  of  the 
thrombus ;  the  more  pedunculate  and  the  more  voluminous  the  sac  the 
more  certain  is  the  thrombosis. 

Traumatic  thrombi  result  from  a  direct  injury  to  the  vessel.  This  may 
be  mechanical,  as  in  the  application  of  ligatures  for  the  obliteration  of 
vessels,  the  tearing  of  the  veins  during  childbirth,  and  the  infliction  of 
wounds  of  every  variety.  The  injury  may  likewise  be  chemical,  from 
the  action  of  caustics ;  somewhat  analogous  to  which,  are  the  effects  of 
heat  and  cold.  Allied  to  the  traumatic  thrombi  are  those  which  arise 


THROMBOSIS  AND  EMBOLISM.  59 

from  acute  inflammation  of  the  intima  extending  from  wounds  or  inflam- 
matory processes  in  the  vicinity  of  blood-vessels. 

Marantic  thrombi  are  those  whose  origin  is  attributable  to  that 
enfeebled  condition  of  the  body  known  as  marasmus.  This  represents  a 
weakening  of  the  several  functions,  especially  the  circulation,  respiration, 
and  locomotion.  Such  may  take  place  in  disease  or  old  age ;  and  it  is 
important  to  bear  in  mind  those  diseases  in  which  marasmus  is  likely 
to  arise,  as  thrombosis  often  proves  a  complication  of  such  affections. 
Protracted  fevers,  as  typhus  and  typhoid,  puerperal  diseases,  the  disturb- 
ances following  surgical  operations,  chronic  wasting  diseases,  as  the  tuber- 
culous and  scrofulous  affections,  are  all  likely  to  be  accompanied  by  throm- 
bosis. Stagnation  of  the  blood,  as  well  as  alterations  of  the  intima,  is  an 
important  local  condition  in  this  variety  of  thrombosis,  which  is  usually 
valvular  or  parietal  at  the  outset,  and  may  be  both  arterial  and  venous. 
Such  thrombi  are  likely  to  become  continued  and  to  serve  as  a  frequent 
source  of  embolism. 

Thrombi  are  also  divided  into  primitive,  or  autochthonous,  and  secondary 
varieties.  The  primitive  thrombus  is  one  which  owes  its  local  origin  to 
conditions  existing  at  the  place  of  its  formation  and  attachment.  The 
secondary  variety  demands  for  its  existence  a  primitive  thrombus,  whose 
place  of  development  is  remote  in  time  and  seat,  and  from  which  a  part 
has  been  transferred  to  serve  as  the  nucleus  for  the  secondary  formation. 

The  continued  thrombus  is  often  confounded  with  the  secondary 
variety.  Continuance  is  rather  a  quality  of  all  thrombi,  and  is  essen- 
tially growth,  whether  by  lamcllation  or  agglomeration.  Such  continued 
thrombi  arc  extended  in  the  course  of  the  circulation,  usually  by  a  conical 
end,  which  is  pointed  toward  the  heart  in  the  case  of  venous  thrombi,  but 
away  from  this  organ  when  the  thrombi  are  arterial. 

Parietal  and  obstructing  thrombi  form  another  subdivision.  The  former 
arise  from  a  limited  part  of  the  wall  of  the  heart  or  blood-vessel,  and  project 
into  its  cavity.  They  are  always  in  contact  with  flowing  blood,  and  are 
white  or  mixed  in  color  and  primitive.  They  may  attain  a  considerable 
size,  and  may  eventually  become  obstructing  thrombi.  The  latter  are  so 
called  when  they  are  of  sufficient  size  to  cause  a  considerable  or  total 
obstruction  to  the  current  of  blood.  In  the  last  case  the  vascular  canal 
is  wholly  filled  by  the  thrombus.  The  shape  of  the  older  parietal  forms 
is  usually  globular  or  pedunculate,  owing  to  the  growth  in  all  directions 
except  at  the  place  of  attachment ;  the  obstructing  thrombi  are  elongated. 

Thrombi  are  also  characterized  by  consistency  and  relative  absence  of 
moisture.  A  thrombus  is  brittle  and  dry  as  compared  with  a  clot.  In 
distinguishing  between  the  two,  difficulty  arises  only  in  the  case  of  a  throm- 
bus which  may  have  formed  within  a  few  hours  before  death.  Post-mortem 
clots  are  moist,  elastic,  readily  withdrawn  from  blood-vessels,  and  have  a 
smooth  and  lustrous  surface.  Their  color  is  either  red,  gray,  grayish- 
yellow,  or  yellow,  and  is  very  often  mixed.  The  lighter  colors  are  due 
to  causes  which  favor  the  precipitation  of  red  blood-corpuscles  before 
actual  clotting  takes  place,  or  which  occasion  an  increase  of  the  white 
blood-corpuscles  in  fibrin.  The  thrombus  becomes  adherent  to  the  vessel 
wall  within  a  few  hours,  after  its  formation,  in  the  case  of  the  red  throm- 
bus, and  at  once,  in  the  case  of  the  white  variety.  A  clot  is  never  adherent, 
although  it  may  seem  so  from  its  entanglement  between  the  trabeculse  and 


60  GENERAL  MORBID  PHO  CESSES. 

tendons  of  the  heart  and  the  cavernous  framework  of  venous  sinuses. 
Such  apparent  adhesions  are  easily  recognized  by  the  smooth,  shining, 
intact  intima  which  is  disclosed  after  the  removal  of  a  clot. 

The  thrombus  not  only  tends  to  become  enlarged  by  further  depositions 
of  material  from  the  blood,  but  it  also  tends  to  become  diminished  in  size 
from  the  contractile  properties  of  its  fibriuous  constituent.  Moisture  is 
forced  from  the  thrombus  in  consequence  of  this  shrinkage,  and  its  dry- 
ness  is  increased  by  subsequent  absorption  through  the  wall  to  which  it 
adheres. 

The  changes  eventually  taking  place  in  the  thrombus  are  known  as 
organization,  calcification,  and  softening. 

Organization  is  the  transformation  of  the  thrombus  into  a  mass  of 
fibrous  tissue.  This  is  accomplished,  according  to  the  researches  of 
Baumgarten,1  by  an  outgrowth  of  endothelium  from  the  iiitima  of  the 
vessel,  the  thrombus  being  absorbed  as  the  growth  of  tissue  advances. 
In  the  case  of  a  thrombus  due  to  the  ligation  of  a  vessel,  a  granulation-tissue 
also  makes  its  way  into  the  thrombus  between  the  ruptured  coats,  and  the 
new- formed  fibrous  tissue  which  replaces  the  thrombus  becomes  vascular- 
ized  through  this  granulation-tissue.  The  vascularization  of  thrombi 
surrounded  by  unbroken  walls  is  most  likely  to  result  from  the  extension 
into  the  thickened  intima  of  new-formed  branches  of  the  vasa  vasorum. 
Cohnheim  claims  that  the  organization  of  the  thrombus  may  take  place 
solely  through  the  entrance  of  migratory  cells,  without  any  active  partici- 
pation of  elements  of  the  vascular  wall.  The  canal  is  thus  obstructed  or 
obliterated  by  a  fibrous  tissue,  which  is  pigmented  or  not,  as  the  pre-exist- 
ing thrombus  contained  red  blood-corpuscles  or  not.  These,  when  present, 
become  transformed  into  granular  or  crystalline  hasmatoidin,  which  may 
remain  as  a  permanent  constituent  of  the  new-formed  tissue. 

Even  when  the  thrombus  is  completely  obstructing  at  the  outset,  it  is 
not  necessary  that  a  total  obliteration  of  the  vessel  should  result  from  its 
organization.  It  not  rarely  happens,  either  before  or  after  the  thrombus 
has  yielded  to  the  fibrous  growth,  in  consequence  of  the  shrinkage  of  the 
fibrin  of  the  thrombus  or  of  the  contraction  of  the  fibrous  tissue  replacing 
it,  that  gaps  arise  Avhich  become  communicating  canals.  Through  these 
the  blood  flows,  and  the  vessel  thus  becomes  only  obstructed,  not  oblit- 
erated. The  sieve-like  tissue  thus  formed  is  spoken  of  as  the  result  of  a 
cavernous  or  sinus-like  transformation  of  the  thrombus.  The  length  of 
time  necessary  for  the  removal  of  the  thrombus  and  its  replacement  by 
fibrous  tissue  varies  considerably.  A  vascularized  granulation-tissue  may 
be  present  within  a  week,  and  in  the  course  of  a  month  the  thrombus  may 
have  been  wholly  removed,  or  a  period  of  months  may  elapse  and  the 
thrombus  and  granulation-tissue  still  be  present  side  by  side. 

The  calcification  of  a  thrombus  takes  place  when  the  latter  becomes 
impregnated  with  salts  of  calcium  and  magnesium.  The  condition  may 
be  present  in  thrombi  which  are  exposed  to  a  rapidly-flowing  arterial 
stream,  as  well  as  in  those  which  lie  in  venous  pockets  outside  the  course 
of  the  direct  current  of  blood.  The  well-known  phlebolites  are  examples 
of  the  latter  variety.  A  calcified  thrombus  may  be  intimately  united  to 
ihe  vascular  wall,  the  results  of  calcification  and  organization  being  asso- 
ciated. Calcification  and,  in  particular,  organization  represent  favorable 
1  Die  sogenannte  Organisation  der  Thrombus,  Leipzig,  1877. 


THROMBOSIS  AND  EMBOLISM.  6J 

events  in  the  history  of  thrombosis,  as  through  their  occurrence  the  process 
comes  to  an  end,  and  disturbances,  either  local  or  remote,  are  prevented. 

The  softening  of  the  thrombus,  on  the  contrary,  is  always  a  source  of 
clanger.  This  is  partly  due  to  the  nature  of  the  products  of  the  soften- 
ing, whether  bland  or  septic,  and  partly  to  the  mechanical  disturbances 
produced  by  the  transfer  of  portions  of  the  softened  thrombus  to  remote 
parts  of  the  body.  All  thrombi  may  become  softened.  When  the  pro- 
cess of  organization  advances  normally,  the  softened  parts  are  absorbed 
as  rapidly  as  the  formation  of  vascularized  fibrous  tissue  progresses.  If 
this  formation  is  checked  or  stopped,  the  process  of  disintegration  still 
continues.  White  corpuscles  undergo  fatty  degeneration  ;  red  corpuscles 
give  up  their  coloring  matter  and  become  converted,  like  the  fibrin,  into 
granules,  and  there  results  a  granular  detritus.  This  is  present  as  a 
viscid,  semi-fluid  material,  either  red,  gray,  or  yellow,  according  to  the 
color  of  the  thrombus.  This  simple  softening  is  to  be  regarded  as  essen- 
tially chemical  in  character,  and  begins  at  the  oldest  portion  of  the  throm- 
bus and  advances  toward  the  periphery.  Its  products  are  capable  of 
absorption  without  the  production  of  serious  disturbances,  and  are  usu- 
ally prevented  from  direct  entrance  into  the  blood-vessel  containing  the 
thrombus  by  the  continuation  of  the  latter  from  new  coagulation  or  depo- 
sition upon  its  surface.  The  thrombus  is  thus  extended  as  the  softening 
progresses. 

When  the  thrombus  is  comparatively  free  from  red  blood-corpuscles, 
the  softened  product,  in  consequence  of  its  yellowish  color,  opacity,  and 
viscidity,  resembles  pus.  The  so-called  encysted  abscesses  projecting  into 
the  cavity  of  the  heart,  from  its  wall,  are  parietal  and  globular  thrombi, 
in  the  interior  of  which  softening  has  occurred.  This  form  of  softening 
is  called  simple  or  bland,  as  it  is  free  from  any.  evidence  of  local  suppura- 
tion, inflammation,  or  general  constitutional  disturbance  attributable  to  an 
absorption  of  poisonous  material. 

Septic  softening  is  accompanied  by  general  evidences  of  a  blood-poison- 
ing, and  by  the  local  phenomena  of  purulent  inflammation.  A  suppurative 
thrombo-phlebitis  or  arteritis,  occurs  ;  that  is,  an  acute  inflammation  of  the 
wall  of  the  vessel,  corresponding  in  its  origin  to  the  seat  of  the  thrombus,- 
and  characterized  by  the  formation  of  pus.  In  the  earliest  stage  the  soft- 
ened thrombus  need  not  present  products  differing  in  appearance  from 
those  occurring  in  simple  softening,  but  their  effect  is  manifested  by  a 
rapidly-advancing  inflammation  of  the  vascular  wall  and  by  the  evidence 
of  septicaemia.  Inoculation  with  such  material  produces  a  group  of  symp- 
toms classified  under  the  head  of  blood-poisoning. 

Cohnheim  Iqys  special  stress  upon  the  presence  of  micrococci  in  the 
softened  material,  and  it  is  generally  agreed  that  the  virulence  of  septic 
softening  is  connected  with,  if  not  due  to,  the  presence  of  microbia.  A 
septic  softening  may  be  induced  by  besmearing,  with  septic  material,  the 
outside  of  a  blood-vessel  containing  a  thrombus,  and  this  form  of  soft- 
ening is  usually  associated  with  those  conditions  favoring  this  relation. 
Such  are  the  gangrenous  wounds  following  surgical  operations,  the  putrid 
inflammatory  processes  affecting  the  uterine  wall  after  childbirth,  the 
offensive  inflammations  of  the  middle  ear,  and  the  like.  It  is  possible 
for  a  septic  softening  to  occur  independently  of  such  contiguous  or  con- 
tinuous relations  with  the  surfaces  of  the  body.  It  is  considered,  how7- 


62  GENERAL  MORBID  PROCESSES. 

ever,  that  the  micrococci  present  in  a  softened  thrombus  must  have 
obtained  admission  from  without  through  one  of  the  surfaces  of  the 
body,  mucous  or  cutaneous,  or  through  undiscovered  abrasions  of  even 
intact  surfaces  of  peculiar  structure,  as  the  alveolar  Avail  or  the  intestinal 
mucous  membrane.  The  thrombus  is  regarded  as  affording  a  favorable 
soil  for  the  growth  and  activity  of  the  organism. 

The  mechanical  effect  of  a  thrombus  varies  according  to  the  venous  or 
arterial  seat  of  the  same.  Venous  thrombi,  as  they  are  continued  toward 
the  heart,  tend  to  become  completely  obstructing  thrombi.  In  most  parts 
of  the  body  the  venous  anastomoses  are  so  numerous  that  the  obstruction 
of  a  vein  is  readily  compensated  for  through  the  collateral  venous  circu- 
lation. When  such  a  compensation  is  prevented  by  an  extension  of  the 
thrombus  from  branch  to  branch,  and  finally  to  the  trunk,  an  accumulation 
of  blood  in  the  peripheral  veins  must  result.  The  remote  parts  become 
swollen,  from  the  distension  of  the  vessels  with  blood  and  the  transudatiou 
of  liquid,  and  eventually  solid  material  from  the  blood.  Venous  throm- 
bosis thus  leads  to  oedema,  and  even  hemorrhage.  The  more  rapidly  the 
obstructing  thrombus  extends,  the  earlier  and  more  extreme  is  the  oedema 
likely  to  become,  while  the  slower  the  advance  of  the  thrombus,  the  more 
favorable  is  the  opportunity  for  an  enlargement  of  the  collateral  vessels 
through  which  a  sufficient  flow  of  blood  is  permitted  to  check  oedema 
and  preserve  nutrition. 

Local  mechanical  disturbances  from  arterial  thrombi  are  scarcely  per- 
ceptible till  obstruction  is  produced,  and  the  results  of  arterial  obstruc- 
tion will  be  mentioned  in  detail  in  connection  with  the  phenomena  of 
embolism.  Cardiac  thrombi  may  occasion  local  disturbances  from  inter- 
fering with  the  action  of  the  valves  of  the  heart.  Those  thrombi  which 
are  attached  to  the  valves,  especially  when  calcified,  may  produce  inflamma- 
tion and  aneurism  of  the  opposed  wall  of  the  heart,  by  friction.  The  most 
frequent  mechanical  disturbance  from  the  non-obstructing  parietal 
thrombi  of  the  heart  and  arteries  results  from  the  detachment  of  frag- 
ments and  their  transfer  as  emboli  to  remote  parts  of  the  body. 

An  embolus  is  a  foreign  body  in  a  blood-vessel,  usually  too  large  to 
•pass  through  the  smallest  capillaries,  and  the  disturbances  resulting  from 
its  presence  are  included  under  the  term  embolism.  Although  most 
emboli  are  detached  portions  of  thrombi,  any  foreign  body  of  suitable 
size  may  become  an  embolus.  Such  are  tissues,  as  the  pulmonary  elastic 
fibres,  fragments  of  diseased  valves  of  the  heart  and  of  the  intima  of 
arteries,  or  portions  of  tumors  growing  into  vascular  canals.  Others  are 
globules  of  oil  entering  the  torn  veins  when  fat-tissue  becomes  crushed, 
or  air-bubbles  admitted  through  veins  either  wounded  by  instruments  or 
opened  after  parturition  by  the  dislodgmeut  of  their  obstructing  thrombi. 
Still  others  are  granules  of  pigment  derived  from  the  coloring-matter  of 
the  blood,  as  in  melauremia,  or  introduced  from  without,  as  india-ink  and 
cinnabar.  The  ecjiinococcus  has  been  found  as  an  embolus,  and  it  is 
highly  probable  that  the  cysticercus,  the  trichina,  and  other  animal  para- 
sites may  be  disseminated  as  emboli  over  the  body. 

Vegetable  parasites,  like  the  bacterium  and  aspergillus,  have  also  been 
included  in  the  list,  although  the  disturbances  resulting  from  their  pres- 
ence are  less  due  to  mechanical  obstruction  than  to  colonization  and 
growth.  The  experimenter  uses  the  most  various  objects  as  emboli — bits 


THROMBOSIS  AND  EMBOLISM.  63 

of  wood,  rubber,  and  glass,  globules  of  mercury,  fragments  of  tissue,  etc. 
Eniboli  are  to  be  regarded  as  of  arterial  or  venous  origin.  The  arterial 
emboli  are  carried  toward  the  capillaries,  while  venous  emboli  are  carried 
toward  the  heart.  The  effect  of  both  is  partly  or  wholly  mechanical,  and 
partly  due  to  the  specific  properties  of  the  constituents. 

The  mechanical  effect  of  an  embolus  is  manifested  by  the  obstruction 
it  offers  to  the  circulation,  and  the  degree  of  the  obstruction  depends  upon 
the  size,  shape,  and  density  of  the  embolus  and  the  nature  and  size  of  the 
vessel  obstructed.  An  embolus  may  be  so  large  as  to  be  unable  to  pass 
through  the  valvular  orifices  of  the  heart.  A  long  and  narrow  embolus 
might  pass  through  a  vessel  which  would  not  admit  one  which  was  short 
and  thick.  A  jagged  and  dense  embolus,  by  repeated  blows  or  prolonged 
and  forcible  contact,  might  cause  a  weakening  or  rupture  of  the  wall  of  a 
vessel,  and  thus  produce  an  aneurism.  Certain  vessels  (the  terminal 
arteries  of  Cohnheim)  furnish  the  sole  supply  of  arterial  blood  to  a  dis- 
trict, and  when  they  are  obstructed,  the  results,  to  be  mentioned  later, 
differ  widely  from  those  taking  place  where  free  vascular  anastomoses 
exist.  When  a  trunk  bifurcates,  the  larger  branch  usually  receives  the 
embolus. 

Venous  emboli  are  those  which  approach  the  heart  by  the  peripheral 
veins  of  the  body  or  the  pulmonary  veins,  and  the  liver  by  the  radicles 
of  the  portal  vein.  Emboli  from  the  veins  of  the  body  are  carried 
through  the  right  side  of  the  heart,  if  not  so  large  as  to  be  stopped  at 
the  tricuspid  or  pulmonary  opening.  As  they  enter  the  latter,  they  are 
carried  along  its  course  under  the  influence  of  gravity  and  the  direction 
and  force  of  the  current,  which  are  determined  by  the  direction  and  rela- 
tive size  of  the  bifurcations  of  the  artery,  the  right  primary  branch  being 
larger  than  the  left.  Eventually,  a  point  of  the  artery  is  reached  whose 
diameter  is  less  than  that  of  the  embolus,  and  the  latter  is  stopped.  This 
point  usually  corresponds  with  a  place  of  bifurcation,  and  the  embolus 
frequently  rides  the  wall  separating  the  branches. 

Emboli  from  the  radicles  of  the  portal  vein  owe  their  most  frequent 
origin  to  thrombi  associated  with  inflammatory  processes  in  the  intestine, 
especially  of  the  csecum  and  vermiform  appendage,  to  inflammatory  pro- 
cesses in  the  spleen  and  obstruction  to  the  flow  of  blood  through  the 
splenic  artery,  or  to  inflammatory  changes  proceeding  from  the  kidneys. 
Such  venous  emboli  are  carried  toward  the  heart,  but  are  stopped  on  the 
\vay  by  the  intrahepatic  branches  of  the  portal  vein. 

Arterial  emboli  are  those  which  enter  the  left  side  of  the  heart  from 
the  lungs,  which  arise  in  the  left  ventricle  or  auricle,  which  may  pass 
through  an  open  foramen  ovale  from  the  right  auricle,  or  which  arise 
from  the  arterial  wall.  They  are  carried  along  the  course  of  the  arterial 
circulation,  and  are  distributed  over  the  different  regions  and  organs  of 
the  body.  Usually  following  the  more  direct  course  of  the  circulation, 
they  are  more  likely  to  enter  the  abdominal  aorta  than  to  be  carried 
toward  the  brain  or  upper  extremities.  Embolism  of  the  carotids,  espe- 
cially of  the  left  carotid,  is  more  likely  to  ensue  than  embolism  of  the 
subclavians.  Embolism  of  the  coronary  arteries  is  rare,  while  embolism 
of  the  splenic  artery,  the  left  renal  and  left  iliac  arteries,  is  comparatively 
common,  and  in  the  order  mentioned. 

When  an  embolus  is  found,  or  embolism  suspected,  the  source  is  always 


64  GENERAL  MORBID  PROCESSES. 

to  be  searched  for  in  those  regions  from  which  the  affected  part  receives 
its  blood.  The  source  of  arterial  and  portal  emboli  is  usually  found 
with  ease,  while  the  pulmonary  embolus  may  come  from  so  wide  a  region, 
the  body-veins,  that  much  time  may  be  spent  before  its  place  of  origin  is 
discovered.  An  appreciation  of  the  laws  of  the  transfer  of  emboli  ren- 
ders such  a  discovery  almost  certain. 

"When  the  embolus  reaches  a  point  beyond  which  it  cannot  pass,  the 
resulting  disturbance  depends  essentially,  as  shown  by  Cohnheim,  upon 
the  presence  or  absence  of  arterial  anastomoses  beyond  the  place  of 
obstruction.  He  gives  the  name  terminal  arteries  to  those  which  have 
no  anastomosing  arterial  branches.  These  are  met  with  in  the  spleen, 
kidneys,  lungs,  brain,  and  retina.  If  the  obstructed  artery  is  not  termi- 
nal, the  embolus  may  produce  no  further  disturbance,  the  collateral  sup- 
ply of  blood  through  the  anastomoses  sufficing  for  the  nutrition  and 
function  of  the  part.  If,  however,  the  vessel  is  a  terminal  artery,  and 
the  embolus  is  completely  obstructing,  the  supply  of  arterial  blood  must 
be  wholly  cut  off  from  the  region  beyond  the  seat  of  obstruction. 

If  the  embolus  does  not  completely  obstruct  at  once,  it  soon  becomes 
sufficiently  large  for  this  result  to  ensue  in  consequence  of  a  secondary 
coagulation.  The  rider  assumes  legs  extending  into  the  arterial  branches 
beyond  the  place  of  obstruction,  and  a  body  which  extends  backward  in 
the  course  of  the  circulation  to  the  nearest  branch.  The  result  of  the 
total  obstruction  of  the  vessel  is  to  cut  off  the  admission  of  arterial 
blood,  producing  a  local  anaemia.  The  contraction  of  the  elastic  tissues 
of  the  part  propels  toward  the  capillaries  a  certain  quantity  of  the 
blood  in  the  vessels  beyond  the  point  of  obstruction,  till  this  force 
becomes  neutralized  by  the  blood-pressure  in  the  vessels  surrounding  the 
obstructed  region.  The  anaemic  part  may  subsequently  become  engorged 
with  blood  ;  it  may  die,  a  region  of  anasmic  necrosis  resulting,  or  the  dead 
portion  may  become  softened. 

The  engorgement  of  the  obstructed  territory  has  received  the  name  of 
hemorrhagic  infarction.  A  solid,  wedge-shaped  mass  of  a  reddish-brown 
color  is  present,  whose  shape  is  due  to  the  arborescent  branching  of  the 
terminal  arteries.  According  to  Cohuheim,  the  engorgement  of  the 
region  with  blood  takes  place  from  venous  regurgitation  into  the 
obstructed  part,  till  the  intravenous  pressure  is  overcome  by  the  resist- 
ance of  the  tissues  in  the  region  affected.  The  capillaries  and  larger 
vessels  thus  become  distended,  and  an  escape  of  liquid  and  solid  con- 
stituents of  the  blood  takes  place.  If  the  veins  are  provided  with  valves, 
or  the  venous  regurgitant  current  is  opposed  by  gravity,  the  hemor- 
rhagic infarction  is  prevented  or  greatly  impeded. 

Litten,1  on  the  contrary,  who  has  furnished  a  recent  contribution  to 
this  subject,  claims  that  the  hemorrhagic  results  of  embolism  are  not 
accomplished  through  venous  regurgitation,  unless  increased  venous  ten- 
sion is  produced  by  coughing,  vomiting,  and  like  efforts.  His  experi- 
ments lead  him  to  maintain  that  arterial  blood  from  surrounding  tissues 
is  supplied  to  the  obstructed  region  th rough  the  anastomosing  capillaries. 
The  force  is  not  sufficient  to  drive  the  blood  through  the  capillaries  into 
the  veins  beyond,  but  an  accumulation  takes  place  in  the  capillaries, 
which  become  dilated  and  distended.  The  escape  of  blood-corpuscles  and 

1  Untcrsuchungen  iiber  den  hemorrhagischen  Infarct.,  etc.,  Berlin,  1879. 


THROMBOSIS  AND  EMBOLISM.  65 

serum  then  takes  place,  the  more  freely,  as  Weigert1  suggests,  the  larger 
and  more  numerous  are  the  pre-existing  spaces  in  the  organ.  Hence  the 
infarction  becomes  the  most  characteristically  developed  in  such  organs 
as  the  lungs  and  spleen.  Causes  which  obstruct  the  venous  flow,  as  well 
as  those  which  increase  the  arterial  tension,  promote  the  hemorrhagic 
infarction. 

A  necrosis  of  the  part  whose  direct  arterial  supply  is  cut  off  takes 
place  when  the  structure  of  the  organ  affected  is  such  that  the  admission 
of  arterial  blood  is  wholly  interfered  with.  This  is  the  case  in  the  heart 
and  kidneys,  and  to  a  less  extent  in  the  spleen.  The  opportunity  is  pre- 
sented for  the  diffusion  of  a  fibrinogenous  fluid,  lymph  or  blood-serum, 
through  the  cells  of  the  organ  which  contains  the  other  essentials  for 
coagulation,  and  the  dead  part  presents  the  characteristics  attributed  by 
Weigert2  to  death  from  clotting  of  the  protoplasm,  coagulative  or 
ischaemic  necrosis. 

Embolism  of  the  cerebral  arteries  produces  softening  of  the  brain,  not 
a  hemorrhagic  infarction  or  a  yellowish  necrosis.  Weigert  attributes 
this  result,  on  the  one  hand,  to  the  absence  in  the  brain  of  abundant  cells 
from  which  are  to  be  had  the  ferment  and  fibrino-plastic  material  neces- 
sary for  coagulation,  and,  on  the  other,  to  the  closure  of  the  spaces  into 
which  blood  might  collect  by  the  rapid  swelling  of  the  tissues  from  the 
exuded  lymph. 

The  hemorrhagic  results  of  embolism  are  also  met  with  in  obstruction 
of  branches  of  the  mesenteric  artery,  which  is  considered  by  Litten,  at 
least  from  its  function  and  in  connection  with  its  sluggish  current,  to 
correspond  with  a  terminal  artery. 

If  the  patient  outlives  these  more  mechanical  results  of  embolism,  the 
local  changes  taking  place  are  those  tending  to  remove  the  extravasated 
blood  or  the  dead  tissues.  The  embolus  has  become  an  obstructing 
thrombus,  and  its  removal  is  accomplished  in  the  manner  already 
stated  in  connection  with  the  subject  of  thrombosis.  The  wedge-shaped 
nodule  of  hemorrhagic  infarction  becomes  decolorized  through  the 
absorption,  in  part,  of  the  blood-pigment.  That  portion  which  is  not 
absorbed  remains  at  the  site  of  the  original  lesion  as  granular  or  crystal- 
line blood-pigment.  A  granulation-tissue  is  formed  at  the  periphery, 
which  extends  into  the  infarcted  region,  very  much  as  the  endothelial 
and  vascularized  growth  extends  into  a  thrombus.  Eventually,  a 
patch  of  cicatricial  tissue  remains  as  the  sole  indication  of  the  previous 
disturbance.  This  termination  is  rather  suggested  for  the  hemorrhagic 
infarctions  of  the  lungs.  The  results  are  more  apparent  and  more  easily 
demonstrated  in  the  case  of  the  anemic  necroses,  and  the  somewhat  irreg- 
ular depressions  with  wedge-shaped  scars,  seen  upon  the  surface  of  the 
spleen  or  kidneys,  call  attention  to  the  probable  nature  of  the  process 
giving  rise  to  these  results.  A  source  of  embolism  must  also  be  asso- 
ciated, that  these  scars  may  be  regarded  as  of  embolic  origin.  The 
embolic  softenings  of  the  brain  are  likewise  represented  in  after  years  by 
losses  of  substance.  The  superficial,  yellow  patches  or  localized  cede- 
matous  blebs,  with  corresponding  atrophy  of  the  convolutions  beneath,  call 
attention  to  a  nutritive  disturbance,  as  do  cyst-like  cavities  in  the  deeper 
parts  of  the  brain.  Here,  too,  a  source  of  embolism  must  be  found,  that 
1  Virchow's  Archiv,  1*78,  Ixxii.  250.  2  MM-,  1880,  Ixxix.  87. 

VOL.  I.— 5 


66  GENERAL  MORBID  PROCESSES. 

the  local  destruction  of  tissue  may  be  attributed  to  embolic  obstruction 
of  vascular  territories. 

"When  the  embolus  arises  from  a  septic  thrombus,  the  results  differ 
from  those  above  described.  The  embolus  then  carries  not  only  mechan- 
ical possibilities,  but  also  a  virulent  action.  The  latter  is  manifested  by 
the  rapid  production  of  local  inflammatory  disturbances,  as  circumscribed 
abscesses  and  gangrenous  destruction  of  tissue.  Since  emboli  are  fre- 
quently lodged  near  the  surfaces  of  organs,  a  septic  pleurisy,  pericarditis, 
or  peritonitis  is  the  usual  result  of  the  dissemination  of  the  virus  con- 
tained in  the  embolus.  This  virus  is  similar  in  character  to  that  found 
in  septic  softening  of  the  thrombus,  and,  like  it,  is  intimately  connected 
with  the  presence  of  microbia.  Whether  the  latter  are  specific  in  cha- 
racter, as  maintained  by  Klebs  and  others,  or  whether  they  are  to  be 
included  among  those  associated  with  putrefactive  processes,  still  remains 
an  open  question. 

The  symptoms  of  thrombosis  obviously  depend  upon  the  resulting 
obstruction  to  the  circulation  of  blood,  and  in  the  case  of  primitive 
thrombi  are  gradual  in  their  occurrence.  The  degree  of  mechanical 
obstruction  is  determined  by  the  nature  of  the  thrombus,  whether  pari- 
etal or  obstructing,  and  by  that  of  the  vessel,  whether  provided  with  anas- 
tomoses sufficient  to  permit  a  compensatory  collateral  circulation  or  not. 
In  the  former  case,  if  the  thrombus  is  small  and  deep-seated,  there  may 
be  no  symptoms  to  indicate  its  presence.  When  the  collateral  circulation 
is  insufficient  to  remove  the  blood  from  a  region  whose  efferent  venous 
trunk  is  completely  filled  writh  a  thrombus,  the  phenomena  of  stagnation 
are  produced.  The  part  becomes  cedematous,  and  red  blood-corpuscles 
escape  from  the  distended  vessel.  If  the  obstructed  vein  is  superficial, 
the  seat  of  the  thrombus  is  indicated  by  the  resistance  and  sensitiveness 
of  the  part.  Characteristic  disturbances  of  function  are  associated  with 
thrombosis  of  the  various  organs  of  the  body.  If  the  cerebral  sinuses  are 
affected,  mental  disturbances  arise ;  if  a  cardiac  thrombosis  is  present,  it 
is  frequently  accompanied  by  irregularity  and  feebleness  of  the  heart. 
When  the  portal  and  renal  veins  are  obstructed,  functional  disturbances 
arise  in  the  parts  from  which  they  receive  their  blood. 

The  symptoms  of  embolism,  like  those  of  arterial  thrombosis,  are 
primarily  due  to  anaemia.  Suddenness  is  their  characteristic  in  embol- 
ism, while  they  are  gradual  and  progressive  in  the  case  of  thrombosis. 
An  embolic  anemia  is  complete  or  incomplete  according  to  the  terminal 
or  anastomosing  character  of  the  obstructed  vessel.  The  effect  of  the 
anaemia  is  to  stop  or  check  the  function  of  the  part,  and  varies  according 
to  the  size  and  situation  of  the  vessel.  Hemiplegia,  or  perhaps  aphasia 
or  other  evidence  of  localized  disturbance,  follows  central  embolism ; 
angina  pectoris,  with  a  disturbed  cardiac  action,  results  from  embolism 
of  the  coronary  artery.  Sudden  suffocative  symptoms,  with  open  air-pas- 
sages, suggest  embolism  of  the  larger  branches  of  the  pulmonary  artery. 
A  considerable  hsematuria  often  excites  suspicion  of  an  embolism  of  the 
renal  artery,  the  hemorrhage  coming  from  the  vessels  in  the  neighbor- 
hood of  the  obstructed  region.  Embolism  of  a  large  artery  of  an 
extremity  is  often  localized  by  the  sensation  of  a  blow  at  the  part,  to  be 
followed  by  absent  pulsation,  pallor,  and  coldness  of  the  region  beyond 
the  place  of  obstruction. 


EFFUSIONS.  67 

The  symptoms  of  the  subsequent  effects  of  thrombosis  and  embolism 
are  to  be  inferred  from  what  has  already  been  stated  with  regard  to  the 
nature  of  the  possible  fesions.  To  enter  into  their  detailed  consideration 
would  demand  more  space  than  is  permitted,  and  would  modify  an  estab- 
lished sequence  or  necessitate  a  repetition,  which  is  undesirable  iii  a  sys- 
tematic treatise. 


Effusions. 

The  various  fluids  of  the  body  are  derived  from  without,  and  admitted 
into  the  blood-vessels.  The  physiological  transudation  through  the 
walls  of  these  vessels,  in  the  main  modified  serum,  becomes  lymph  as  it 
appears  in  the  several  lymph-spaces.  From  the  latter  the  transuded 
fluid  either  returns  through  the  lymph-vessels  to  the  blood-current  or 
makes  its  appearance  upon  surfaces  as  secretions.  These  are  variously 
modified  as  they  pass  through  the  specific  cells  of  glands  or  as  they  are 
met  with  in  the  several  closed  cavities  of  the  body. 

The  transudations  thus  occurring  may  vary  in  quantity  within  certain 
limits,  the  latter  being  somewhat  indefinite,  owing  to  the  difficulties  in 
the  way  of  exactly  measuring  the  fluid  transuded.  The  greater  part  of 
this  transudation  is  represented  by  the  quantity  of  lymph  flowing  through 
the  main  lymph-trunk,  and  of  the  secretion  from  the  glandular  surfaces 
of  a  given  region  of  the  body ;  but  that  transuded  fluid  is  not  included 
which  may  return  to  the  blood-vessels  without  being  carried  into  the 
general  lymph-current  or  secreted  from  a  gland.  Such  a  direct  return 
may  be  considered  to  take  place  whenever  the  pressure  upon  the  outside 
of  the  vessel  wall  is  greater  than  that  within  the  latter,  or  when  the 
chemical  composition  of  the  fluids  on  the  two  sides  of  the  filter  permits 
endosmosis  as  well  as  exosmosis.  This  varying  relation  in  the  direction 
of  the  current  through  the  vessel  wall  is  likely  to  be  of  frequent,  if  not 
constant,  occurrence  in  connection  with  the  physiological  processes  taking 
place  throughout  the  body. 

The  undue  accumulation  of  the  transudation  in  the  various  closed 
cavities  of  the  body  is  known  as  dropsy,  and  the  fluid  present  is  regarded 
as  an  effusion  or  an  exudation.  These  terms  are  often  applied  somewhat 
vaguely,  now  being  used  as  synonymous,  again  as  representing  different 
conditions  of  the  transudation,  which  are  attributed  to  the  varying  condi- 
tions of  its  accumulation. 

Exudation  is  more  generally  used  when  an  inflammatory  process  is  the 
cause  of  the  increased  transudation,  while  effusion  is  more  strictly  associ- 
ated with  causes  other  than  inflammatory.  In  the  present  consideration 
this  etiological  distinction  will  be  maintained. 

To  appreciate  the  conditions  under  which  pathological  accumulations 
of  fluid,  whether  effusions  or  exudations,  may  arise,  it  is  desirable  to  bear 
in  mind  the  essential  conditions  which  prevail  in  the  occurrence  of  trans- 
udation, since  the  former  are  likewise  chiefly  derived  from  the  blood  and 
are  transuded  through  the  walls  of  its  vessels.  These  conditions  are 
largely  dependent  upon  the  laws  governing  the  diffusion  of  substances 
through  an  animal  membrane,  the  vascular  wall  representing  the  filter. 
As  a  living  membrane  its  relation  is  dependent  upon  vital  as  well  as 


68  GENERAL  MORBID  PROCESSES. 

physical  conditions,  and  the  former  produce  certain  important  modifica- 
tions in  the  physical  process  of  filtration. 

The  transudation  through  the  vessels  takes  place  chiefly  through  those 
with  the  thinnest  walls,  the  capillaries,  although  it  is  probable  that  a  cer- 
tain degree  of  transudation  may  also  occur  through  the  walls  of  the 
smallest  veins.  The  causes  which  are  instrumental  in  promoting  the 
circulation  of  the  blood — viz.  the  contraction  and  dilatation  of  the  heart, 
the  contraction  of  the  arteries,  the  inspiratory  action  of  the  thorax,  and 
muscular  movements  throughout  the  body — are  also  essential  in  produ- 
cing the  flow  of  lymph ;  and  the  existence  of  pressure  upon  the  hsemic 
side  of  the  filter  is  the  first  feature  of  importance  in  occasioning  the 
trausudation.  The  constant  removal  of  the  transudation  from  the  outer 
side  results  from  the  pressure  being  less  in  this  position. 

At  the  same  time,  an  increase  in  the  quantity  of  blood  in  the  vessels  is 
not  necessarily  productive  of  any  considerable  increase  in  the  fluid  trans- 
uded. Cohnheim  calls  attention  to  the  experiments  of  Worm  Miiller, 
which  show  that  a  plethoric  condition  may  readily  be  produced  by  the 
injection  of  quantities  of  blood  into  the  circulation  of  animals,  the  amount 
of  which  cannot  exceed  twice  the  volume  of  the  animal's  blood  without 
producing  death.  Although  a  temporary  increase  of  the  blood-pressure 
results,  a  return  to  the  normal  quickly  follows.  This  is  permitted  by  the 
propulsion  of  the  excess  of  blood  into  the  capillaries  and  veins,  which 
become  consequently  distended,  especially  those  of  the  abdominal  organs. 
There  is  no  increased  transudation  corresponding  with  the  quantity  of 
fluid  introduced,  nor  is  there  any  considerable  distension  of  the  blood- 
vessels of  the  skin,  subcutaneous  or  intermuscular  connective  tissue. 
Such  experiments  show  no  permanent  increase  in  the  blood-pressure 
within  the  large  veins  if  there  is  no  obstruction  to  the  admission  of 
venous  blood  into  the  heart,  presumably  owing  to  their  capacity  for 
considerable  distension. 

Although  experiments  show  that  a  simple  plethora  with  great  disten- 
sion of  the  capillaries  of  the  abdominal  organs  occasions  no  considerable 
increase  of  transudation,  a  different  result  follows  a  hydrsemic  plethora l 
induced  by  the  injection  of  immense  quantities  of  salt  water  into  the 
blood-current — often  six  times  as  much  liquid  as  the  animal  had  blood. 
Here,  too,  the  arterial  blood-pressure  shows  no  permanent  increase,  nor 
does  that  Avithin  the  large  veins  become  perceptibly  increased  till  enor- 
mous quantities  of  fluid  are  injected.  The  blood  flows  through  the  vessels 
with  increased  rapidity  in  consequence  of  the  diminished  friction  of  the 
diluted  blood,  and  an  increased  transudation  begins  at  once.  The  various 
glands,  salivary  and  gastro-intestinal,  kidneys  and  liver,  secrete  more 
copiously,  and  the  flow  of  a  dilute  lymph  from  the  thoracic  duct  becomes 
greatly  increased,  while  that  from  the  cervical  lymphatics  becomes  mode- 
rately accelerated.  The  lymph  from  the  extremities,  however,  is  no 
greater  in  quantity  than  that  flowing  from  an  animal  in  a  perfectly  normal 
condition.  The  localization  of  the  increased  trausudatiou  from  the  blood- 
vessels is  further  characterized  by  the  abundant  accumulation  of  watery 
fluid  in  all  the  abdominal  organs  and  abdominal  cavity,  in  the  salivary 
glands  and  surrounding  connective  tissue,  while  elsewhere  in  the  body 
the  organs  and  tissues  are  almost  invariably  in  the  same  condition  with 
1  Cohnheim  and  Lichtheim,  Virchow's  Archiv,  1877,  Ixix.  106. 


EFFUSIONS.  69 

regard  to  moisture  as  are  those  of  a  healthy  animal  under  normal  cir- 
cumstances. 

The  importance  of  these  experiments  with  reference  to  the  causes  of 
the  transudation  of  fluid  from  the  blood  is  obvious.  The  pressure  upon 
the  walls  of  the  blood-vessels  cannot  become  sufficiently  increased  to  be 
accompanied  with  augmented  transudation  until  limits  are  reached  which 
are  beyond  the  possibilities  of  occurrence  in  the  human  body.  When 
such  limits  are  attained  in  animals,  the  increased  pressure,  however  great 
it  may  be,  does  not  suffice  to  produqg  a  general  transudation,  but  one 
limited  to  the  vessels  of  those  parts  of  the  body  whose  normal  function 
is  connected  with  too  abundant  transudation  of  fluid.  A  simple 
hydrremic  condition  of  brief  duration  has  been  proven,  by  experiment, 
insufficient  to  give  rise  to  increased  trausudatiou,  neither  increased  secre- 
tion nor  increased  flow  of  lymph  taking  place.  The  inference  from  these 
experiments  is  that  an  increased  transudation  is  more  dependent  upon  con- 
ditions of  the  filter  than  upon  those  of  blood-pressure.  The  absence  of 
any  observable  changes  in  the  filter  leads  to  the  assumption  of  an 
increased  permeability,  of  physiological  occurrence  in  certain  parts  of 
the  body,  as  the  chief  feature  in  the  occurrence  of  increased  trans- 
udations. 

Dropsy  arises  when  the  transudation  is  accumulated.  As  dropsical 
accumulations  are  transudations  from  the  blood,  essentially  blood-serum 
with  a  diminished  percentage  of  albumen,  and  as  such  blood-serum  is 
practically  lymph  from  its  presence  in  the  lymph-vessels,  dropsical  effu- 
sions are  to  be  regarded  as  stagnant  lymph.  Such  stagnations  may  be 
present  in  the  small  lymph-spaces  within  the  connective  tissue,  or  in  the 
larger  lymph-sacs,  as  the  peritoneal,  pleural,  pericardial,  and  scrotal 
cavities.  In  like  manner,  the  stagnation  may  take  place  in  the  cavities 
of  joints  and  in  those  of  the  brain  and  cord,  although  the  latter  represent 
functional  rather  than  structural  lymph-canals. 

The  term  osdema  is  applied  to  the  accumulation  in  the  connective-tissue 
lymph-spaces  in  general,  while  the  term  auasarca  is  confined  to  those  cases 
where  the  subcutaneous  lymph-spaces  are  concerned.  The  accumulation 
in  the  great  lymph-cavities  is  known  as  ascites  when  peritoneal,  hydro- 
thorax  when  pleural,  hydropericardium  when  pericardial,  hydrocele  when 
in  the  cavity  of  the  tunica  vaginalis,  hydrocephalus  if  within  the  ventri- 
cles of  the  brain,  and  hydromyelocele  when  within  the  central  canal  of  the 
spinal  cord. 

The  accumulation  of  dropsical  effusions  may  be  considered  as  possibly 
resulting  from  an  obstruction  to  the  channels  through  which  the  transuda- 
tion should  flow,  or  from  insufficient  force  to  overcome  normal  obstruc- 
tions, or  from  an  abnormally  increased  transudation. 

Lymph-channels  are  frequently  obstructed,  but  no  appreciable  diffused 
retention  of  lymph  results  unless  the  thoracic  duct  is  obstructed.  _  This 
rare  affection  is  followed  by  enormous  distension  of  the  thoracic  and 
abdominal  portions  of  the  parts  beyond  the  stenosis.  Ascites  and  hydro- 
thorax  may  follow,  but  not  necessarily  any  considerable  oedema  of  the 
peripheral  parts  of  the  body.  As  a  result  of  the  distension  of  the  thoracic 
duct,  rupture  is  not  unlikely  to  take  place,  and  the  effused  fluid  contains 
chyle.1 

1  Quincke,  Deutsches  Archivfiir  Klin.  Mod.,  1875,  xvi.  121. 


70  GENERAL  MORBID  PROCESSES. 

That  the  obstruction  is  not  followed  by  oedema  is  attributable  to  the 
innumerable  anastomoses  between  the  lymph-spaces,  and  also  to  the  prob- 
ability that  a  part  of  the  transuded  fluid  returns  to  the  blood-vessels 
when  the  obstruction  is  impassable. 

The  forces  necessary  to  promote  the  flow  of  lymph  have  already  been 
mentioned,  and  their  entire  removal  is  inconsistent  with  life.  A  diminu- 
tion of  their  activity  is  more  likely  to  result  in  a  diminished  flow  of 
lymph  than  its  accumulation,  although  a  slowing  of  the  lymph-current 
may  represent  a  favoring  element  in  the  accumulation  of  an  increased 
transudation. 

The  occurrence  of  dropsy  with  unobstructed  lymph-channels,  and  in 
the  presence  of  efficient  agencies  in  promoting  the  flow  of  lymph,,  indicates 
the  importance  of  an  increased  transudation  as  the  chief  element  in  the 
occurrence  of  a  dropsical  accumulation.  An  increased  trausudation,  with 
resulting  oedema,  is  readily  produced  by  preventing  the  flow  of  blood 
from  a  part,  and  may  be  directly  observed  with  the  microscope.  Cohn- 
heim  states  that  after  a  sudden  venous  obstruction,  in  case  an  efficient 
collateral  circulation  does  not  interfere,  the  capillaries  and  small  veins 
become  distended  with  stagnant  blood  and  appear  as  masses  of  red  blood- 
corpuscles.  This  distension  results  from  the  continuance  of  the  arterial 
flow  into  the  capillaries  of  the  obstructed  region  under  a  pressure  which 
is  only  neutralized  by  the  resistance  of  the  tissues  and  the  transudation 
from  the  capillaries.  Sotnitschewsky1  shows  that  a  concurrent  paralysis  of 
the  vaso-motor  nerves,  as  claimed  byffanvier,  is  unnecessary.  The  transu- 
dation through  the  capillary  wall  is  increased,  the  flow  of  lymph  from 
the  part  is  accelerated,  and  oedema  arises  when  the  trausudation  is  so 
much  augmented  that  the  calibre  of  the  lymph-vessels  is  insufficient  for 
for  its  removal ;  and  the  greater  this  insufficiency  the  greater  is  the  oedema. 
With  the  continuance  of  the  arterial  flow  and  intravenous  resistance,  red 
blood-corpuscles  are  forced  through  the  filter,  and  form  an  important 
constituent  of  the  effusion  from  venous  stagnation. 

Although  the  existence  of  an  increased  pressure  upon  the  capillary  wall 
is  obvious  from  the  experiment  referred  to,  there  is  no  increased  arterial 
pressure — rather  a  diminution — and  the  important  element  in  occasioning 
the  increased  permeability  of  the  capillary  wall  is  the  obstruction  to  the 
outflow  of  venous  blood  from  the  oedematous  region.  In  consequence  of 
the  latter  the  arterial  flow  is  followed  by  increased  transudation. 

Dropsies  resulting  from  venous  obstruction,  as  well  as  those  following 
an  obstruction  of  the  thoracic  duct  or  its  branches,  or  of  the  several 
lymphatics  of  a  part,  are  classified  as  mechanical  dropsies.  That  from 
venous  obstruction  is  the  most  frequent,  and  its  seat  may  lie  in  the  course 
of  venous  trunks  or  in  the  heart,  lungs,  or  liver.  The  venous  obstruc- 
tion must  be  so  situated  that  the  stagnant  blood  is  unable  to  find  a  ready 
escape  through  collateral  branches.  The  more  sudden  and  complete  it  is, 
the  more  likely  is  the  effusion  to  contain  considerable  numbers  of  red 
blood-corpuscles. 

In  addition  to  the  element  of  venous  stagnation  in  producing  increased 

transudation,  the  condition  of  the  filter  is  of  importance.     The  occurrence 

of  oedema  in  chronic  diseases,  especially  of  the  kidneys,  and  in   those 

attended  with  protracted   suppuration,   continued  hemorrhage,   and  the 

1  Virchow's  Archiv,  1879,  Ixxvii.  85. 


EFFUSIONS.  71 

rapid  growth  of  tumors,  has  usually  been  attributed  to  the  watery  con- 
dition of  the  blood,  with  a  diminution  of  the  albumen.  Cohnheim,  how- 
ever, suggests  that  the  condition  of  the  vessel  wall  is  of  more  importance 
than  the  contents  as  the  immediate  cause  of  the  increased  trausudatiou. 
The  more  or  less  protracted  action  of  various  agents — temperature,  in- 
sufficient oxygen,  and  diminished  albumen — is  likely  to  so  modify  the 
condition  of  the  endothelium  as  to  favor  an  increased  permeability  of  the 
wall.  Experiments  show  that  a  simple  acute  hydrsemia  produces  no 
increased  transudation,  and  that  a  chronic  hydrsemia,  if  connected  with 
dropsy,  is  likely  to  be  influential  by  increasing  the  permeability  of  the 
wall.  Even  in  those  cases  where  a  hydrsemia  and  an  oedema  co-exist,  the 
localization  of  the  latter  is  favored  by  obvious  disturbances  of  the  func- 
tion of  the  capillary  walls,  as  in  case  of  the  cutaneous  oedema  after  scar- 
latina. In  like  manner,  a  feeble  heart,  favoring  venous  stagnation,  and 
gravitation  are  of  importance,  as  general  causes,  in  promoting  dropsy  in 
hydrsernic  conditions. 

The  possibility  of  the  occurrence  of  oedema  through  nervous  influence 
is  not  to  be  denied.  The  localized  and  fleeting  oedema  of  urticaria  and 
erythema,  the  swollen  lip  and  tongue  in  connection  with  digestive  disturb- 
ances, are  not  to  be  explained  by  the  two  main  factors  of  oedema — viz. 
venous  stagnation  and  increased  permeability  of  the  vascular  walls. 
Cohnheim  refers  to  the  rapid  occurrence  of  oedema  of  the  tongue  as  a 
result  of  irritation  of  the  lingual  nerve,  and  oedema  is  known  to  occur 
rapidly  in  cases  of  acute  myelitis.  A  similar  result  follows  the  experi- 
mental destruction  of  the  spinal  cord,  although  the  mechanism  of  its  pro- 
duction is  not  apparent. 

Dropsies  are  subdivided,  as  regards  their  distribution,  into  general  and 
local  forms.  The  causes  producing  the  two  varieties  are  essentially  those 
already  described.  The  causes  of  all  local  dropsies  are  not  always  to  be 
regarded  as  the  same.  Regions  which  are  the  seat  of  mechanical  dropsies 
are  often  affected  by  inflammation,  with  abundant  serous  exudation — the 
so-called  inflammatory  dropsy.  The  properties  of  the  effusion  and  exuda- 
tion are  quite  different,  the  former  having  a  small  percentage  of  albumen, 
but  few  leucocytes,  with  a  corresponding  absence  of  fibrin,  and  few  or 
many  red  blood-corpuscles.  The  exudation,  on  the  contrary,  is  highly 
albuminous,  though  less  so  than  the  blood-plasma ;  it  contains  numerous 
leucocytes  and  much  fibrin ;  under  ordinary  circumstances  there  are  but 
few  red  blood-corpuscles. 

The  local  dropsies  are  often  characterized  by  special  terms.  Hydrops 
ex  vacuo  is  applied  to  the  collections  of  fluid  found  in  closed  cavities  with 
unyielding  walls,  as  the  cranium  and  thorax,  or  to  the  recurrence  of  fluid 
in  cavities  from  which  the  same  has  been  rapidly  removed,  in  the  absence 
of  inflammatory  disturbances.  Collateral  oedema  is  usually  applied  to  the 
association  of  oedema  with  inflammatory  disturbances,  and  represents  an 
extension  of  the  inflammatory  process  to  the  region  concerned.  (Edema 
of  the  glottis  and  circumscribed  oedema  of  the  lung  are  instances. 
The  term  hypostatic  oedema  is  often  used  to  designate  the  association  of 
oedema  and  inflammation,  the  former  caused  by  the  latter,  and  to  indicate 
the  effect  of  gravitation  in  the  localization  of  oedema  from  the  general 
causes  already  mentioned. 

Another  localized  oedema  of  interest,  from  its  frequent  occurrence  and 


72  GENERAL  MORBID  PROCESSES. 

importance,  is  oedema  of  the  lungs,  often  taking  place  toward  the  end 
of  life,  at  times  quite  suddenly.  This  form  has  usually  been  attributed 
to  increased  transudation  from  arterial  congestion  or  venous  stagnation. 
The  former  view  is  diivctly  refuted  by  the  experiments  of  Welch,1  who 
offers  the  explanation  now  accepted.  With  the  obliteration  of  three- 
fourths  of  the  arterial  supply  to  the  lungs  of  the  animals  experimented 
upon,  no  O2dema  resulted  from  the  assumed  collateral  fluxion  into  the 
branches  of  the  pulmonary  artery  which  were  left  open.  The  obliteration 
of  the  same  area  of  venous  distribution  was  nec«— ary  before  the  occur- 
rence of  oedema,  CEdema  of  the  lungs  was  further  found  to  result  from 
a  ligature  of  the  aorta  near  the  heart.  The  comparative  frequency  of 
oedema  of  the  lungs  in  man,  and  the  rarity  of  <uch  extreme  mechanical 
disturbances  as  those  produced  experimentally,  led  Welch  to  paralyze  the 
left  ventricle.  The  conditions  as  regards  the  pulmonary  circulation  then 
corresponded  with  those  mentioned  as  causes  for  (edema  from  venous 
obstruction.  The  continued  action  of  the  right  ventricle  forced  blood  into 
the  pulmonary  capillaries,  where  it  was  compelled  to  accumulate  in  con- 
sequence of  the  inability  of  the  left  ventricle  to  receive  and  expel  it. 
Welch  consequently  regards  the  immediate  cause  of  this  form  of  pul- 
monary oedema  as  a  predominant  weakness  of  the  left  ventricle.  A 
weak  heart  does  not  suffice  for  the  production  of  the  oedema,  since  this 
condition  is  not  found  when  both  ventricles  are  alike  enfeebled. 


Degenerations. 

The  degenerations  represent  disturbances  in  the  nutrition  of  the  tissues 
of  the  body,  in  consequence  of  which  their  functions  become  impaired, 
if  not  destroyed.  The  latter  result  obviously  attends  the  death  of  cells, 
which  may  occur  in  the  course  of  the  degeneration.  The  processes  con- 
cerned are  called  uecrobiotic  by  Virchow,  as  they  represent  vital  pro- 
cesses leading  to  death.  Although  in  many  of  them  the  cell  is  decaying 
during  their  continuance,  its  recover}'  is  possible  with  the  disappearance 
of  the  conditions  which  have  transformed  physiological  into  pathological 
processes.  The  degenerations  affect  intercellular  substance  as  well  as 
cells,  and  are  called  metamorphoses,  infiltrations,  or  degenerations,  as  a 
transformation  of  normal  into  abnormal  material,  or  the  addition  of 
extraneous  substances,  or  the  functional  impairment  of  the  part  a»umes 
the  greatest  prominence. 

Cloudy  Swelling,  Albuminoid  Infiltration,  Granular  Degeneration,  Paren- 
ckymatous  Degeneration. 

Of  the  various  modifications  in  the  appearance  of  cells  under  patho- 
logical conditions,  there  is  none,  perhaps,  more  commonly  met  with  than 
that  known  by  the  above  terms.  A  granular  appearance  may  be  regarded 
as  an  essential  characteristic  of  protoplasm,  and  is  an  attribute  of  cells  of 
epithelial  origin  as  well  as  of  tnoee  which  belong  to  other  groups  of  tis- 
sues. The  abundance  of  granules  present  in  a  normal  cell  depends  largely 
upon  its  shape,  size,  and  situation.  These  granules  present  various  rela- 
1  Virchow' s  Archil',  1878,  Ixxii.  375. 


DEGENERATIONS.  73 

tions  to  chemical  agents,  some  being  soluble  in  alcohol  and  ether,  others 
in  acids  and  alkalies,  and  many  of  them,  especially  those  met  with  in  the 
form  of  degeneration  now  being  considered,  show  from  the  various  reac- 
tions that  they  are  of  the  nature  of  albumen.  Since  their  exact  compo- 
sition, in  all  instances,  is  undetermined,  they  are  called  albuminoid,  and 
when  in  excess  the  cell  is  considered  to  be  infiltrated  with  these  granules, 
and  the  organ  presents  the  appearances  regarded  as  characteristic  of  an 
albuminoid  infiltration.  A  granular  cell  becomes  much  more  granular 
when  it  is  thus  infiltrated,  and  it  is  therefore  a  matter  of  difficulty  to 
recognize  from  the  appearance  of  certain  single  cells,  as  those  of  the  liver 
or  kidney,  whether  or  not  the  number  of  granules  present  is  abnormally 
increased.  When,  however,  a  large  number  of  cells  of  any  given  organ 
contain  more  than  the  normal  quantity  of  these  albuminoid  granules,  the 
appearance  of  the  organ  becomes  modified.  In  extreme  cases  the  latter 
is  swollen,  doughy  in  consistency,  with  ill-defined  structural  details,  and 
in  all  instances  presents  an  opaque  appearance.  The  term  cloudy  swell- 
ing is  thus  purely  descriptive,  and  was  applied  by  Virchow  to  designate 
the  optical  appearances  of  the  condition  in  question.  The  granules,  which 
disappear  on  the  addition  of  acids  and  alkalies,  are  apparently  either  added 
to  the  cell  or  result  from  a  precipitation  within  the  same. 

Frequently  associated  with  these  albuminoid  granules  are  others,  dis- 
tinctly recognizable  as  globules  of  fat.  An  apparent  increase  of  nuclei  is 
often  observed,  and  in  certain  organs,  as  the  kidneys,  the  cells  seem  less 
coherent  than  is  normally  the  case.  The  study  of  this  condition  in  the 
kidneys  is  further  of  interest  as  indicating  that  the  border-line  between 
a  parenchymatous  degeneration  and  a  parenchymatous  inflammation  is 
purely  arbitrary.  From  similar  exciting  causes  there  may  be  associated, 
with  the  described  alterations  of  the  epithelial  lining  of  the  tubes,  the 
exudation  of  albumen,  the  formation  of  casts,  the  dcsquamation  of  epi- 
thelium, and  the  presence  of  leucocytes  within  the  tubules. 

AVhen  the  macroscopic  changes  are  of  moderate  degree,  and  the  disturb- 
ance of  function  relatively  slight,  while  the  concurrent  alterations  else- 
where, from  the  simultaneous  action  of  the  same  cause,  are  predominant 
and  characteristic  of  the  disease,  the  condition  is  conveniently  regarded  as 
a  degeneration  occurring  in  the  course  of  the  latter,  rather  than  an  inflam- 
mation. The  latter  term,  on  the  contrary,  is  to  be  applied  when  the 
granular  infiltration  of  the  cells  is  associated  with  other  evidences  of  an 
inflammatory  exudation,  and  when  the  pathological  disturbances  are  to 
be  directly  attributed  to  the  parenchymatous  changes. 

It- is  customary  to  speak  of  cloudy  swelling  as  a  nutritive  change,  and 
the  condition  may  be  induced  by  those  causes  which  interfere  with  the 
nutrition  of  parts  or  of  the  whole  of  an  organ.  Many  authorities  regard 
this  granular  or  parenchymatous  degeneration  as  closely  allied  to  fatty 
degeneration,  since  many  of  the  causes  which  produce  the  one  occasion 
the  other.  The  former  is  often  spoken  of  as  an  earlier  stage  of  the  latter, 
from  the  frequent  association  of  the  albuminoid  granules  with  numer- 
ous globules  of  fat  as  a  result  of  the  more  prolonged  or  more  intense 
action  of  a  given  cause. 

Organs  which  give  evidence  of  a  granular  degeneration  contain,  as  a 
rule,  a  diminished  quantity  of  blood.  This  feature  is  usually  attributed 
to  the  pressure  of  the  swollen  cells  upon  capillary  blood-vessels.  The 


74  GENERAL  MORBID  PROCESSES. 

ansemic  organ  obviously  becomes  still  more  cloudy,  gray,  and  opaque  in 
appearance  from  the  diminished  quantity  or  impoverished  quality  of  the 
blood. 

The  granular  degenerations  of  the  heart,  liver,  and  kidneys,  as  a  whole, 
usually  occur  simultaneously,  and  afford  a  most  important  means  for  the 
post-mortem  recognition  of  the  infective  diseases.  The  condition  is  there- 
fore to  be  looked  for  in  the  exanthemata,  especially  in  small-pox  and 
scarlet  fever,  also  in  erysipelas,  septicaemia  in  its  manifold  forms,  diph- 
theria, typhoid  and  typhus  fevers,  cerebro-spinal  meningitis,  etc.  A 
common  feature  in  all  these  cases  is  the  occurrence  of  fever,  and  it  has 
been  claimed  that  this  element  is  the  cause  of  the  degeneration.  In  oppo- 
sition to  this  view  is  the  well-known  fact  of  its  presence  in  afebrile  cases 
of  poisoning  from  carbonic  oxide,  and  its  absence  in  certain  cases  of 
pneumonia  and  exposure  to  high  temperatures. 

The  universal  occurrence  of  cloudy  swelling  in  fatal  cases  of  the  affec- 
tions above  mentioned  leads  to  the  inference  of  its  presence  in  those 
instances  terminating  in  recovery  without  obvious  permanent  impairment 
of  the  organs  and  tissues  concerned.  It  is  therefore  agreed  that  the 
process  may  terminate  in  resolution — i.  e.  in  a  disappearance  of  the  excess 
of  granular  material.  On  the  other  hand,  its  association,  under  circum- 
stances, with  fatty  degeneration  suggests  as  extremely  probable  that  the 
latter  condition  may  represent  a  result  of  the  albuminoid  infiltration. 
Even  if  this  more  serious  issue  exists,  the  possibilities  are  still  at  hand 
for  an  absorption  of  the  degenerated  material  and  a  restitution  of  the 
destroyed  protoplasm.  The  effect  upon  the  individual  is  evidently  deter- 
mined by  the  persistence  and  dissemination  of  the  condition,  which,  in 
turn,  are  controlled  by  the  immediate  cause  and  the  peculiarities  of 
the  individual  acted  upon. 

Fatty  Metamorphosis,  Fatty  Degeneration,  and  Fatty  Infiltration. 

The  fat  which  is  present  within  the  body  under  physiological  condi- 
tions owes  its  origin  primarily  to  the  food  taken.  A  diet  which  is  abun- 
dantly fatty  furnishes  a  direct  source  for  much  of  the  fat  which  appears 
accumulated  in  the  various  organs  and  tissues..  Although  it  may  now 
appear  that  such  a  statement  needs  but  little  confirmation,  it  is  not  long 
since  the  opinion  prevailed  that  nearly  all  the  fat  in  the  body  came  from 
the  hydrocarbons  of  the  food.  This  seemed  all  the  more  plausible  as 
the  herbivora  readily  accumulated  fat,  although  their  diet  might  contain 
this  element  in  very  small  quantities.  Hofmaun1  made  a  decisive  experi- 
ment with  reference  to  the  origin  of  fat  from  fatty  food  by  feeding  a  dog, 
made  lean  by  starvation,  with  bacon  in  abundance,  but  with  little  meat.  In 
the  course  of  a  few  days  the  greater  part  of  the  fat  introduced  was  depos- 
ited within  the  tissues  of  the  animal.  Other  experimenters  have  arrived 
at  a  similar  result,  and  it  can  no  longer  be  questioned  that  fat,  accumu- 
lated within  the  body,  owes  its  origin  chiefly  to  the  absorption  of  fat  from 
the  food  taken. 

Another  source  for  the  fat  of  the  body  has  long  been  suggested — 
namely,  the  albuminates  of  the  food.  In  the  admirable  article  on  the 
formation  of  fat  by  Voit,2  from  which  most  of  the  information  herein 

1  Zeilschrift  filr  Biologie,  1872,  viii.  153. 

9  Herrmann's  Ilandbuch  der  Physiologie,  1881,  vi.  1,  235. 


DEGENERATIONS.  75 

presented  is  derived,  it  is  claimed  that  he  and  Pettenkofer  were  the  first 
to  prove  the  origin  of  fat  in  the  body,  under  normal  conditions,  from 
albumen.  This  proof  was  an  inference,  however,  although  presenting  a 
high  degree  of  probability.  Valuable  evidence  in  the  same  direction 
was  furnished  by  Kemmerich,  who  found  that  the  milk  of  a  cow  during 
a  certain  period  held  more  fat  than  was  contained  in  the  food ;  Subbotin 
and  Voit  have  shown  that  more  milk  is  secreted  the  richer  the  diet  in 
albumen.  Still  other  observers  have  furnished  more  decisive  proof  that 
fat  is  formed  from  albuminates. 

Two  sources  for  fat  in  the  body  under  physiological  conditions  are 
thus  recognized :  1,  the  free  fat  in  the  food ;  2,  the  fat  derived  from  the 
decomposition  of  the  albuminates  of  the  food. 

Voit  admits  the  possibility  of  the  hydrocarbons  serving  as  a  third 
source,  although  this  possibility  is  unnecessary  in  most  cases.  Should 
instances  arise,  however,  where  other  sources  for  fat  are  found  insufficient, 
the  hydrocarbons  must  be  regarded  as  filling  the  gap. 

Fat  which  is  taken  into  the  body  is  considered  to  be  either  consumed 
or  stored.  That  which  is  stored  is  chiefly  accumulated  in  the  great  res- 
ervoirs— viz.  the  subcutaneous  and  periuephritic  fat  tissue,  the  mesentery, 
omentum,  and  bone-marrow — although  it  may  be  found  elsewhere,  in 
the  fluids  and  tissues  of  the  body.  This  accumulation  serves  as  a  source 
to  be  drawn  from  in  case  of  need,  and  is  called  upon  where  the  easily- 
decomposed  soluble  albumen  is  disposed  of  by  the  functional  activity  of 
the  cells.  An  acting  muscle  demands  food  for  its  work,  and  consumes 
first  the  soluble  albumen,  then  the  fat.  An  excessive  waste  of  fat  is 
delayed  by  the  decomposition  of  hydrocarbons,  but  the  demands  may 
become  so  great  that  albumen,  fat,  and  hydrocarbons  are  consumed  more 
rapidly  and  constantly  than  they  can  be  supplied.  It  being,  therefore, 
admitted  that  fat  is  formed  from  the  albuminates,  as  well  as  from  the 
fat  of  the  food,  the  question  readily  presents  itself  whether  fat  may  not 
be  formed  from  the  fixed  albuminates  of  the  body,  especially  from  those 
contained  within  its  cells. 

It  is  well  known  that  in  the  secretion  of  sebum  the  superficial  cells  of 
the  sebaceous  follicles  contain  fat  in  great  quantity,  while  the  deeper  layers 
are  comparatively  free  from  any  appearances  indicative  of  the  presence 
of  fat.  It  is  further  admitted  that  when  pus  is  retained  for  a  time  the 
individual  corpuscles  contain  i fat-drops  in  quantity  and  become  trans- 
formed into  fatty  granular  corpuscles.  Eventually,  the  pus  is  trans- 
formed into  a  detritus  in  which  fat-drops  are  found  in  great  number. 

Similar  appearances  may  be  present  in  the  protoplasm  of  muscular 
tissue,  the  cells  of  the  liver,  kidneys,  and  gastric  glands,  when  poisonous 
doses  of  phosphorus  or  arsenic  are  given.  The  occurence  of  an  acute  fatty 
metamorphosis  of  the  cells  of  various  organs  in  new-born  children  has  re- 
peatedly been  observed.  The  presence  of  fat  in  various  organs  of  the  body 
in  pernicious  anaemia,  and  in  the  heart  in  connection  with  stenosis  of  the 
coronary  artery,  is  universally  recognized.  The  abuse  of  alcohol,  long-con- 
tinued obstruction  to  the  flow  of  venous  blood,  exposure  to  high  tempera- 
tures, are  all  known  to  be  conditions  in  connection  with  which  fat-drops  are 
found  in  the  various  cells  of  the  body.  The  effects  of  poisoning  with  phos- 
phorus and  arsenic  are  of  special  importance,  as  showing  that  the  abundance 
of  fat  present  in  the  cells  represents  a  result  of  the  degeneration  of  these  cells, 


76  GENERAL  MORBID  PROCESSES. 

since  it  takes  place  when  the  animal  is  deprived  of  food.  Although 
there  is  an  evident  destruction  of  albumen,  there  is  also  a  diminished 
elimination  of  carbonic  acid  and  admission  of  oxygen.  These  facts  are 
explicable  on  the  ground  that  the  fat  present  is  not  consumed,  and  the 
accumulation  in  the  cells  is  evidence  of  this  lack  of  consumption.  The 
fat  is  not  simply  stored,  as  none  is  taken  in,  nor  is  any  food  received 
from  which  fat  might  be  formed.  Its  presence,  therefore,  must  be  re- 
garded as  due  to  degeneration. 

Since  fat  may  be  formed  in  the  body  as  a  result  of  the  metamorphosis 
of  cell-protoplasm,  it  is  desirable  to  ascertain  whether  there  are  any 
means  by  which  stored  fat  may  be  distinguished  from  that  present  as  the 
result  of  a  degeneration  of  the  cell.  The  term  fatty  infiltration  lias 
been  used  to  indicate  the  presence  of  stored  fat,  the  latter  being  regarded 
as  simply  taken  into  the  cell  and  retained  for  a  longer  or  shorter  time, 
without  any  necessary  interference  with  other  functions  possessed  by  the 
cell. 

In  fatty  degeneration,  on  the  contrary,  it  is  considered  that  the  quantity 
of  fat  present  indicates  a  corresponding  diminution  in  the  albumiuatcs  of 
the  cell,  and  is  connected  with  a  diminution  in  the  function  of  the  latter, 
all  the  greater  the  more  abundant  the  fat. 

It  is  found  that  in  fatty  infiltration,  as  a  rule,  the  fat  is  present  in  large 
drops,  the  size  of  the  cell  being  increased  in  proportion  to  the  quantity 
of  fat  present.  Although  there  may  be  several  drops  present,  they  tend 
to  run  together,  as  is  suggested  by  their  different  size,  varying  proximity, 
and  the  constant  presence  of  a  considerable  quantity  of  protoplasm.  In 
organs,  on  the  contrary,  whose  function  is  seriously,  even  fatally, 
impaired,  the  fat,  as  a  rule,  assumes  rather  a  granular  form.  Many 
minute  fat-drops  are  present,  and  the  cell  is  not  particularly,  if  at  all, 
increased  in  size.  The  more  abundant  the  fat  the  less  the  protoplasm. 
Appearances  are  met  with  indicating  a  transition  between  cells  with  few 
fat-granules  and  those  with  many. 

If  the  morphological  appearances  of  fatty  infiltration  and  of  fatty 
degeneration  were  constant,  there  would  obviously  be  little  or  no  difficulty 
in  determining  the  nature  of  the  process  manifested  by  the  presence  of 
fat.  The  exceptions  occur  both  in  fatty  infiltration  and  fatty  degenera- 
tion. In  the  cells  of  the  liver  of  an  animal  poisoned  with  phosphorus 
fat  makes  its  appearance  in  large  drops,  while  in  the  heart  and  kidneys 
of  the  same  animal  the  fat  is  present  in  a  granular  form. 

During  absorption  from  the  intestine  in  the  process  of  digestion  fat 
is  present  in  the  epithelium  in  a  finely  granular  form.  When  diges- 
tion is  completed  fat  is  no  longer  met  with  in  these  cells.  The  pres- 
ence of  large  or  small  drops,  therefore,  cannot  be  regarded  as  a  sufficient 
test  of  the  origin  of  the  fat.  It  is  of  equal,  if  not  greater,  importance 
to  bear  in  mind  the  organ  concerned. 

In  the  heart,  liver,  kidneys,  and  gastric  glands,  as  well  as  elsewhere, 
with  the  exception,  perhaps,  of  the  mammary  gland,  the  presence  of  many 
small  fat-drops  in  the  cells  indicates  a  degeneration  of  its  protoplasm. 
The  presence  of  large  fat-drops,  on  the  contrary,  in  the  organs  and  tissues, 
with  the  exception  of  the  liver,  indicates  an  infiltration.  Large  fat-drops, 
then,  may  be  present  in  the  cells  of  the  liver  as  the  result  of  an  infiltration 
or  of  a  degeneration.  In  order  to  form  a  satisfactory  opinion  of  the 


DEGENERA  TIONS.  1 7 

nature  of  the  appearances  in  the  liver  in  doubtful  cases,  it  is  important  to 
note  the  condition  of  those  organs  which  may  be  simultaneously  in  a 
state  of  fatty  degeneration. 

The  accumulation  of  fat  under  physiological  conditions  is  obviously 
brought  about,  on  the  one  hand,  by  those  causes  which  permit  a  free 
introduction,  absorption,  and  deposition,  and,  on  the  other,  by  those 
which  check  its  oxidation  or  elimination  with  the  secretions  of  the  body, 
as  the  bile,  in  which  it  may  be  present  to  a  considerable  extent.  A  diet 
rich  in  fat,  or  in  albuminates  readily  converted  into  fat,  offers  a  favorable 
element  for  the  absorption  of  fat  by  the  healthy  individual.  If  the  organ- 
ism demands  but  little  of  this  fat  for  oxidation,  as  in  the  case  of  the  seden- 
tary person,  an  accumulation  is  likely  to  occur.  This  may  become  so 
considerable  that  obesity  results.  Tissues  in  which  normally  but  little 
fat  is  accumulated  may  become  infiltrated  to  a  large  extent.  The  inter- 
muscular  fibrous  tissue  thus  becomes  loaded,  and  the  activity,  as  well  as 
the  nutrition,  of  the  muscles  is  impaired.  This  accumulation  may  be 
manifested  not  only  in  the  voluntary  muscles,  but  in  the  heart  as  well, 
which  may  present  abundant  sub-pericardial  and  sub-endocardial  fat,  the 
myocardium  also  being  interlarded  with  streaks  of  fat,  the  so-called  fatty 
infiltration  of  the  heart.  The  abdominal  walls  may  become  thickened  to 
the  extent  of  a  couple  of  inches,  and  the  mesentery,  omentum,  peri- 
nephritic  tissue,  and  liver  may  become  enormously  increased  in  weight 
from  the  mass  of  accumulated  fat. 

This  infiltration  of  fat  may  take  place  under  pathological  as  well  as  phys- 
iological conditions.  It  is  apparent  that  those  causes  which  check  oxidation 
are  likely  also  to  prevent  the  consumption  of  fat,  and  it  is  well  known 
that  the  destructive  processes  in  the  lung,  grouped  under  the  term  pul- 
monary consumption,  accomplish  this  result.  Something  more,  however, 
is  necessary  than  the  obliteration  of  pulmonary  blood-vessels  and  the  de- 
struction of  an  aerating  surface.  There  may  be,  as  in  emphysema  of  the 
lung,  a  diminished  respiratory  and  vascular  surface,  yet  evidences  of 
fatty  infiltration,  particularly  of  the  liver,  are  wanting.  It  seems  prob- 
able that  the  constant  anaemia,  with  the  loss  of  the  blood-corpuscles,  of 
pulmonary  phthisis  is  an  important  additional  factor  in  checking  oxida- 
tion in  this  disease.  This  factor,  it  is  needless  to  say,  is  not  a  necessary 
occurrence  in  pulmonary  emphysema. 

Litten1  has  shown  that  when  certain  animals  are  exposed  to  high  tem- 
peratures the  appearances  of  fatty  infiltration  and  degeneration  are  present 
in  various  organs  of  the  body.  He  attributes  the  fatty  degeneration  to  a 
direct  poisoning  of  the  red  blood-corpuscles  and  a  resulting  diminution 
of  the  oxidizing  processes. 

It  is  universally  admitted  that  in  chronic  alcoholism  a  fatty  liver  is 
frequently  met  with,  even  in  the  absence  of  those  chronic  interstitial 
tissue-changes  usually  characterized  under  the  name  cirrhosis.  Alcohol  is 
known  to  check  the  reception  of  oxygen  and  the  elimination  of  carbonic 
acid,  and,  whatever  other  disturbance  of  cell-activity  it  may  produce,  its 
effect  in  favoring  the  accumulation  of  fat  is  directly  attributable,  in  part 
at  least,  to  this  disturbance  of  oxidation. 

In  those  conditions  known  as  cachexise,  the  constant  accompaniment  of 
progressive  and  wasting  diseases,  as  cancer,  leucaemia,  chronic  dysentery, 

1  Virch&uts  Archiv,  1877,  Ixx.  10. 


78  GENERAL  MORBID  PROCESSES. 

etc.,  a  fatty  infiltration,  particularly  of  the  liver,  is  a  frequent  accom- 
paniment. A  cachexia  is  dependent  upon  a  complex  series  of  processes, 
many  of  which  tend  to  check  oxidation,  and  in  this  respect  is  to  be 
grouped  with  the  conditions  previously  mentioned.  That  the  associated 
fatty  infiltration  is  intimately  connected  with  the  deficient  oxidation  is 
not  to  be  doubted,  although  the  agents  producing  this  deficiency  may 
vary  in  detail. 

The  causes  which  favor  fatty  degeneration  are  numerous,  and  the  result 
represents  one  of  the  most  serious  conditions  which  can  affect  an  organ. 
As  oxidation  represents  the  chief  means  of  normally  disposing  of  fat,  so, 
pathologically,  deficient  oxidation  favors  the  retention  of  fat  due  to  degen- 
eration. Were  a  constant  renewal  of  protoplasm  to  take  place,  the 
degenerated  fat  might  be  displaced  into  the  circulation  or  retained  within 
the  cell.  If  the  latter  event  should  occur,  the  result  would  be  apparent 
as  an  infiltration,  owing  to  the  increased  size  of  the  cell,  although  the 
condition  giving  rise  to  the  presence  of  the  fat  is  a  degenerative  process. 
The  importance  of  impairment  of  nutrition  as  the  chief  cause  for  fatty 
degeneration  is  thus  obvious.  It  may  readily  be  produced,  experimentally, 
by  measures  which  check  the  flow  of  blood  to  a  part.  The  same  meas- 
ures necessarily  prevent  the  presence  of  abundant  oxygen,  as  fewer  red 
blood -corpuscles  are  presented. 

Fatty  degeneration  resulting  from  impaired  nutrition  is  apparent  in 
the  heart  in  consequence  of  stenosis  of  its  coronary  arteries,  in  the  kid- 
neys as  a  result  of  interstitial  processes  obstructing  the  capillary  circula- 
tion, in  the  brain  from  obliterative  processes  in  the  arteries  at  the  base  or 
within  the  organ,  and  in  blood-vessels  from  the  effect  of  age. 

The  cause  of  fatty  degeneration  may  be  general  as  well  as  local.  In 
poisoning  from  phosphorus  and  arsenic  the  appearances  in  most  of  the 
organs  indicate  an  actual  destruction  of  protoplasm.  Analysis  of  the 
secretions  confirms  this  inference,  as  the  production  of  urea  is  largely 
increased.  Furthermore,  there  is  less  oxygen  taken  in  and  less  carbonic 
acid  eliminated.  As  has  been  previously  stated,  these  conditions  may  be 
present  in  the  starving  animal.  The  fatty  degeneration  is  thus  easily 
explained  as  a  metamorphosis  of  cell -protoplasm,  and  the  deficient  oxi- 
dation of  the  fat  calls  direct  attention  to  its  accumulation  rather  than 
elimination. 

In  acute  yellow  atrophy  of  the  liver  and  in  cases  of  severe  jaundice 
fatty  degenerations  are  constantly  met  with.  That  the  origin  and  accu- 
mulation of  fat  in  these  affections  is  also  due  to  rapid  tissue-metamor- 
phosis and  checked  oxidation  is  highly  probable.  Although  the  elim- 
ination of  urea  diminishes  rather  than  increases,  as  shown  by  Schultzen 
and  Biess,  there  are  other  links  in  the  chain  of  retrograde  changes,  as 
the  appearance  of  leuciu  and  tyrosin,  indicative  of  the  extensive  destruc- 
tion of  albuminates. 

It  is  unnecessary  in  a  work  of  the  present  character  to  call  attention  to 
all  the  possible  circumstances  under  which  fat  is  present  in  the  body  as 
the  result  of  degeneration.  Mention  may  be  made  of  the  acute  paren- 
chymatous  (fatty)  degeneration  of  new-born  children,  of  the  results  of 
excessive  bleeding,  and  of  pernicious  ancemia  otherwise  occasioned.  The 
fatty  degeneration  of  the  uterus  after  parturition,  of  paralyzed  muscles, 
and  of  tumors,  the  atrophic  fatty  degeneration  of  the  liver  in  chronic 


DEGENERATIONS.  79 

passive  congestion  (nutmeg  liver),  are  all  well-known  examples.  To 
these  may  be  added  the  fatty  degenerations  associated  with  amyloid  and 
interstitial  processes.  It  is  apparent  that  in  most  of  these  instances 
the  common  features  of  rapid  tissue-metamorphosis  and  deficient  oxida- 
tion are  present,  and,  being  present,  offer  a  ready  explanation  for  the 
appearance  of  the  fat. 

The  clinical  importance  of  fatty  metamorphosis  requires  consideration 
in  connection  with  the  description  of  the  diseases  in  which  its  occurrence 
is  a  constant  feature.  As  the  presence  of  fat  in  cells  is  not  necessarily 
pathological,  so  an  interference  with  the  function  of  the  cell  is  not  invari- 
ably implied  by  its  presence.  When  its  existence  is  suggestive  of  a  local 
destruction  of  albuminates,  a  diminution  of  cell-activity  is  a  necessary 
consequence.  Such  diminished  activity  must  produce  different  results  as 
the  cells  are  those  of  muscles,  of  vessels,  or  of  glandular  organs. 

Even  if  fat  is  found  in  cells  under  conditions  favoring  such  a  sugges- 
tion, it  does  not  follow  that  the  destruction  of  the  cell  must  result.  Not 
only  is  it  possible  that  the  fat  may  be  reserved  for  eventual  oxidation, 
and  its  place  in  the  protoplasm  be  filled  by  normal  constituents,  but  it 
is  also  possible  that  the  fat  may  be  eliminated,  as  such,  from  the  body. 
The  latter  event  is  made  apparent  by  the  experiments  of  numerous 
observers  referred  to  by  Cohnheim,  who  have  found  free  fat  in  the  urine 
after  its  introduction  into  the  venous  current. 

Cheesy  Metamorphosis,  Cheesy  Degeneration,  Caseation. 

Virchow  introduced  the  term  cheesy  metamorphosis,  tyrosis,  to  desig- 
nate the  process  resulting  in  the  incomplete  absorption  of  pus  and  the  pro- 
duction of  apparently  similar  changes  in  certain  other  occasional  constitu- 
ents of  the  body.  The  characteristic  cheesy  appearances  were  regarded 
as  due  to  the  inspissation  of  the  material  concerned,  in  consequence  of 
the  absorption  of  its  fluid.  With  this  inspissation  there  was  frequently 
associated  a  partial  fatty  degeneration,  and  the  cheesy  matter  repre- 
sented dead  material,  which  might  undergo  further  changes,  of  which  soft- 
ening and  calcification  were  the  more  important. 

Inflammatory  products,  as  pus  and  fibrin,  were  especially  prone  to 
become  thus  transformed,  as  well  as  other  relatively  transitory  materials 
of  new  formation  —  viz.  tubercle  and  parts  of  various  tumors.  The 
type  of  the  cheesy  metamorphosis  was  found  in  the  enlarged  lymphatic 
glands,  commonly  called  scrofulous. 

The  importance  of  a  clear  understanding  of  the  cheesy  metamorphosis 
is  now  a  matter  of  history.  It  is  merely  necessary  to  allude  to  the  fact 
that  these  cheesy  products  were  formerly  regarded  as  indicative  of 
the  presence  of  tubercle,  and  were  the  tubercles.  Tuberculization  and 
the  cheesy  condition  were  synonymous  terms,  and  their  indiscriminate 
use  led  to  much  confusion  with  reference  to  the  nature  of  tubercle. 

Quite  recently  Weigert1  has  called  attention  to  the  conditions  present 
in  necrosis  resulting  from  the  intermediate  stoppage  of  the  blood-current 
in  a  part.  The  effect  is  manifested,  under  favoring  circumstances,  by  a 
cheesy  appearance  of  the  affected  region,  to  which  the  terms  decolorized 
hemorrhagic  infarction,  anaemic  or  ischsemic  necrosis,  have  been  applied. 
1  Virchow's  Archiv,  1880,  Ixxix.  87. 


80  GENERAL  MORBID  PROCESSES. 

Weigert  lavs  stress  upon  the  existence  of  a  coagulation  of  the  protoplasm 
of  the  cells,  with  an  early  disappearance  of  the  nuclei,  as  the  essential  feature 
of  this  form  of  necrosis,  the  conditions  present  being  regarded  as  analogous 
to  those  met  with  in  the  coagulation  of  the  blood.  The  term  coagulative 
necrosis  has  consequently  been  introduced  by  Cohnheim  to  represent  the 
process  first  fully  described  in  detail  by  "Weigert.  The  optical  and  phys- 
ical properties  of  the  ischremic  or  coagnlative  necroses  of  tissue  are  often 
manifested  as  cheesy  appearances,  although  the  term  coagulative  necrosis 
includes  conditions  which  do  not  present  a  suggestion  of  cheese.  It  is 
thus  apparent  that  cheesy  appearances  may  result  in  two  ways  :  1,  by  the 
inspissation  of  material  in  a  state  of  partial  fatty  degeneration ;  2,  by  a 
coagulation  of  the  constituents  of  cells  whose  blood -supply  is  suddenly 
and  completely  cut  off.  In  the  more  restricted  sense  these  caseous  appear- 
ances are  regarded  as  indicative  of  a  cheesy  metamorphosis  which  arises 
by  the  former  of  these  methods.  Cheesy  appearances,  on  the  contrary, 
dependent  upon  the  sudden  death  of  a  part,  indicate  an  ischsemic  or 
coagulative  necrosis. 

Whatever  may  be  the  origin  of  the  cheesy  condition,  the  material  pre- 
senting this  appearance  is  liable  to  further  changes,  known  as  softening 
and  calcification.  The  former  event  results  from  the  soaking  of  the  dead 
part  with  liquid,  in  consequence  of  which  a  detritus  results.  The  soften- 
ing usually  begins  at  the  oldest  part  of  the  cheesy  mass,  and  advances 
toward  the  periphery.  The  sanatory  evacuation  of  the  emulsive  detritus 
is  permitted  when  a  surface  continuous  with  that  of  the  external  surface 
of  the  body  is  reached,  as  instanced  by  the  escape  of  softened  cheesy 
material  from  the  lungs  through  a  bronchus.  The  possibility  of  the  com- 
plete removal  of  the  dead  mass  is  thus  at  hand,  and  an  eventual  oblitera- 
tion of  the  resulting  cavity  may  take  place  by  an  adhesive  inflammation 
of  its  walls. 

The  complete  absorption  of  the  cheesy  material  of  an  ischaemic  necrosis 
may  occur  by  the  extension  into  the  latter  of  a  granulation-tissue  from 
the  periphery.  Whenever  cheesy  appearances  are  found  on  surfaces,  as 
the  degenerated  tubercles  of  mucous  membranes  or  the  circumscribed 
necroses  in  diphtheritic  inflammation  or  in  typhoid  fever,  healing  may 
be  accomplished  by  their  detachment  as  sloughs,  a  clean  ulcer  being  left. 
Cheesy  material  is  frequently  encapsulated — i.  e.  imbedded  in  a  layer  of 
dense  connective  tissue,  a  condition  which  indicates  a  local  cessation  of 
the  process  through  which  the  cheesy  appearances  arose.  The  same  may 
be  said  of  the  infiltration  of  the  cheesy  mass  with  earthy  salts — calcifica- 
tion— an  event  which  will  again  be  referred  to  in  connection  with  the 
consideration  of  the  general  subject. 

Hyaline  Degeneration,  Fibrinom  Degeneration,  Croupous  Metamorphosis. 

Certain  of  the  conditions  now  regarded  as  indicative  of  a  coagulative 
necrosis  or  a  hyaline  degeneration  were  previously  described  by  Wagner 
as  the  result  of  a  croupous  or  fibriuous  metamorphosis.  According  to  this 
observer,  the  cell-contents  were  transformed,  under  certain  circumstances, 
into  a  substance  resembling  externally  clotted  fibrin.  The  formation  of 
croupous  and  diphtheritic  membranes,  especially  of  the  larynx,  pharynx, 
and  trachea,  was  thus  explained,  also  the  hyaline  casts  of  the  kidney. 


DEGENERATIONS.  81 

The  results  of  this  metamorphosis  presented  a  hyaline  appearance  under 
the  microscope,  and  the  term  hyaline  degeneration  is  now  applied  more 
especially  to  indicate  the  production  of  microscopic  changes,  while  the 
hyaline  appearances  visible  to  the  eye  are  rather  included  under  mucous, 
colloid,  or  amyloid  metamorphoses. 

The  limitations  in  the  use  of  the  term  hyaline  degeneration  are  but  ill 
defined.  On  the  one  hand,  there  is  included  the  transformation  of  mus- 
cular tissue,  first  discovered  by  Zenker ;  on  the  other,  the  various  changes 
described  by  Recklinghausen  and  others,  among  which  are  embraced  the 
results  of  Wagner's  croupous  metamorphosis.  As  the  hyaline  appear- 
ances are  a  frequent  result  of  coagulative  necrosis,  these  terms  are  fre- 
quently used  to  indicate  the  same  condition,  according  as  the  optical  or 
etiological  features  are  uppermost  in  the  mind  of  the  observer. 

The  hyaline  or  waxy  degeneration  of  muscular  fibre  described  by 
Zenker  represents  a  metamorphosis  of  the  protoplasm  of  striated  muscle 
in  particular,  although  the  fusiform  cells  of  the  muscular  coat  of  the 
stomach  and  intestine  may  present  a  similar  transformation. 

The  microscopic  appearances  are  more  characteristic  than  those  visible 
to  the  naked  eye.  To  the  latter  the  muscle  appears  paler,  more  translu- 
cent, and  homogeneous,  and  proves  to  be  more  brittle  than  normal.  The 
muscular  fibres  are  found  with  the  microscope  to  be  swollen,  irregular  in 
outline,  the  myosin  transformed  into  flaky,  glistening  masses,  without 
evidence  of  the  normal  transverse  striation.  These  appearances  have 
given  rise  to  the  term  waxy  degeneration,  which  suggests  a  possibility 
of  confusion  with  the  earlier  recognized  waxy  degeneration  of  organs, 
due  to  the  presence  of  amyloid  material.  The  wraxy  transformation  of 
muscular  fibre,  however,  does  not  present  the  reaction  with  iodine  charac- 
teristic of  amyloid  substance.  The  degeneration  of  the  muscle  is  usually 
regarded  as  the  result  of  a  coagulation  of  the  myosin,  and  it  is  claimed 
by  Cohuheim  that  the  latter  takes  place  only  in  dead  muscle,  either 
during  the  life  of  the  individual  or  as  a  post-mortem  appearance. 

The  hyaline  degeneration  of  muscular  fibre  is  found  in  certain  febrile 
diseases,  as  typhoid  and  typhus  fevers,  scarlatina,  variola,  and  cerebro- 
spinal  meningitis.  It  may  also  be  met  with  when  a  muscle  has  been 
exposed  to  violence,  as  in  the  insane  who  have  been  placed  under  mechan- 
ical restraint.  It  has  further  been  found  in  the  vicinity  of  tumors, 
especially  where  muscles  have  been  invaded  by  their  growth.  Cohn- 
heim  and  Weil  describe  a  similar  condition  in  the  tongue  of  frogs  after 
ligature  of  the  lingual  artery. 

The  pathological  importance  of  the  above-mentioned  degeneration  of 
muscle  is  most  prominent  in  cases  of  typhoid  fever.  The  occurrence  in 
this  disease  of  the  hsematoma  or  blood-tumor  of  the  rectus  abdominis  is 
thus  explained,  the  degenerated  muscle  and  its  contained  blood-vessels 
being  ruptured.  The  muscles  of  the  thigh  and  the  diaphragm  frequently 
undergo  this  degeneration ;  the  change  is  more  rarely  met  with  in  other 
muscles  of  the  body. 

Recklinghausen  regards  a  hyaline  substance,  hyalin,  as  a  normal  con- 
stituent of  cell-protoplasm  which  escapes  in  drops  when  the  cell  dies. 
Its  presence  indicates  a  diminution  in  the  vitality  of  the  cell  from  various 
causes.  Under  the  microscope  it  appears  as  a  sharply  defined,  highly 
refractive  meshwork,  enclosing  spaces  of  irregular  shape  and  size,  in 
VOL.  I.— 6 


82  GENERAL  MORBID  PROCESSES. 

which  are  frequently  found  nuclei,  more  rarely  cells  or  granules.  Lang- 
hans  has  described  this  appearance  as  channelled  fibrin.  It  has  been  met 
with  in  the  placenta,  diphtheritic  membranes,  blood-vessels,  tubercles, 
and  gummata. 

The  latest  contribution  to  the  history  and  nature  of  this  form  of  degen- 
eration has  been  furnished  by  Vallat,1  from  whose  article  many  of  the 
above  data  have  been  obtained. 

Mucous  Degeneration,  Mucous  Metamorphosis,  Mucous  Softening. 

Of  the  various  degenerations  presenting  a  colloid — i.  e.  gelatinous — 
condition,  the  mucous  variety  is  one  of  the  most  striking.  Its  gross 
appearances  may  not  diifer  materially  from  those  to  be  described  under 
the  head  of  colloid  degeneration,  but  the  diagnostic  characteristic  of  the 
change  is  to  be  found  in  the  presence  of  mucin.  The  presence  of  this 
substance  is  readily  detected  by  the  addition  of  acetic  acid  to  mucus,  the 
effect  being  a  fibrillated  appearance  of  the  latter,  the  fibres  presenting  a 
more  or  less  parallel  distribution.  This  fibrillation  of  mucus  is  regarded 
as  the  result  of  a  coagulation  of  its  mucin,  previously  held  in  solution  by 
an  alkali.  Mucin  is  thus  present  in  the  body  as  a  normal  constituent, 
and,  in  the  secretions  from  mucous  membranes,  owes  its  origin  to  the 
existence  of  epithelial  cells,  whether  these  represent  gland-cells,  as  in  the 
case  of  the  muciparous  glands  of  the  bronchial  mucous  membranes,  or 
whether  they  are  superficial  cells,  as  those  of  the  gastric  and  intestinal 
mucous  membranes. 

In  the  origin  of  mucus  as  a  secretion  from  glands  Heidenhain2  claims 
that  a  destruction  of  gland-cells  accompanies  the  continuance  of  the  secre- 
tion. At  the  outset,  however,  the  mucin  escapes  from  the  cells,  the  latter 
remaining  relatively  intact.  With  the  persistence  of  the  secretion  there 
results  a  destruction  and  a  new  formation  of  the  muciparous  cells.  In  the 
pathological  production  of  mucus  from  mucous  membranes,  as  in  catarrh, 
there  is  no  reason  to  doubt  that  the  persistence  of  an  irritation  is  the 
cause  of  abundant  mucus,  and  that  the  latter  is  dependent  upon  the  rapid 
formation  and  destruction  of  epithelial  cells. 

The  origin  of  mucus  from  epithelial  cells  under  physiological  and 
pathological  conditions  being  apparent,  it  readily  follows  that  the  epi- 
thelioid  cells  of  tumors  might  be  supposed  to  be  liable  to  a  similar  meta- 
morphosis. It  is  well  known  that  cancerous  tumors,  especially  those  of 
the  stomach  and  large  intestine,  are  frequently  met  with,  which  present 
an  abundant  gelatinous  material,  more  or  less  completely  filling  the 
spongy,  fibrous  meshwork.  These  are  the  alveolar,  gelatinous,  or  colloid 
cancers. 

The  gelatinous  or  colloid  material  often  gives  the  reaction  of  mucin, 
and  the  microscopic  appearances  of  the  tumor  show  that  the  jelly-like 
substance  lies  in  that  part  of  the  tumor  which  corresponds  with  the  posi- 
tion of  the  epithelioid  cells.  The  latter  are  found  in  various  stages  of 
degeneration,  the  appearances  being  similar  to  those  observed  in  the 
mucous  degeneration  of  true  epithelium. 

The  prevailing  theory  of  the  origin  of  cancer  from  epithelial  structures 

1  Virchmu's  Archiv,  1882,  Ixxxix.  193. 

2  Hermann's  Hundbuch  der  Physiologic,  1880,  V.  64. 


DEGENERATIONS  83 

readily  suggests  an  explanation  for  the  frequency  of  the  mucous  variety 
of  cancer  in  connection  with  those  parts  from  which  mucus  normally 
arises  from  the  degeneration  of  the  epithelium. 

The  mucous  metamorphosis  aifects  connective  tissues  as  well  as  epithe- 
lium. The  "Whartonian  jelly  of  the  umbilical  cord  and  the  vitreous 
humor  of  the  eye  are  known,  through  the  investigations  of  Virchow,  to 
owe  their  gelatinous  condition  to  the  presence  of  mucin.  The  latter  lies 
in  the  intercellular  substance ;  that  is,  between  the  cells.  The  appear- 
ance of  these  indicates  ^no  degenerative  process,  but  the  presence  of 
mucin  is  obviously  an  essential  constituent  of  the  tissue.  Whether  this 
mucin  represents  a  transformation  of  the  gelatin  of  the  intercellular  sub- 
stance, or  a  secretion  from  the  fixed  cells,  or  a  metamorphosis  of  the 
migratory  cells  of  the  tissue,  is  not  known.  In  mucous  tissue,  however, 
there  is  present  mucin,  wholly  independent  of  any  epithelial  degeneration. 
Mucous  tissue  is  present  in  the  eye  as  a  normal  constituent  of  the  adult, 
and  in  the  umbilical  cord  as  a  normal  constituent  of  the  infant  at  full 
term.  It  is  also  abundantly  met  with  in  the  subcutaneous  and  inter- 
muscular  tissues  of  the  foetus.  Its  pathological  occurrence  in  the  adult 
as  a  circumscribed  tumor,  the  myxoma,  may  also  be  mentioned. 

A  gelatinous  substance  containing  mucin  is  found  in  the  adult  inde- 
pendent of  the  mucous  tissue,  but  obviously  arising  from  a  transfor- 
mation of  intercellular  substance.  The  most  striking  example  of  this 
occurrence  is  the  cystoid  softening  of  cartilage,  especially  of  the  costal 
cartilages  of  old  people,  the  basis  substance  being  transformed  into  a  fluid 
containing  mucin.  A  similar  metamorphosis  is  of  frequent  occurrence 
in  the  intervertebral  disks  and  in  the  destruction  of  cartilage  in  acute 
and  chronic  inflammations  of  the  joints.  The  intercellular  substance  of 
cartilaginous  tumors  also  becomes  softened  and  converted  into  a  liquid 
containing  mucin. 

In  osteomalacia  and  in  the  absorption  of  bone  the  mucous  degeneration 
of  the  bone-cartilage  plays  an  important  part.  The  lime  salts  are 
first  set  free,  and  the  cartilage  then  undergoes  a  mucous  degeneration ;  the 
product  is  either  absorbed  or  remains  as  a  liquid  within  cavities  of  large 
or  small  size.  The  mucous  metamorphoses  of  fibrous  and  fat-tissues, 
likewise  of  bone-marrow,  are  well  recognized  instances  of  the  occurrence 
of  a  mucous  transformation  of  the  intercellular  substance  of  connective 
tissues.  Finally,  clotted  fibrin,  so  often  met  with  as  the  product  of  the 
inflammation  of  serous  surfaces,  may  undergo  a  mucous  metamorphosis, 
and,  thus  transformed,  offer  a  suitable  material  for  absorption. 

Colloid  Degeneration,  Colloid  Metamorphosis. 

Laennec  used  the  term  colloid  in  a  descriptive  sense  to  indicate  a 
gelatinous  appearance,  and  for  a  long  time  its  use  was  thus  restricted. 
As  the  colloid  appearances  were  found  to  differ  in  their  chemical  reaction, 
their  distribution,  and  their  pathological  importance,  and  as  the  term  was 
further  extended  to  include  appearances  seen  with  the  microscope,  it 
obviously  became  necessary  to  subdivide  the  colloid  series  of  changes 
according  to  the  observed  differences.  Its  use  is  now  limited  to  those 
gelatinous  conditions  or  appearances  due  to  the  presence  of  a  fixed  albu- 
minate,  homogeneous  or  finely  granular,  translucent,  colorless  or  pale 


84  GENERAL  MORBID  PROCESSES. 

yellow,  of  varying  consistency,  which  does  not  become  fibrillated  on  the 
addition  of  acetic  acid,  and  which  does  not  change  in  color  when  acted 
upon  by  iodine.  This  albuminate  is  considered  in  most  instances  to  repre- 
sent the  result  of  a  transformation,  a  metamorphosis  of  cells,  and  is  asso- 
ciated with  an  impairment  of  their  function — a  degeneration  which  is 
progressive,  and  leads,  sometimes,  to  the  destruction  of  the  organ,  a? 
occurs  in  certain  instances  of  colloid  degeneration  of  the  thyroid  body. 
Usually,  the  process  is  limited,  affecting  particular  parts  rather  than 
the  whole  of  an  organ.  The  reaction  presented  by  a  solution  of  sodium 
albuminate  in  the  presence  of  neutral  salts  leads  to  the  view  that  colloid 
material  may  represent  a  coagulation  of  an  albuminous  substance  or  sub- 
stances under  favoring  conditions.  The  presence  of  colloid  masses  in  the 
kidney  thus  meets  with  a  plausible  explanation. 

The  place  of  its  typical  occurrence  is  the  thyroid  body  in  certain  cases 
of  goitre,  and  it  is  early  met  with  as  a  homogeneous  substance  replacing 
the  granular  cell-protoplasm.  With  its  increase  the  latter  disappears, 
and  the  entire  cell  is  transformed  into  a  homogeneous  sphere.  At  times 
the  colloid  substance  may  be  seen  to  project  from  the  surface  of  the  cell 
as  a  pale  rounded  clump.  The  aggregation  of  these  clumps  results  in  the 
presence  of  masses  of  various  size,  in  which  may  be  found  granules  of 
fat  or  pigment  and  crystals  of  cholesterin,  which  are  accidental,  not 
essential.  Colloid  masses  are  sometimes  met  with — in  lymphatic  glands, 
for  instance — as  concretions,  mulberry-like  aggregations  of  stratified 
colloid  bodies,  which  may  be  infiltrated  with  earthy  salts.  Colloid 
material  may  eventually  become  liquefied,  transformed  into  a  sodium 
albuminate ;  and  the  presence  of  cysts  in  certain  varieties  of  goitre  is  thus 
explained.  The  coexistence  in  the  kidney  of  colloid  accumulations  and 
watery  cysts  has  led  to  the  view  that  the  latter  may,  under  certain  cir- 
cumstances, result  from  the  former  through  the  liquefaction  of  the  colloid 
material.  The  same  view  is  held  with  regard  to  the  origin  of  cysts  fre- 
quently met  with  in  the  choroid  plexuses. 

The  colloid  metamorphosis  of  cells  is  also  to  be  found  in  the  epithelium 
of  mucous  membranes  and  their  glands,  in  the  prostate,  suprarenal  cap- 
sule, sebaceous  glands  of  the  skin,  and  in  the  cells  of  certain  tumors. 

Amyloid  Degeneration,  Amyloid  Infiltration,  Waxy  Degeneration,  Larda- 

ceous  Degeneration. 

The  colloid  appearances  due  to  the  amyloid  degeneration  of  cells  are 
of  the  greatest  clinical  importance  from  their  frequent  occurrence  and  the 
gravity  of  the  symptoms  connected  with  their  presence.  In  amyloid 
degeneration  there  is  the  transformation  of  the  cell-protoplasm  into  an 
albuminous  material  different  from  other  albuminates  found  in  the  body. 
This  transformation  is  at  the  expense  of  the  functional  activity  of  the 
cell,  and  the  latter  becomes  inert.  Amyloid  degeneration  represents  no 
mere  substitution,  but  an  addition,  since  the  affected  tissue  is  increased  in 
volume.  The  albuminate  Avas  called  amyloid  by  Virchow  in  consequence 
of  its  color-reaction  with  iodine.  Its  method  of  origin  is  wholly 
unknown,  never  being  found  in  the  circulating  fluids  nor  in  articles  of 
food.  It  is  met  with  chiefly  in  the  cell,  although  its  presence  in  the 
intercellular  substance  of  old  people  is  recognized,  and  its  occurrence  in 


DEGENERATIONS.  85 

the  midst  of  the  thrombotic  deposition  on  inflamed  valves  and  in  the 
results  of  inflammatory  processes  is  also  recorded. 

At  present  the  question  is  under  discussion  whether  the  amyloid  degen- 
eration may  affect  cells'  of  the  most  varied  character,  or  whether  it  is 
limited  to  those  of  connective  tissues.  Eberth1  maintains  that  in  all 
cases  the  amyloid  disturbance  is  seated  in  the  connective  tissue.  Kyber,2 
the  latest  investigator,  in  opposition  to  this  view  maintains  that  this  affec- 
tion is  not  limited  to  the  connective  tissue,  but  may  also  be  seated  in  the 
parenchymatous  cells  of  organs.  Whether  the  one  of  these  views  is  to 
exclude  the  other,  or  whether  both  are  not  correct,  remains  for  future 
investigation  to  decide. 

Wherever  the  amyloid  material  may  be  situated,  the  result  is  a  trans- 
formation of  the  cells  into  a  homogeneous,  glistening,  colorless  material, 
which  occupies  more  space  than  the  original  cell,  and,  when  abundant,  is 
accompanied  with  a  loss  of  the  primitive  details  of  the  cell-structure. 
This  material  is  recognized  by  the  color  it  presents  when  acted  upon  by 
iodine  alone,  by  iodine  and  sulphuric  acid,  or  by  methyl-aniline.  The 
first  produces  a  reddish-brown  color,  the  second  a  blue,  and  the  last  a 
violet  or  purple  color.  These  reactions  are  all  characteristic,  and  the  first 
is  of  special  value  in  the  macroscopic  recognition  of  the  process,  while 
the  last  two  are  of  special  importance  in  the  microscopic  recognition  of 
the  earlier  stages  of  the  affection. 

With  the  advance  of  the  degeneration  and  its  dissemination,  the  organ 
affected  presents,  in  the  diseased  portions,  pale-gray,  glistening,  translucent 
patches,  and  becomes  increased  in  size  and  density  in  proportion  to  the 
quantity  of  amyloid  material  present.  The  change  appears  primarily 
in  the  vessel  wall  or  outside  the  same,  and  there  results  a  diminution 
in  the  calibre  of  the  vessels,  with  a  lessened  quantity  of  blood  in  the 
organ. 

From  the  homogeneous  and  translucent  appearance  of  the  surface  and 
the  increased  density  of  the  tissues  the  resemblance  to  bacon  or  wax  is 
suggested,  and  the  terms  lardaceous,  bacouy,  or  waxy  degeneration  have 
been  applied.  Notable  differences  in  degree  and  seat  occur  in  connection 
with  the  organs  diseased.  In  the  spleen,  for  example,  the  change  may 
be  limited  to  the  arteries  of  the  Malpighian  bodies  and  their  immediate 
surroundings.  To  this  condition  the  term  sago  spleen  is  applied,  the 
enlarged,  rounded,  translucent,  and  projecting  bodies  suggesting  gran- 
ules of  boiled  sago.  The  appearances  of  the  diseased  part  are  further 
affected  by  the  association  of  other  conditions,  as  the  presence  of  fat  or 
pigment.  When  fat  is  present,  it  is  often  to  be  regarded  as  a  result  of 
the  gradual  and  progressive  increase  in  the  obstruction  to  the  circulation 
of  blood  in  the  organ. 

Athough  so  little  is  known  of  the  immediate  cause  of  amyloid  degen- 
eration, its  distribution  in  the  various  organs  of  the  body  is  fully  ascer- 
tained, as  well  as  certain  of  the  conditions  which  are  likely  to  be  followed 
by  its  presence.  It  is  known  to  occur  as  a  localized  process  in  cartilage, 
in  the  conjunctiva,  in  certain  tumors,  cardiac  thrombi,  scars,  retained 
inflammatory  products,  and  renal  casts.  The  causes  of  this  localized 
appearance  are  wholly  obscure,  and  little  or  no  general  inconvenience 
results.  Its  presence,  however,  on  a  large  scale  and  in  various  parts  of 

1  Virchow's  Archiv,  1880,  Ixxx.  138;  1881,  Ixxxiv.  2  Ibid.,  1880,  Ixxxi.  7,  111. 


86  GENERAL  MORBID  PROCESSES. 

the  body  at  the  same  time,  is  met  with  under  such  circumstances  as  indi- 
cate a  distinct  etiological  relation.  An  appreciation  of  these  circum- 
stances is  of  importance,  since  their  existence  demands  an  investigation 
as  to  the  probable  presence  of  the  degeneration.  The  organs  thus  affected 
are  the  spleen,  liver,  kidneys,  and  intestine.  It  is  to  their  disturbance 
of  function  that  the  pathological  importance  of  amyloid  degeneration  is 
to  be  especially  attributed. 

Other  organs  which  may  sometimes  be  affected  are  the  lymphatic 
glands,  pancreas,  suprarenal  capsules,  omeutum,  uterus,  bladder,  prostate 
gland,  heart,  and  thyroid  body.  In  the  case  of  a  general  diffused  infil- 
tration these  organs  are  variously  degenerated,  now  some,  and  again 
others,  showing  a  more  extensive  alteration,  while  few  or  many  may  be 
simultaneously  diseased.  The  longer  the  process  has  continued,  the 
greater  the  degree  of  the  disturbance  and  the  larger  the  number  of  the 
organs  infiltrated.  Although,  in  general,  a  period  of  months  and  years 
may  be  demanded  for  these  extensive  changes,  very  serious  disturbances 
may  arise  within  a  short  time,  and  Cohnheim l  records  several  cases  which 
suggest  that  widely  diffused  amyloid  degeneration  may  occur  within  a  few 
months — in  one  instance  in  less  than  four  months. 

All  that  is  at  present  known  with  regard  to  the  etiology  of  this  process 
applies  to  certain  general  diseases  with  which  in  the  course  of  time  it  is 
likely  to  be  associated.  These  have  one  element  in  common,  that  of 
chronicity,  and  are  likewise  the  occasion  of  a  progressive  wasting  of  the 
body.  Of  these  affections,  that  which  holds  the  first  place  is  chronic  pul- 
monary consumption,  especially  that  form  in  which  extensive  destruction 
of  the  lungs  and  ulcers  of  the  intestine  are  present.  Another  disease  whose 
effects  are  in  like  manner  to  be  regarded  as  general  is  syphilis,  and  in  the 
later  stages  of  this  disease  amyloid  degeneration  is  likely  to  occur,  and  often 
to  represent  by  its  resulting  disturbances  the  immediate  cause  of  death. 
Again,  chronic  suppurative  processes,  especially  those  due  to  disease  of 
the  bones  and  joints,  are  a  frequent  antecedent  of  amyloid  degeneration. 
Finally,  the  process  has  been  found  in  connection  with  leucaemia,  chronic 
intermittent  fever,  rickets,  gout,  and  certain  malignant  tumors.  This 
last  group,  however,  is  one  in  whose  sequence  the  degeneration  is  to  be 
regarded  as  exceptional. 

The  clinical  importance  of  this  process  is  due  to  the  resulting  disturb- 
ances in  the  function  of  such  important  organs  as  the  liver  and  intestines, 
the  spleen  and  lymphatic  glands,  and  the  kidneys.  The  nature  of  Ihese 
disturbances  obviously  demands  detailed  consideration  in  connection  with 
the  description  of  the  diseases  of  the  respective  organs.  It  may  be  men- 
tioned here  that  the  infiltration  of  the  walls  leads  to  a  narrowing  of  the 
calibre  of  blood-vessels,  and  thus  a  diminution  in  the  supply  of  blood  to 
the  part  or  organ.  The  resulting  impairment  of  nutrition  becomes 
enhanced  from  the  condition  of  the  blood,  which  is  impoverished  from 
the  simultaneous  infiltration  of  the  blood-making  organs.  The  nutrition 
of  the  individual  thus  suffers  as  well  as  that  of  the  immediately  diseased 
organ.  Fatty  degeneration  and  atrophy  of  the  parenchymatous  cells  of 
organs  like  the  liver  and  kidneys  is  the  constant  result  of  long-continued 
and  extensive  infiltration  of  these  glands. 

Mention  is  intentionally  omitted  of  the  so-called  amyloid  bodies,  cor- 

1  Virehou/s  Archiv,  1872,  liv.  271. 


DEGENERATIONS.  87 

pora  amylacea,  considered  in  connection  with  amyloid  degeneration  in 
most  text-books  on  pathology  and  pathological  anatomy.  They  usually 
present  a  different  reaction  with  iodine,  their  origin  has  but  little  in  com- 
mon, their  distribution  is  for  the  most  part  unlike,  and  little  or  no  clin- 
ical importance  is  to  be  attached  to  their  presence. 

Calcification,  Ossification,  Petrifaction. 

"When  salts  previously  held  in  solution  are  precipitated  under  abnormal 
circumstances  in  the  tissues  of  the  body,  the  part  is  said  to  be  calcined, 
ossified,  or  petrified.  Although  these  terms  are  often  used  as  equivalent, 
the  last  is  to  be  regarded  as  more  general  than  its  predecessors,  since  it 
includes  the  deposition  of  other  than  the  calcareous  salts. 

In  the  pathological  ossification,  as  well  as  its  physiological  prototype, 
the  carbonates  and  phosphates  of  calcium  and  magnesium  are  present  in 
a  specially  formed  tissue  of  the  nature  of  bone-cartilage,  whereas  calcifi- 
cation occurs  independently  of  such  a  new-formed  tissue.  The  deposition 
of  the  calcareous  salts  takes  place  either  in  the  cells  or  intercellular  sub- 
stance of  living  or  dead  tissues,  when  the  terms  calcification  or  ossification 
are  applied,  or  as  accumulations  of  various  size  in  tissues  or  canals,  which 
are  known  as  concretions  and  calculi. 

The  immediate  causes  of  the  physiological  deposition  in  the  formation  of 
bone  are  so  obscure  that  only  more  or  less  probable  explanatory  theories 
are  advanced,  to  all  of  which  obvious  objections  arise.  The  causes  of  a 
pathological  precipitation  may  be  regarded  as  equally  hidden.  It  is 
apparent,  however,  that  old  age  usually  furnishes  the  necessary  factors. 
This  in  part  may  be  due  to  the  feeble  nutrition  associated  with  impair- 
ment of  function  in  advancing  years.  In  part  it  may  be  the  result 
of  the  numerous  opportunities  offered  in  a  long  life  for  the  occurrence  of 
inflammation,  the  products  of  which  are  frequently  infiltrated  with  cal- 
careous salts.  The  latter  are  apparently  kept  in  solution  by  the  action 
of  living  cells,  for,  though  presented  to  all  in  the  fluids  of  the  body,  they 
are  precipitated  most  constantly  in  dead  parts  or  in  the  vicinity  of  those 
cells  whose  function  is  presumably  lessened  from  disease  or  age.  The 
solvent  action  of  living  cells  is  further  demonstrated  by  the  effect  of  the 
giant-cells  in  removing  calcium  salts  from  living  or  dead  bone. 

The  causes  of  calcification  are  therefore  to  be  regarded  as  local,  depend- 
ing upon  a  destruction  or  weakening  of  the  cells  of  a  part — conditions 
which  are  directly  attributable  to  an  interference  with  nutrition.  The 
deposition  of  calcium  salts  thus  represents  a  disorder  of  nutrition,  and 
may  be  experimentally  produced  by  agencies  which  occasion  a  necrosis 
of  tissues. 

Although  the  immediate  causes  of  the  precipitation  of  the  calcium  salts 
must  be  expressed  somewhat  vaguely,  the  places  and  effects  of  their  accu- 
mulation are  sufficiently  well  known,  as  are  the  resulting  appearances. 
The  presence  of  these  salts  in  sufficient  quantity  produces  a  homogene- 
ous, granular,  strongly  refractive  appearance  of  the  cell  or  intercellular 
substance,  in  addition  to  a  greatly  increased  resistance  to  pressure.  When 
muriatic  acid  is  added  to  the  affected  part,  the  salts  are  dissolved,  with 
the  escape  of  abundant  bubbles  of  gas  when  a  carbonate  is  present,  and 
with  a  rapid  fading  of  the  glistening  appearance,  without  effervescence, 


88  GENERAL  MORBID  PROCESSES, 

when  the  salt  is  a  phosphate.  After  the  removal,  the  cell  or  intercellular 
substance  is  readily  recognized,  with  such  modifications  in  its  appearance 
as  may  be  due  to  the  action  of  the  strong  acid.  The  parts  in  which  this 
deposition  or  infiltration  has  taken  place  are  either  relatively  normal  ID 
appearance  or  variously  altered  from  disease,  and  the  calcium  salts  are  to 
be  regarded  as  absorbed  from  the  constituents  of  the  food  and  deposited, 
or  as  taken  up  and  transferred  from  the  bones  of  the  body.  That  both 
sources  are  drawn  upon  is  obvious  from  the  abnormal  presence  of  calcareous 
material  in  the  soft  parts,  in  connection  with  increased  density  of  the  bones, 
as  well  as  with  a  diminution  in  the  density  of  the  latter.  The  term 
calcification  is  more  correctly  applied  to  the  presence  of  the  salts  in  nor- 
mal tissues  other  than  bone,  or  in  the  products  of  disease  not  simulating 
bone-cartilage  in  structure.  A  pathological  ossification  is  to  be  consid- 
ered present  when  an  actual  new  formation  of  bone  has  taken  place  so 
limited  and  so  situated  as  not  to  suggest  a  tumor  of  bone,  or  when  the 
calcium  salts  are  deposited  in  a  new-formed  tissue  whose  structure  stimu- 
lates that  of  bone-cartilage. 

Tissues  which  may  become  calcified  are,  in  the  first  instance,  the  con- 
nective tissues,  and  of  these  fibrous  tissue  and  cartilage  are  especially 
liable.  Epithelial,  muscle — in  particular  the  unstriped  variety — and 
ganglion-cells  may  also  become  calcified.  The  frequency  with  which 
blood-vessels,  especially  arteries,  are  affected  is  such  that  it  is  re- 
garded as  almost  normal  in  advancing  years  that  calcareous  mate- 
rial should  be  deposited  within  the  vascular  walls.  A  distinction  is 
drawn  between  an  ossification  and  a  calcification  of  the  blood-vessels. 
The  former  term  should  be  limited  to  the  osteoid  plates  so  often  found 
as  circumscribed  thickenings  of  the  aortic  intiina,  and  which  are  obvi- 
ously new-formed  patches  of  fibrous  tissue  in  which  the  calcium  salts 
are  accumulated.  A  calcified  artery,  on  the  contrary,  is  one  usually  of  a 
size  varying  between  that  of  the  common  iliac  and  the  temporal  arteries, 
whose  wall  has  become  rigid  and  unyielding,  suggestive  of  a  pipe-stem, 
from  the  presence  of  calcareous  deposits  in  the  muscular  middle  coat. 

From  the  frequency  with  which  the  osseous  plates  of  the  aorta  are 
associated  with  the  fatty  and  fibrous  changes  in  chronic  inflammation  of 
the  intiina,  the  so-called  atheromatous  degeneration  of  the  same,  it  is 
customary  to  speak  of  the  calcified  artery  at  the  wrist  or  temple  as  an 
atheromatous  artery  or  as  evincing  an  atheromatous  degeneration.  The 
common  feature  in  the  aortic  changes  and  in  the  calcified  muscular  coat  is 
the  element  of  age.  They  are  frequently,  though  not  necessarily,  associ- 
ated. The  one  is  the  result  of  an  inflammatory  process  productive  of  a 
new,  fibrous,  tissue  in  which  the  calcium  salts  are  infiltrated;  while  the 
other  is  due  to  a  deposition  of  the  latter  in  the  normal,  pre-existing,  mus- 
cular elements  of  the  vessel. 

Calcification  and  ossification  of  blood-vessels  are  frequent  when  the 
latter  become  dilated,  as  in  aneurisms,  whether  these  occur  as  circum- 
scribed tumors  or  as  a  serpentine  elongation  and  widening  of  the  affected 
vessel. 

Cartilage  is  also  a  tissue  which  presents  a  double  relation  to  calcareous 
deposition.  On  the  one  hand,  there  may  exist  an  ossification  resulting 
from  the  extension  of  a  growth  of  bone  from  the  perichondrium  into  the 
cartilage.  The  structure  of  this  bone  presents  all  the  details  found  in  nor- 


DEGENERATIONS.  89 

mal  bone — lacunae,  lamellae,  and  marrow-spaces.  On  the  other  hand,  a 
section  of  the  cartilage,  especially  the  costal  cartilages,  may  contain  opaque, 
gray,  or  grayish-yellow  patches,  grating  under  the  knife,  which  are  wholly 
due  to  the  presence  of  calcium  salts  in  the  hyaline  intercellular  substance 
of  the  cartilage.  This  calcification  of  the  cartilage,  which  may  also  involve 
the  capsules  of  the  cells,  is  frequently  associated  with  an  ossification, 
although  this  relation  is  in  no  way  essential. 

Calcification  of  the  placenta,  of  the  fibrous  framework  of  the  lungs,  of 
the  mucous  membrane  of  the  stomach,  or  of  the  atrophied  glomeruli  of  the 
kidney,  are  well-recognized  instances  of  the  infiltration  of  calcareous  ma- 
terial in  normal  or  atrophied  tissues.  On  the  contrary,  ossification  of  the 
fibrous  inflammatory  products  of  the  pleura,  pericardium,  and  peritoneum 
are  instances  of  a  pathological  bone-formation,  analogous  in  its  nature 
to  that  met  with  in  the  ultima  of  the  aorta.  The  fibrinous  and  fibrino- 
cellular  products  of  the  inflammation  of  serous  surfaces  are  favorable  posi- 
tions for  the  deposition  of  calcium  salts,  as  are  thrombi  arising  from  the 
walls  of  blood-vessels.  The  latter  are  rather  instances  of  the  calcification 
of  dead  parts,  analogous  to  the  members  of  the  group  which  includes  the 
formation  of  calculi  and  concretions,  the  calcification  of  the  dead  foetus  in 
abdominal  parturition,  of  cheesy  lymphatic  glands,  and  of  cheesy  material  in 
the  lungs  and  elsewhere.  Finally,  there  remains  the  calcification  of  tumors 
of  the  most  varied  nature,  the  salts  being  present  either  in  living  or  dead 
parts  of  the  tumor. 

Instances  of  the  deposition  in  the  tissues  of  other  than  calcareous  salts 
are  abundantly  met  with  in  gout.  In  this  disease  cartilage,  ligaments, 
and  tendons,  bone-marrow,  muscle,  the  endocardium  and  aorta,  the  mem- 
branes of  the  brain  and  spinal  cord,  the  skin  and  kidneys,  may  contain 
deposits  of  acicular  crystals  and  amorphous  granules.  Although  these 
deposits  are  largely  composed  of  sodium  urate,  calcium  urate  may  be 
present  with  other  salts,  as  sodium  chloride  and  calcareous  compounds. 
According  to  Ebstein,1  the  earthy  salts  in  gout  are  deposited  in  necrotic 
patches  of  previously  diseased  tissue.  The  local  conditions  are  therefore 
analogous  to  those  concerned  in  the  formation  of  chalky  concretions. 

Concretions  and  calculi  are  collections  of  earthy  salts,  the  former  lying 
within  tissues,  the  latter  being  present  in  canals  opening  externally.  Both 
represent  the  results  of  a  deposition  in  and  upon  organic  material,  which 
is  often  an  inflammatory  product,  at  times  surrounding  a  foreign  body  act- 
ing as  the  exciting  cause  of  the  inflammation. 

The  earthy  matter  of  which  the  concretion  is  composed  consists  mainly 
of  carbonate  and  phosphate  of  calcium,  while  the  chemical  properties  of 
the  calculi  often  vary  in  accordance  with  the  nature  of  the  secretion  which 
flows  by  them.  The  salivary,  pancreatic,  intestinal,  lachrymal,  and  pros- 
tatic  calculi  are  chiefly  formed  of  calcareous  salts.  These  salts  also  are  an 
important,  if  not  the  chief,  constituent  of  biliary  and  urinary  calculi.  In 
the  former  pigment,  bile  acids,  and  cholesterin  may  also  be  present.  Uri- 
nary calculi  are  of  still  more  varied  composition,  containing  not  only  the 
calcium  salts,  as  the  oxalate,  phosphate,  and  carbonate,  but  also  uric  acid 
and  the  urates  of  sodium  and  ammonium,  in  addition  to  the  ammoniaco- 
magnesian  phosphate. 

The  infiltration  with  calcium  salts  may  prove  beneficial  as  well  as  inju- 
1  Die  Naiur  und  Behandlung  der  Giclit,  Wiesbaden,  1882,  45. 


90  GENERAL  MORBID  PROCESSES. 

rious — beneficial  under  those  circumstances  where  further  changes  might 
prove  harmful,  as  in  the  softening  of  cheesy  material  or  the  maceration  of 
a  dead  foetus  in  the  abdominal  cavity.  The  calcification  of  certain  tumors, 
as  the  fibro-myoma  of  the  uterus,  is  equally  sanatory,  the  further  growth 
of  the  calcified  parts  being  thus  checked.  The  calcification  of  an  aneuris- 
mal  sac  may  prove  beneficial  in  strengthening  a  weakened  blood-vessel. 

The  injurious  effects  are  seen  more  particularly  in  case  of  the  calca- 
reous infiltration  of  the  middle  coat  of  arteries.  Such  vessels  become 
converted  into  rigid  and  unyielding  tubes  at  various  parts  of  their  course, 
and  the  nutrition  of  peripheral  parts  becomes  correspondingly  lessened. 
Hence,  in  great  measure,  the  liability  of  old  people  to  serious  inflammatory 
processes  from  trivial  irritation  of  peripheral  portions  of  the  body,  such 
inflammations  often  terminating  in  gangrene. 

The  calcification  and  ossification  of  the  cardiac  valves  and  the  calcifica- 
tion of  attached  thrombi,  furnish  frequent  and  constant  occasion  for  dis- 
turbances in  the  functions  of  the  heart,  resulting  in  dilatation  and  hyper- 
trophy, with  the  sequence  of  symptoms  of  chronic  valvular  endocarditis. 

The  great  clinical  importance  of  the  presence  of  calcium  salts  in  the 
circulatory  apparatus  is  such  that  further  reference  in  this  place  to  its 
results  is  unnecessary,  as  its  special  relations  are  more  important  than  its 
general  features. 

Calculi  act  as  local  causes  of  inflammation,  and  their  presence  is  likely 
to  be  followed  by  ulceration,  abscess,  and  stenosis,  perhaps  obliteration,  of 
the  smaller  canals  in  which  they  may  lie. 

Pigmentation. 

The  pathological  pigmentation  of  the  body  results,  presumably,  from 
the  metamorphosis  of  the  coloring  matter  of  the  blood  or  from  the  intro- 
duction from  without  of  pigments  insoluble  in  the  fluids  of  the  body. 
The  former  of  these  methods  has  recently  been  studied  by  Langhans1 
and  Cordua,2  and  the  present  views  of  this  subject  are  chiefly  due  to  their 
observations,  as  well  as  to  the  earlier  investigations  of  Virchow  and  others. 

The  haemoglobin  contained  in  red  blood-corpuscles  is  considered  to  be 
composed  of  a  coloring  matter,  hsematin,  combined  with  an  albuminate, 
globulin.  When  blood  is  removed  from  the  body  the  haemoglobin  is 
readily  separated  from  the  corpuscles  by  various  agents,  and  is  then  dis- 
solved in  the  plasma,  which  becomes  lac-colored.  This  solubility  of  the 
haemoglobin  is  of  importance  in  connection  with  the  absorption  of  extra  v- 
asated  blood.  During  the  time  necessary  for  this  process  to  take  place, 
observable  changes  are  apparent  in  the  color  of  the  affected  part  when 
its  seat  is  superficial,  especially  cutaneous.  These  changes  in  color  are 
largely  dependent  upon  the  modifications  undergone  by  the  haemoglobin. 

It  is  well  known  that  a  yellowish  discoloration  of  the  general  surface  fre- 
quently takes  place  when  extensive  internal  hemorrhages  have  occurred,  con- 
stituting a  form  of  jaundice  (haematogenous)  attributed  to  the  presence  of  the 
coloring  matter  of  the  blood.  As  yet  there  has  been  no  satisfactory  chemical 
analysis  of  this  diffused  pigment,  which  if  not  hsematin  must  be  regarded 
as  its  derivative,  although  a  coexistent  increase  of  the  urobilin  in  the 
urine  has  been  observed.  The  association  of  the  stained  skin  and  urine, 

1  Virchouu's  Archiv,  1870,  xlix.  66. 

2  Ueber  Resorptionsmechanixmus  von  Elutergussen,  Berlin,  1877. 


DEGENERATIONS.  9] 

in  the  absence  of  causes  favoring  an  absorption  of  bile-pigment,  leads  to 
the  inference  that  the  abnormal  discoloration  is  due  to  the  absorption 
into  the  circulating  fluids  of  the  body  of  a  pigment  dissolved  out  of  the 
extravasated  red  blood-corpuscles.  This  view  is  confirmed  by  the 
microscopic  examination  of  the  latter,  which  discloses  the  presence  of 
pale,  shadowy,  round  outlines  enclosing  faintly  granular  material,  which 
are  regarded  as  decolorized  red  corpuscles.  In  the  course  of  a  few  days 
glistening  crystals  and  granules  of  a  yellowish-red  color  make  their 
appearance  in  the  midst  of  the  unabsorbed  blood.  The  crystals  are 
usually  oblique  rhombic  prisms,  varying  in  size  from  the  larger  symmet- 
rical shapes  to  the  more  minute,  apparently  granular,  forms.  Acicular 
crystals  are  also  to  be  met  with,  more  yellow  than  red  in  color,  and  are 
sometimes  present  in  great  abundance,  although  they  may  be  wholly  absent. 
Virchow  has  applied  the  term  haematoidin  to  these  crystals.  Owing  to 
the  resemblance  in  the  chemical  reactions  of  solutions  of  haematoidin  and 
of  the  biliary  coloring  matter,  bilirubin,  and  to  the  similar  crystalline 
forms  of  the  latter,  it  has  been  maintained  that  the  two  are  identical. 
Late  investigations  indicate  that  solutions  of  crystals  with  the  appear- 
ances of  haematoidin  are  not  invariably  alike  in  their  reaction.  A  solution 
of  these  in  chloroform  may  become  decolorized  when  acted  upon  by  a 
dilute  alkali,  or  it  may  not  be  thus  altered.  Bilirubin  presents  the 
former  relation,  while  chloroform  solutions  of  the  coloring  matter  of 
the  yelk  of  egg  and  of  the  corpus  luteum,  called  lutein  or  hsemolutein, 
are  not  decolorized  by  an  alkali.  Although  the  crystalline  forms  of 
hsematoidin  and  bilirubin  are  not  to  be  distinguished,  it  is  not  to  be 
conceded  that  the  two  substances  are  identical.  As  Maly,1  the  latest 
writer  on  this  subject,  states,  the  term  haematoidin  is  merely  indicative 
of  a  microscopical  picture.  Although  the  identity  of  the  coloring  mat- 
ter of  the  blood  and  of  the  bile  is  not  admitted,  the  intimate  relation 
of  the  two  is  not  only  suggested  by  the  similarity  of  crystalline  form, 
but  by  the  relation  determined  between  urobilin,  bilirubin,  and  haema- 
globin.  Urobilin  is  the  coloring  matter  extracted  from  the  urine  in  fever 
by  Jaffe,  and  it  has  since  been  obtained  from  bilirubin  by  Maly,2  who 
has  given  it  the  name  of  hydrobilirubin.  This  hydrobilirubin  has  also 
been  derived  from  haemoglobin.  According  to  Maly,  this  genetic  relation 
between  the  coloring  matter  of  the  blood  and  bile,  shown  in  the  produc- 
tion of  hydrobilirubin,  is  the  only  chemical  evidence  of  the  connection 
of  the  two  pigments. 

Haematoidiu  is  to  be  regarded  not  only  as  directly  derived  from  solu- 
tions of  haemoglobin,  but  as  originating  through  the  medium  of  indifferent 
cells.  Langhans  claims  that  this  pigment  is  formed  within  movable  cells 
which  accumulate  in  great  numbers  in  the  vicinity  of  the  blood-clot,  and, 
in  virtue  of  their  amoeboid  properties,  take  into  themselves  the  extravasated 
corpuscles,  entire  or  in  fragments.  The  indifferent  cell  may  become  en- 
larged into  a  giant-cell,  and  then  contain  numbers  of  whole  or  disinte- 
grated red  corpuscles.  In  time  these  colored  corpuscles  and  fragments 
become  smaller,  more  glistening,  and  darker-colored,  and  eventually  are 
transformed  into  granular  or  crystalline  haematoidin.  These  granules 
may  be  set  free  by  the  fatty  degeneration  of  the  cell,  or  may  be  trans- 
ferred within  the  cell  to  distant  parts. 

1  Hermanns  Handbuch  der  Physiologic,  1880,  vii.  155.  '  Op.  cit.,  161. 


92  GENERAL  MORBID  PROCESSES. 

The  diffusion  and  absorption  of  a  solution  of  haemoglobin,  and  the 
formation  of  crystals  of  haematoidiu  from  the  same  or  through  the 
medium  of  cells,  are  supplemented  by  an  apparent  inspissation  and 
condensation  of  the  haemoglobin.  The  resulting  dark-brown  pigment 
may  remain  at  the  seat  of  the  hemorrhage  indefinitely,  and  may  be 
accompanied  with  reddish-brown  flakes,  which,  as  shown  by  Kunkel,1 
are  composed  of  hydrated  ferric  oxide. 

Another  feature  in  the  absorption  of  extravasated  blood  is  to  be  found 
on  examination  of  the  nearest  chain  of  lymphatic  glands.  These  may  be 
seen  swollen,  of  a  dark-red  color,  and  homogeneous  surface.  In  density 
and  color,  as  well  as  shape,  they  suggest  the  small  supplementary  spleens 
so  frequently  met  with.  These  glands  owe  their  change  in  appearance 
to  the  presence  of  large  numbers  of  unaltered  red  blood-corpuscles 
which  have  entered  the  lymphatics  traversing  the  region  of  hemorrhage. 
Within  the  lymph-glands  they  undergo  a  metamorphosis  similar  to 
that  taking  place  at  the  part  from  which  they  were  transferred.  In 
the  course  of  weeks  or  mouths  there  remains  in  the  place  of  extrav- 
asation simply  pigment,  either  as  crystals  or  granules.  Such  pigment 
may  remain  for  years  imbedded  within  the  tissues,  or  it  may  become 
absorbed,  no  trace  of  the  original  disturbance  remaining.  Its  removal 
may  take  place  presumably  through  a  local  solution  of  the  pigment  or 
the  transfer  of  the  granules  or  crystals  by  means  of  wandering  cells  to 
the  nearest  lymphatic  glands  or  to  the  more  remote  parts  of  the  body. 
An  eventual  elimination  may  occur  through  the  secretions,  especially  the 
urine  or  bile,  or  there  may  result  a  deposition  and  permanent  retention 
of  the  granules. 

The  investigations  of  Langhans  are  especially  interesting,  as  suggesting 
efficient  means  for  the  production  of  pigment  by  cells  whose  function  is 
intimately  connected  with  pigmentation,  as  the  cells  of  the  rete  Malpighii, 
of  the  choroid,  and  of  certain  tumors.  The  observations  of  Gussen- 
bauer,2  however,  lead  to  the  conclusion  earlier  advanced  by  Virchow, 
that  pigment  may  be  produced  by  the  diffusion  into  cells,  outside  the  ves- 
sels, of  a  solution  of  the  pigment  of  the  blood  in  the  plasma  of  the  latter. 
A  precipitation  of  this  dissolved  pigment  into  granules  is  considered  as 
eventually  taking  place. 

The  method  of  origin  of  pigment  thus  described  applies  only  to  those 
discolo rations  which  are  unquestionably  due  to  the  metamorphosis  of  the 
coloring  matter  of  the  blood.  Examples  are  furnished  not  only  by  the 
extravasation  of  blood  on  a  large  scale,  but  also  by  the  escape  of  red 
blood-corpuscles  in  small  numbers.  Such  an  escape  takes  place  from  the 
pulmonary  vessels  in  chronic  obstruction  to  the  admission  of  blood  into 
the  left  side  of  the  heart.  The  resulting  brown  induration  of  the  lungs 
owes  its  color  to  the  metamorphosed  blood-pigment  which  is  present  as 
haematoidin  in  the  interstitial  tissue  of  the  lungs,  as  well  as  contained 
within  amoeboid  cells  in  the  alveolar  and  bronchial  cavities. 

It  is  probable  that  a  similar  transformation  of  haemoglobin  takes  place 
in  the  spleen  and  elsewhere  in  melanaemia.  In  this  condition  the  black 
granules  of  pigment,  although  differing  in  color  and  form  from  haema- 
toidin, contain  iron,  and  have  received  the  name  melanin.  These  granules 
are  either  free  in  the  blood  or  are  contained  within  the  white  blood-cor- 

1  Virchorfs  Archiv,  1880,  Ixxxi.  381.  *  Ibid.,  1875,  Ixiii.  322. 


DEGENERATIONS.  93 

puscles.  Their  origin  in  the  spleen  is  directly  suggested  by  their  fre- 
quent presence,  often  in  considerable  numbers,  in  the  large,  so-called 
splenic,  corpuscles  of  the  blood  in  the  hepatic  capillaries.  Eventually, 
the  pigment  is  found  at  more  remote  points  in  the  circulation,  and 
becomes  fixed  in  the  interstitial  tissue  of  the  various  organs  of  the 
body. 

The  black  pigment  of  the  cells  of  melanotic  tumors,  also  called  mela- 
nin, is  not  to  be  directly  traced  to  the  haemoglobin.  Virchow1  early  called 
attention  to  the  absence  of  iron  in  such  pigment.  Ferrated  and  non-fer- 
rated  varieties  of  melanin  are  thus  to  be  recognized,  the  term  being  used 
in  the  same  way  as  hsematoidin,  indicative  of  a  microscopical  appearance. 
A  still  further  complication  in  the  composition  of  melanin  is  suggested 
by  Kunkel,2  who  has  isolated  a  ferrated  pigment  from  melauotic  tumors. 
It  shows,  however,  with  the  spectroscope,  no  relation  to  hcematin,  biliru- 
bin,  or  hydrobilirubin.  That  its  nature  is  similar  to  the  normal  pigment 
of  the  skin  and  choroid  is  suggested  by  the  customary  origin  of  the  mela- 
notic tumors  in  such  pigmented  tissues,  and  by  the  resemblance  in  appear- 
ance and  reactions. 

That  pigment  of  the  most  varied  sort  may  be  introduced  into  the  body 
from  without,  and  may  remain  indefinitely  in  the  organism,  is  sufficiently 
well  known  from  the  results  of  tattooing.  What  is  essential  in  such  cases 
is,  that  the  pigment  shall  be  finely  divided  and  insoluble  in  the  fluids  of 
the  body.  The  most  important  of  such  pigmentations  are  those  taking 
place  through  inhalation  into  the  lungs.  The  reception  by  this  channel 
of  particles  of  soot  is  so  common  that  it  is  most  exceptional  for  the  lungs 
of  an  adult  to  be  free  from  the  bluish-black  discoloration  due  to  this 
agent.  Particles  of  coal-dust  presenting  the  details  of  vegetable  struct- 
ure are  met  with  in  the  lungs  of  individuals  exposed  to  an  atmosphere 
charged  with  this  material.  The  worker  compelled  to  inhale  the  dust  of 
iron  eventually  accumulates  a  store  of  this  substance,  the  quantity  of 
which  is  essentially  dependent  upon  the  length  of  exposure,  the  degree 
of  impregnation  of  the  atmosphere,  and  the  insufficient  nature  of  the 
protectives  employed. 

Although  a  large  part  of  the  pigmentation  under  such  circumstances  is 
due  to  the  direct  presence  of  the  foreign  bod),  the  appearances  are  also 
partly  the  result  of  consequent  minute  hemorrhages.  The  coal-dust  and 
the  iron-filings  are  often  sharp  and  jagged  fragments,  which  penetrate  the 
delicate  tissues,  and  the  escaping  red  blood-corpuscles  are  acted  upon  by 
the  amoeboid  cells  in  the  air-passages,  with  the  consequent  formation  of 
haematin  or  hsematoidin,  as  are  the  blood-corpuscles  in  larger  hemorrhages. 
The  inhaled  pigment  finds  its  way,  either  directly  or  by  the  agency  of 
amoeboid  cells,  into  the  lymphatics  and  fibrous  tissue  of  the  lungs,  and 
remains  indefinitely  either  in  the  bronchial  and  pulmonary  lymphatic 
glands  or  in  the  interstitial  tissue  of  the  lungs. 

Attention  may  be  here  called  to  that  pigmentation  of  the  skin  and 
deeper-seated  parts  of  the  body,  especially  of  the  kidneys,  known  by  the 
term  argyria.  The  long  continued  internal  use  of  nitrate  of  silver,  in 
former  years  so  extensively  employed,  especially  in  diseases  of  the  nervous 
system,  results  in  the  reduction  of  the  silver  and  its  deposition  as  minute 
particles  in  the  tissues.  Whether  the  silver  is  first  reduced  in  the  intes- 

1  Virchow's  Archiv,  1847,  i.  378.  2  Ziegler,  op.  tit.,  100. 


94  GENERAL  MORBID  PROCESSES. 

tine  and  then  absorbed,  or  whether  it  is  absorbed  as  an  albuminate  and 
subsequently  reduced,  still  remains  an  open  question. 

Although  the  pathological  pigmentations  form  an  extended  series  of 
alterations,  the  clinical  importance  of  the  condition  may  be  regarded  in 
many  instances  as  trivial.  The  pigments  resulting  from  extravasation 
produce  no  disturbance  of  function.  The  presence  of  bile-pigment  does 
not  account  for  the  symptoms  of  jaundice.  The  clinical  importance  of 
melanaBmia  has  perhaps  been  overrated.  The  earlier  observations  led 
directly  to  the  inference  that  mechanical  obstruction  to  the  circulation  in 
various  organs  might  take  place.  The  particles  of  pigment  and  the  cells 
containing  them  were  so  numerous  that  this  inference  seemed  quite  prob- 
able. The  evidence  is  still  lacking,  however,  which  proves  the  existence 
of  definite  symptoms  and  characteristic  lesions  as  the  result  of  the  mela- 
nsemic  condition. 

The  inhaled  foreign  bodies,  as  coal  and  iron,  are  productive  of  greater 
disturbances,  and  are  well  known  as  efficient  causes  in  the  production  of 
chronic  pulmonary  consumption.  The  coal-miner's  and  scissors-grinder's 
phthises  usually  have,  as  an  anatomical  basis,  catarrhal  conditions  of  the 
aerating  surfaces  and  interstitial  inflammations  of  the  pulmonary  con- 
nective tissue.  Mechanical  obstruction  to  the  aeration  of  the  blood  may 
also  be  present  from  the  extreme  quantity  of  the  foreign  material  in  the 
lungs. 


Tuberculosis. 

Until  the  investigations  and  discoveries  of  the  past  few  years,  the  pres- 
ence of  tubercles  in  the  various  organs  and  tissues  of  the  body  had  been 
regarded  as  the  essential  element  of  tuberculosis.  The  evidence  to  be 
presented  in  the  following  pages  will  show  that  the  immediate  cause  of 
tubercles  may  produce  other  lesions  as  well,  and  that  the  presence  of  a 
specific  virus  as  the  efficient  cause  of  whatever  may  be  the  lesion,  rather 
than  the  existence  of  tubercles,  is  to  be  regarded  as  the  characteristic 
feature  of  the  disease  tuberculosis. 

The  tendency  of  the  present  is  to  regard  the  latter  term  as  including 
the  various  morbid  processes  connected  with  the  origin,  presence,  and 
growth  of  a  specific,  organized  virus,  their  dissemination,  metamorphoses, 
and  effects.  Whether  all  those  processes  in  connection  with  which  the 
virus  is  found  are  due  to  the  latter,  or  whether  some  may  not  arise  and 
exist  independently  of  the  same,  are  among  the  questions  whose  answer 
is  remote  rather  than  at  hand. 

As  the  presence  of  the  cause  of  tuberculosis  is  the  test  demanded  by 
some  authorities  for  the  existence  of  the  process,  so  the  anatomical  classifi- 
cation has  depended  upon  the  existence  of  the  tubercle.  The  substitution  of 
tubercle  for  organized  virus  in  the  general  definition  of  tuberculosis  repre- 
sents the  distinction  between  the  anatomical  and  the  etiological  classifica- 
tion of  this  affection. 

A  tubercle  was  originally  a  small  rounded  body,  a  little  tuberosity,  and 
at  the  close  of  the  last  century  the  specific  tubercle  was  distinguished  from 
other  rounded  nodules. 

Till  the  discovery  of  Yillemin,  the  recognition  of  the  tubercle  was  essen- 


TUBERCULOSIS.  95 

tially  based  upon  its  anatomical  characteristics.  Previous  to  the  studies 
of  Reinhardt  and  Virchow  these  related  to  appearances,  which  yere  at- 
tributed to  a  deposition  of  material,  scrofulous  or  tuberculous,  from  the 
blood  or  lymph.  The  idea  was  eventually  maintained  that  this  material 
formed  the  basis  of  a  growth  or  new  formation,  and  Virchow  showed 
that  the  tubercle  was  composed  of  a  tissue,  of  cells  and  intercellular  sub- 
stance, growing  within  and  from  pre-existing  tissues.  He  classified  the 
tubercles  among  the  tumors  as  circumscribed  new  formations  whose 
structure  resembled  that  of  granulation-tissue.  The  specific  tubercle  was, 
at  the  outset,  minute,  smaller  than  a  millet-seed,  submiliary,  although 
indefinite  numbers  of  these  minute  tubercles  might  be  grouped  together 
and  form  closely  massed  aggregations.  From  this  agglomeration  of 
single  tubercles,  and  their  frequent  association  with  inflammatory  prod- 
ucts, both  of  which  were  prone  to  early  death  and  transformation  into  a 
cheese-like  mass,  the  extensive  tubercular  infiltrations  of  organs  arose. 
The  latter  were  regarded  as  a  frequent  cause  of  the  wasting  disease  phthisis, 
which  was  either  pulmonary,  intestinal,  or  renal  according  as  the  lungs, 
intestine  and  mesenteric  glands,  or  kidneys  were  the  predominant  seat  of 
the  tubercular  growth. 

The  histological  features  of  the  tubercle  were  further  investigated  by 
Wagner,1  who  described  the  resemblances  and  differences  of  the  structure 
of  the  tubercle  and  the  lymphatic  gland.  Schiippel 2  soon  after  published 
his  monograph,  essentially  confirming  the  statements  of  Wagner.  Ac- 
cording to  these  observers,  the  typical  tubercle,  as  found  in  lymphatic 
glands,  presents  essentially  the  same  peculiarities  of  structure  when  seen 
elsewhere  in  the  body.  This  structure  consists  of  a  non-vascularized  net- 
work of  fibres,  in  the  meshes  of  which  cells  are  imbedded.  The  fibrous 
network  resembles  the  reticulum  of  a  lymphatic  gland,  and  nuclei  are 
often  found  at  those  points  where  the  fibres  are  united.  This  appearance 
has  suggested  that  the  network  is  formed  of  branching  and  anastomosing 
cells.  Within  the  meshes  are  three  sorts  of  cells — viz.  giant-cells,  epi- 
thelioid  (endothelioid)  cells,  and  small,  round,  indifferent  cells.  One  or 
several  giant-cells,  each  with  its  abundant  nuclei,  lie  near  the  centre"  of 
the  tubercle  or  are  diffused  throughout  the  same.  These  are  usually 
immediately  surrounded  by  the  large  epithelioid  cells,  with  one  or  more 
nuclei,  which  are  often  so  numerous  as  to  compose  the  greater  part  of  the 
tubercle.  The  indifferent  cells,  resembling  lymph-corpuscles,  occur  singly 
or  in  groups,  distributed  throughout  the  tubercle  more  abundantly  at  the 
periphery,  between  the  cells  previously  described,  and  with  them  com- 
pletely fill  the  spaces  of  the  fibrous  network. 

Although  the  typical  tubercle  is  thus  constituted,  the  structural  fea- 
tures depend  somewhat  upon  its  age.  It  is  generally  admitted  that  the 
freshest  tubercles,  as  found  in  the  external  coat  of  the  smaller  arteries  of 
the  pia  mater,  are  composed  of  little  else  than  a  circumscribed  accumulation 
of  small,  round  cells,  without  a  distinct  reticulum.  The  giant-cells,  the 
epithelioid  cells,  and  the  well-characterized  reticulum  appear  as  the  tuber- 
cle increases  in  age.  It  is  thought  probable  that  the  giant-cells  represent 
the  agglomeration  of  the  small,  round  cells  in  pre-existing  cavities,  lymph- 
atics, blood-vessels,  or  secretory  canals.  The  epithelioid  cells  in  like 

1 "  Das  tuberkelahnliche  Lymphadenom,"  Archiv  der  Heilkunde,  1870,  xi.  6 ;  xii.  1. 
a   Untersuchungen  iiber  Lymphdrusen- Tuber  kulose,  1871. 


96  GENERAL  MORBID  PROCESSES. 

manner  are  considered  to  result  from  the  enlargement  or  fusion  of  the 
smaller  cells,  while  the  reticulum  represents  either  a  secretion  from,  or  a 
transformation  of,  the  cellular  elements  of  which  the  tubercle  is  composed. 

The  subsequent  history  of  the  tubercle  is  dependent  upon  its  meta- 
morphoses. These  are  known  as  cheesy  degeneration,  calcification,  and 
fibrous  transformation. 

The  absence  of  blood-vessels,  already  stated,  and  the  abundantly  cell- 
ular nature  of  the  growth,  with  the  possible  action  of  micro-organisms, 
result  in  a  tendency  to  the  early  death  of  the  cells  and  a  necrosis  of  the 
tubercle.  This  is  the  cheesy  degeneration,  and  is  regarded  as  a  form  of 
coagulative  necrosis,  which  begins  at  the  centre,  advances  toward  the 
periphery,  and  results  in  the  transformation  of  the  gray  into  a  yellow 
tubercle.  This  termination  in  cheesy  degeneration  likewise  affects  inflam- 
matory products  surrounding  the  tubercle,  and  even  relatively  normal 
tissues  in  which  numerous  tubercles  may  lie.  This  cheesy  material  either 
softens  or  becomes  infiltrated  with  lime  salts,  calcified.  The  softening 
of  the  tubercle  results  in  the  formation  of  a  material  capable  of  removal 
as  a  discharge  from  the  surfaces  of  the  body  or  by  absorption  through 
the  lymphatics  and  blood-vessels.  In  the  former  event  ulcers  arise  upon, 
and  cavities  com'municate  with,  the  surfaces  of  the  body  opening  externally. 

The  cheesy  material  frequently  becomes  calcified,  thus  remaining  as  a 
comparatively  inert  mass.  The  earthy  salts  may  be  diffused  throughout 
a  uniformly  cheesy  basis,  or  they  may  be  deposited  in  a  partially  softened, 
cheesy  menstruum,  when  a  mortar-like  material  results. 

The  tubercle  becomes  fibrous  with  the  diminution  in  the  number  of  its 
cells  and  the  increase  in  the  thickness  of  the  reticulum,  with  the  trans- 
formation of  the  latter  into  a  homogeneous  hyaline  substance.  The  corni- 
fied,  horn-like  tubercle  is  one  whose  size  is  diminished  from  the  shrinkage 
of  its  cells  into  glistening  flakes,  without  an  evident  associated  cheesy  or 
fatty  degeneration. 

The  intimate  relation  of  scrofula  to  tuberculosis  has  been  variously 
expressed  from  time  to  time  in  accordance  with  the  amount  and  accuracy 
of  the  existing  knowledge.  At  the  outset  the  enlargement  of  the  lymph- 
atic glands,  especially  of  the  neck,  characterized  the  scrofulous  affec- 
tion. As  the  enlargements  of  the  glands  were  found  to  present  intrinsic 
differences  connected  with  differing  clinical  histories,  only  those  glands 
were  regarded  as  scrofulous  which  presented  the  cheesy  appearances. 
With  the  recognition  of  the  cheesy  condition  of  tubercles  the  latter  were 
identified  with  the  scrofulous  gland,  from  the  cheesy  condition  common  to 
both. 

This  identification  of  scrofula  and  tubercle  prevailed  till  Virchow 
showed  that  cheesy  material  might  have  a  different  origin,  and  maintained 
that  there  were  cheesy  lymphatic  glands  without  tubercle,  as  well  as 
tuberculous  lymphatic  glands  which  might  become  cheesy.  A  distinc- 
tion was  thus  drawn  between  scrofula  and  tuberculosis.  The  former 
term  was  applied  to  that  condition  of  the  individual  which  favored  the 
retention  and  cheesy  degeneration  of  inflammatory  products,  not  only  in 
the  lymphatic  glands,  but  elsewhere  in  the  body.  Tuberculosis,  on  the 
contrary,  was  characterized  by  the  production  of  tubercles  which  wrere 
often  accompanied  by  retained  inflammatory  products,  both  of  which 
were  prone  to  undergo  cheesy  degeneration. 


TUBERCULOSIS.  97 

The  frequent  association  of  well -defined  tubercles  with  what  were 
regarded  as  antecedent  scrofulous  disturbances  also  suggested  an  intimacy 
of  relation  between  scrofula  and  tuberculosis.  Virchow l  had  always 
maintained  the  possibility  of  regarding  tuberculosis  as  a  heteroplastic  or 
metastatic  scrofula.  The  occurrence  of  cases  of  tuberculosis  without  evi- 
dence of  an  antecedent  scrofula  prevented  him  from  making  a  more  abso- 
lute statement  of  the  above  relation. 

The  views  with  regard  to  the  connection  between  scrofula  and  tuber- 
culosis have  become  essentially  modified  of  late  years  as  a  result  of  the 
investigations  concerning  the  etiology  of  tuberculosis. 

In  185G,  Buhl2  first  published  his  view,  although  he  had  for  several 
years  been  impressed  with  the  idea,  that  miliary  tuberculosis  was  an  infec- 
tive disease  resulting  from  the  absorption  of  a  specific  virus.  He  based 
his  theory  upon  the  almost  constant  coexistence  of  one  or  several  cheesy 
collections  and  miliary  tubercles.  The  former  were  recognized  as  the 
remains  of  previous  inflammatory  processes,  and  the  tubercles  were 
looked  upon  as  the  immediate  result  of  the  absorption  of  this  cheesy 
material.  The  individual  thus  infected  himself.  Buhl3  claimed  that 
the  simultaneous  occurrence  of  tubercles  and  inflammatory  products  was 
the  co-effect  of  the  same  cause,  and  that  the  acute  miliary  tuberculosis,  as 
a  localized  process,  was  merely  an  inflammation  with  the  development  of 
tubercles.  He  restricted  the  term  tuberculous  inflammation,  however,  to 
those  forms  which  necessarily  and  from  the  beginning,  produced  tuber- 
cles whose  presence  was  limited  to  the  tissue  inflamed.  The  tuberculous 
inflammation  was  regarded  as  a  primary  condition,  while  the  acute 
miliary  tuberculosis  was  a  secondary  process  resulting  from  infection. 

The  tuberculous  inflammation  of  this  author  was  largely  characterized 
by  those  features  which,  with  the  exception  of  the  constant  presence  of 
tubercles,  were  recognized  by  others  as  attributes  of  a  scrofulous  inflam- 
mation. At  the  same  time,  he  objected  to  the  latter  term  as  a  substitute, 
since  its  use  would  imply  that  no  other  cheesy  product  than  that  from  a 
tuberculous  inflammation  would  serve  as  the  origin  of  tubercles.  Buhl 
strictly  maintained  that  the  absorption  of  any  cheesy  material,  whatso- 
ever its  source,  might  give  rise  to  a  general  growth  of  tubercle  in  the 
body. 

The  views  of  this  author  were  popularized  mainly  through  the  teach- 
ings of  Niemeyer4  concerning  pulmonary  consumption.  The  latter 
adhered  to  Virchow's  views  relating  to  scrofulous  inflammation,  but. 
maintained  that  most  consumptives  were  in  imminent  danger  of  becom- 
ing tuberculous  in  accordance  with  the  doctrines  of  Buhl. 

The  theory  of  an  infectious  origin  of  tuberculosis,  advanced  from  time 
to  time  by  others,  but  most  forcibly  presented  and  maintained  by  Buhl, 
was  first  demonstrated  by  Villemin5  in  1865.  This  observer  showed 
that  certain  animals,  especially  rabbits  and  guinea-pigs,  might  be  suc- 
cessfully inoculated,  beneath  the  skin,  with  fragments  of  gray  tuber- 
cle, cheesy  products,  sputum,  and  blood  from  cases  of  phthisis.  The 
development  of  tubercles  took  place  within  three  weeks  after  the  inocu- 

1  Die  Krankhnften  Geschwiilste,  1864-65,  ii.  629. 

2  Lungenentsi'mdung,  Tuberkulose  und  Sc.hwwdsucht,  1872,  iii.  8  Op.  cit.,  123. 

4  tylinische  Vortrage  uber  die  Lungenschwindsucht,  1867. 

5  Eludes  sur  la  Tiiberculose,  Paris,  1868,  528. 

VOL.  I.— 7 


98  GENERAL  MORBID  PROCESSES. 

lation,  and  became  general  within  four  weeks.  He  also  demonstrated 
that  rabbits  became  tuberculous  when  inoculated  with  bits  of  the  tumors 
occurring  in  the  pearly  distemper  of  cattle. 

Villemin's  observations  have  been  repeatedly  confirmed  and  extended  ; 
although  subjected  to  the  severest  criticism  and  control,  their  results  are 
so  constant  that  the  law  of  the  iuoculability  of  tubercle  is  almost  uni- 
versally regarded  as  fixed.  Its  value  as  a  test  is  evident  from  the  state- 
ment of  Cohuheim,1  who  regards  as  tuberculous  only  that  which  pro- 
duces tuberculosis  when  transferred  to  suitable  animals.  The  transfer 
may  be  made  in  various  ways.  Chauveau  and  others  were  successful  in 
producing  an  intestinal  tuberculosis  by  the  introduction  of  tuberculous 
material  into  the  intestinal  canal  of  animals,  especially  the  Herbivora. 
Tappeiner2  succeeded  in  producing  pulmonary  tuberculosis,  with  or  with- 
out general  tuberculosis,  in  dogs,  by  compelling  them  to  breathe  air  in 
which  were  contained  minute  particles  of  sputa  from  tuberculous  pulmo- 
nary cavities. 

The  production  of  a  tuberculosis  of  the  iris,  as  well  as  of  remote 
organs,  by  the  inoculation  of  tuberculous  material  into  the  anterior 
chamber  of  the  eye,  was  an  ingenious  method  devised  by  Cohuheim  and 
Salomonsen.3  It  permitted  the  direct  observation  of  the  several  steps  in 
the  process  of  absorption  of  the  inoculated  material  and  development  of 
the  tubercles. 

The  objections  to  the  various  experiments  above  alluded  to  are  based 
upon  the  assumption  that  the  results  of  the  inoculation  are  not  tubercles, 
but  inflammatory  products  resembling  tubercles.  It  is  further  advocated 
that  the  inoculation  of  indifferent  material,  as  bits  of  glass  or  hairs,  as 
well  as  other  foreign  substances,  will  produce  the  so-called  artificial 
tuberculosis,  especially  in  rabbits  and  guinea-pigs.  It  is  admitted  that 
these  animals  readily  become  tuberculous  when  exposed  to  simple  inflam- 
matory irritants,  the  local  action  of  which  frequently  results  in  the  pro- 
duction of  cheesy  material.  This  termination  is  now  regarded  as  due  to 
faults  in  the  method  of  experimentation,  the  animals  not  being  thor- 
oughly protected  from  the  influence  of  the  virus  of  tuberculosis. 

The  objection  on  the  ground  of  structure  loses  its  force  in  connection 
with  the  well  known  differences  in  the  structure  of  miliary  tubercles  in 
the  human  body,  already  mentioned.  The  tubercles  resulting  from 
inoculation  often  resemble  in  structure  the  meuingeal  tubercles  of  the 
brain  rather  than  the  type  presented  by  tubercles  in  lymphatic  glands. 
The  development  of  tubercles  in  the  iris  may  take  place  without  any 
permanent  inflammatory  reaction.  The  association  of  evidences  of  in- 
flammation with  the  development  of  the  tubercle  is  therefore  unnecessary. 

The  experiments  of  Villemin  have  not  only  demonstrated  the  infec- 
tious nature  of  tuberculosis,  but  have  also  led  to  a  more  accurate  know- 
ledge of  the  relation  between  tuberculosis  and  its  allied  affections,  scrofula 
and  pearly  distemper. 

The  anatomical  characteristics  of  scrofula  have  obviously  proved  insuf- 
ficient in  determining  the  relation  presented  by  this  affection  to  tuber- 
culosis. The  tendency  to  cheesy  degeneration  of  its  inflammatory  prod- 

1  Di-e  Tuberkulose  vom  StandpunJcte  der  Infect ions- Lehre,  1880,  13. 

2  Virchow's  Archiv,  1878,  Ixxiv.  393. 

s  Cohnheim's  Vorlesungen  iiber  Allyemeine  Patholoyie,  2te  Auflage,  1882,  i.  707. 


TUBERCULOSIS.  99 

acts  was  the  feature  of  chief  importance.  Villemin  showed  that  por- 
tions of  a  scrofulous  (cheesy)  gland  when  inoculated  were  followed  by  tuber- 
culosis, and  that  the  inoculation  of  cheesy  material  from  non-tuberculous 
or  non-scrofulous  sources  was  not  followed  by  this  result.  The  assump- 
tion of  Buhl,  that  the  absorption  of  cheesy  material,  as  such,  was  the  cause 
of  tuberculosis,  was  thus  disproved.  The  frequency  with  which  the 
inoculation  of  cheesy  material,  from  what  were  regarded  as  scrofulous 
sources,  wa3  followed  by  tuberculosis,  led  to  more  exact  studies  concern- 
ing the  anatomical  peculiarities  of  scrofulous  inflammation.  Koster1 
called  attention  to  the  regularity  of  the  occurrence  of  miliary  tubercles  in 
the  fungous  granulations  of  the  inflamed  joints  of  scrofulous  and  tuber- 
culous individuals.  Wagner2  and  Schiippel3  discovered  that  scrofulous 
glands,  in  most  if  not  in  all  instances,  were  tuberculous  glands.  The 
regularity  of  the  presence  of  tubercles  in  scrofulous  abscesses  and  ulcers 
of  the  skin  and  in  scrofulous  caries  was  shown  by  Friedliinder.4  This 
observer  likewise  called  attention  to  the  presence  of  agglomerated  tuber- 
cles as  the  chief  constituent  of  the  new  formation  of  lupus.  These 
anatomical  discoveries  resulted  in  uniting  more  closely  the  affections 
scrofula  and  tuberculosis  from  the  histological  standpoint,  and  the  union 
has  become  more  firmly  cemented  from  the  etiological  investigations. 

Sch tiller5  has  shown  that  the  introduction  of  finely  divided  material 
from  a  scrofulos  joint — that  is,  from  one  containing  tubercles — into  the 
lungs  of  rabbits  was  followed  by  a  tuberculosis  of  the  tracheal  wound, 
the  lungs,  and  liver.  Similar  experiments  with  reference  to  the  intro- 
duction of  lupus-tissue  produced  results  suggestive  of  tubercle,  if  not 
actually  tuberculous. 

The  intimacy  of  relation  between  tuberculosis  and  pearly  distemper 
is  a  necessary  result  of  Villemin's6  experiment,  in  which  the  rabbit  became 
tuberculous  after  inoculation  with  fragments  of  the  pearly  tumor.  Ger- 
lach,7  and  especially  Schiippel,8  showed  that  the  structure  of  the  nodules 
of  the  pearly  distemper  is  the  same  as  that  of  the  tubercles  of  man, 
and  that  the  two  diseases  are  identical  from  the  histological  point  of 
view. 

From  the  anatomical  identification  and  the  etiological  connection,  as 
shown  by  Villemin,  Gerlach,  and  Aufrecht,  the  pearly  distemper  became 
designated  as  a  bovine  tuberculosis. 

The  experiments  of  Villemin  were  further  productive  in  leading  to  the 
discovery  by  Koch  of  the  bacillus  tuberculosis.  It  was  early  obvious 
that  certain  cheesy  material  and  gray  tubercles  possessed  the  infectious 
qualities,  and  Villemin9  maintained  that  the  immediate  cause  of  the  latter 
was  a  germ  introduced  from  without,  which  propagated  and  perpetuated 
itself  in  man  and  certain  animals.  This  view  acquired  prominence 
through  the  investigations  of  Klebs,  who  in  1877  claimed  to  have  iso- 
lated the  micrococci  which  produced  tubercles  when  injected  into  animals. 
Three  years  later  Schuller10  confirmed  the  statements  of  Klebs,  and  asserted 
that  he  had  been  enabled  to  obtain  infective  micrococci  by  cultivation  from 

1  FireWs  Archiv,  1869,  xlviii.  95.  2  Loc.  cit.  *  Op.  cit. 

4  Volktmarm'a  klinische  Vortriiye,  1873,  Ixiv. 

5  Untermchungen  iiber  die  Emkhung  vnd   Urscic/icn  der  Kkrophulosen  und  TvJ>erkulosen 
Ge/enkleiden,  1880.  6  Op.  cil.,  537.  7  Virchovfs  Archiv,  1870,  li.  290. 

8  Ibid.,  1872,  Ivi.  38.  9  Op.  cil.,  G20.  10  Op.  cit.,  55. 


100  GENERAL  MORBID  PROCESSES. 

miliary  tubercles,  scrofulous  glands  and  joints,  and  from  the  tissue  of  lupus. 
Aufrecht l  found  micrococci,  single  and  in  chains,  and  short  glistening 
rods,  within  tubercles  resulting  from  inoculation  with  material  from  pearly 
tumors.  The  same  organisms  were  found  in  tubercles  produced  by  the 
inoculation  of  tubercles  from  man,  and  he  regarded  these  rod-shaped 
bodies  as  the  specific  element  productive  of  miliary  tuberculosis. 

The  isolation  of  the  virus  of  tubercle  was  thus  regarded  as  an  open 
question  till  the  announcement  by  Koch2  of  the  constant  presence  of  a 
hitherto  unknown,  characteristic,  well  defined  organism  in  all  tuber- 
culous affections,  which,  when  isolated  and  introduced  into  animals, 
produced  tuberculosis,  the  resulting  tubercles  likewise  containing  the 
organism. 

The  latter,  the  bacillus  tuberculosis,  was  to  be  seen  in  preparations 
methodically  treated  and  carefully  stained  with  aniline  colors,  by  all  of 
which,  excepting  the  browns,  the  bacillus  was  tinged.  It  was  found  in 
miliary  tubercles  of  the  lung,  cerebral  and  intestinal  tubercle,  cheesy 
bronchitis  and  pneumonia,  phthisical  sputa,  scrofulous  glands,  and  fungous 
inflammation  of  the  joints.  It  was  also  seen  in  the  nodules  of  pearly 
distemper  and  in  the  cheesy  masses  from  the  lungs  of  cattle.  It  was 
furthermore  met  with  in  the  cheesy  lymphatic  glands  of  swine,  in  the 
tubercular  nodules  of  a  fowl,  and  in  the  tubercles  of  guinea-pigs,  rabbits, 
and  monkeys.  The  bacilli  were  likewise  found  in  the  tubercles  resulting 
from  the  inoculation  of  animals  with  tubercular  virus  from  its  various 
sources. 

The  microphytes  were  described  as  very  slender  rods,  varying  in  length 
from  cne-fourth  the  diameter  of  a  red  blood-corpuscle  to  its  entire  diam- 
eter, and  spores  were  occasionally  seen  within  the  rods.  In  shape  and 
size  they  resembled  the  bacilli  of  leprosy,  but  the  latter  were  narrower 
and  pointed  at  the  ends.  They  were  found  in  greatest  abundance  when 
the  tuberculous  process  was  recent  and  rapidly  advancing,  and  were 
present  within,  as  well  as  between,  cells.  The  younger  giant-cells  con- 
tained them  in  larger  numbers  than  the  older  forms.  They  were  present 
at  the  periphery  of  cheesy  nodules  rather  than  at  the  centre. 

The  bacilli  were  cultivated  through  successive  generations  and  required 
a  temperature  of  between  30°  C.  and  41°  C.  (86°  F.-105.80  F.)  for  their 
development,  one  of  37°  C.  or  38°  C.  (98.6°  F.  or  100.4°  F.)  being  the 
most  favorable.  The  crop  first  became  apparent  on  the  tentli  day  after 
sowing,  and  the  growth  extended  through  a  period  of  three  to  four  weeks, 
forming  a  compact  scale.  The  cultivated  bacilli,  even  propagated  through 
several  generations,  when  inoculated,  produced  the  same  positive  results  as 
follow  the  inoculation  of  fragments  of  tuberculous  material,  although 
animals  might  be  used  which  are  not  easily  infected  with  tuberculosis. 

Koch's  publication  was  immediately  followed  by  a  statement  from 
Baurngarten3  of  his  discovery  of  rod-like  bacteria  in  the  tubercles  of 
rabbits  resulting  from  the  inoculation  with  pearly  masses,  and  in  the 
pleural  and  perieardial  tubercles  of  man.  They  were  made  evident  by 
treating  the  sections  for  microscopic  examination  with  very  dilute  solutions 
of  soda  or  potash. 

1  Pathologist-he  MittheHungen,  1881,  p.  43. 

1  Berliner  Hinische  Wochcvxchrift,  1882,  p.  15. 

3  Centralblatt  fur  die  med.  Wissenschaften,  1882,  xv.  257. 


TUBERCULOSIS.  101 

The  discoveries  of  Koch  thus  show  that  the  production  of  tuberculosis 
is  dependent  upon  the  presence  of  distinctive  bacilli,  and  that  these  bacilli 
are  present  not  only  in  miliary  tubercles,  but  in  scrofulous  glands  and 
joints,  in  cheesy  inflammation  of  the  lungs,  and  in  the  pearly  distemper 
of  animals.  The  identification  of  tuberculosis  with  the  pearly  distemper 
and  certain  scrofulous  affections  is  thus  established  from  the  etiological  as 
well  as  the  histological  point  of  view. 

As  the  bacilli  are  to  be  regarded  as  the  virus  of  tuberculosis,  so  their 
introduction  into  the  human  body  is  necessary  for  the  production  of  this 
disease  in  man.  It  is  obvious,  however,  that  other  factors  than  the  virus 
are  necessary,  for  not  every  one  exposed  to  the  reception  of  tubercular 
bacilli  becomes  tuberculous.  It  may  well  be  that  scrofula  is  still  to  be 
regarded  as  that  condition  of  the  solids  and  liquids  of  the  body  which 
offers  favorable  opportunities  for  the  retention  and  growth  of  the  bacilli, 
and  thus  for  the  production  of  tuberculosis.  Forrnad1  claims  that  lie  has 
discovered  structural  peculiarities  of  tissue  as  a  cause  for  the  scrofulous 
habit,  which  he  regards  as  synonymous  with  a  predisposition  to  tubercu- 
losis. These  peculiarities  are  manifested  by  a  narrowness  of  the  lymph- 
spaces  and  their  partial  obliteration  by  cellular  elements.  He  also  main- 
tains that  these  features  are  not  only  of  congenital  origin,  but  may  be 
acquired  through  malnutrition  and  confinement. 

The  occurrence  of  a  local,  circumscribed  tuberculosis  in  extreme  old 
age,  without  antecedent  or  other  concurrent  evidence  of  scrofulous  dis- 
turbances, suggests  that  favorable  opportunities  for  the  development  of 
the  tubercular  bacillus  may  arise  in  advancing  years.  In  like  manner, 
the  frequent  termination  in  phthisis  of  cases  of  diabetes  suggests  the 
likelihood  of  tuberculous  inflammation  arising  in  the  absence  of  any 
evidence  of  previous  scrofulous  or  tuberculous  disease.  The  scrofulous 
condition  or  constitution,  as  indicated  by  vulnerable  tissues,  with  a  pro- 
tracted course  of  inflammations,  and  a  persistence  of  their  products, 
with  a  tendency  to  cheesy  degeneration,  may  still  exist  without  a  sign  of 
tuberculosis.  Those  who  claim  that  scrofula  and  tuberculosis  are  identical 
must,  in  the  light  of  Koch's  discovery,  demonstrate  the  presence  of 
the  bacillus  in  all  scrofulous  inflammations,  and  deny  the  existence  of 
scrofula  apart  from  indisputable  manifestations  of  the  activity  of  the 
bacilli  of  tuberculosis.  It  may  be  that  such  evidence  will  be  presented ; 
until  it  is  collected  scrofula  and  tuberculosis  are  to  be  regarded  as  distinct 
though  often  coexistent.  The  scrofulous  person  is  frequently  tuberculous, 
the  tuberculous  person  is  usually  scrofulous;  the  non-scrofulous  person, 
however,  may  die  of  tuberculosis,  while  the  individual  may  be  scrofulous 
without  containing  tubercle. 

The  actual  inheritance  of  tuberculosis  is  very  unlikely,  although  this 
disease  is  frequently  found  in  successive  generations  of  a  single  family. 
The  various  members  of  the  family  are  rather  to  be  regarded  as  furnish- 
ing a  suitable  soil  for  the  growth  of  the  tubercular  bacillus,  and  their  expo- 
sure to  its  seed  is  favored  by  the  existence  of  tuberculosis  in  one  or  more 
members  of  the  household.  The  scrofulous  condition  is  still  to  be  regarded 
as  hereditary  as  well  as  acquired,  and  the  scrofulous  remain  as  the  class  to 
be  especially  protected  from  the  reception  and  effects  of  the  bacilli  of 
tuberculosis. 

1  Studies  from  the  Pathological  Lab.  of  the  Univ.  of  Penim.,  reprint,  1882,  xi.  3. 


102  GENERAL  MORBID  PROCESSES. 

It  is  obviously  a  matter  of  importance  to  determine  in  any  given  case 
of  phthisis  whether  bacilli  are  present  or  absent.  A  ready  means  of  ascer- 
taining this  fact  is  offered  by  the  examination  of  the  sputum  in  cases  of  pul- 
monary phthisis,  the  feces  in  intestinal  phthisis,  the  urine  in  renal  phthisis, 
and  the  aspirated  pus  in  cases  of  supposed  tuberculosis  of  the  joints. 
Koch  has  found  in  examining  the  sputa  from  numerous  cases  of  phthisis 
that  the  bacilli  were  present  in  one-half  the  number,  and  that  they  were 
absent  from  the  sputa  of  individuals  who  were  not  phthisical.  Balmer 
and  Fraentzel1  have  found  bacilli  in  the  sputum  from  one  hundred  and 
twenty  cases  of  phthisis,  and  concluded  that  the  progress  of  a  case  of  pul- 
monary tuberculosis  might  be  readily  determined  from  the  number  and 
degree  of  development  of  the  typical  bacilli  present  in  the  sputum.  The 
more  numerous  and  well -developed  bacilli,  with  distinct  and  constant 
spores,  were  found  in  the  graver  cases,  which  advanced  more  rapidly. 
The  sputum  of  the  protracted  cases  contained  few,  small,  and  thin  bacilli 
with  scanty  spores.  The  presence  of  fever  was  associated  with  numerous 
bacilli,  while  its  absence  was  noted  in  those  cases  where  but  few  were  present. 

The  bacilli  are  readily  detected  by  means  of  the  staining  method 
devised  by  Koch.  Various  modifications  have  been  presented  from  time 
to  time,  of  which  that  of  Ehrlich 2  has  proved  the  most  satisfactory'.  The 
essential  features  are  to  obtain  a  dry,  thin  layer  of  a  selected  portion  of 
the  suspected  sputum,  which  is  then  to  be  deeply  stained  with  'fuchsin  or 
methyl-violet ;  the  excess  of  color  is  to  be  removed  with  nitric  acid,  and 
the  preparation  is  then  ready  for  examination  with  the  microscope.  A 
power  of  four  or  five  hundred  diameters  is  sufficient  for  the  recogni- 
tion, and  the  object  should  be  illuminated  with  a  flood  of  light  through 
a  large  diaphragm  or  an  achromatic  condenser.  The  bacillus  retains 
the  color  notwithstanding  its  exposure  to  the  acid,  and  the  violet  colors 
are  more  strongly  presented  if  the  preparation  is  tinted  yellow  after 
the  action  of  the  acid.  If  the  bacilli  are  stained  red  with  fuchsin,  the 
background  should  be  made  blue.  It  is  important  that  the  reagents 
should  be  freshly  prepared  and  filtered,  that  other  bacteria  may  not 
obscure  the  picture,  and  that  all  the  apparatus  employed  should  be 
thoroughly  clean. 

A  fragment  of  thick,  opaque  sputum  is  to  be  taken  in  forceps,  placed 
on  a  cover-glass,  and  spread  into  a  thin  layer  by  means  of  a  second  cover- 
glass.  The  prepared  slide  is  then  to  be  passed  slowly  through  an  alcoholic 
flame,  or  that  of  a  Buusen  burner,  till  the  layer  of  sputum  is  dried.  A  satu- 
rated alcoholic  solution  of  methyl-violet  or  fuchsiu  is  made  and  filtered,  and 
added,  drop  by  drop,  to  a  filtered,  saturated  solution  of  aniline  oil  shaken  in 
water.  The  color  is  to  be  added  with  stirring  till  an  opalescent  film  forms 
on  the  surface  of  the  mixture.  The  slide  containing  the  dried  sputum  is 
to  be  placed  in  or  on  this  staining  fluid,  and  allowed  to  remain  for  half  an 
hour  or  less,  the  application  of  warmth  hastening  the  process,  when  it  is 
removed,  and  the  specimen  is  decolorized  in  a  solution  of  one  part  of  nitric 
acid  and  two  parts  of  water.  The  preparation  is  then  washed  in  water,  and 
may  be  examined  directly  in  water,  glycerin,  or,  after  dehydration  in 
alcohol,  in  oil  of  cloves.  The  tinted  bacilli  are  made  more  prominent  by 
a  secondary  staining,  for  a  minute  or  two,  of  the  red  (fuchsiu)  preparation 

1  Berliner  klinisclie  Wochenschrifi,  1882,  xlv.  679. 
*Allg.med.  Centr  Zeitung,  1882,  xxxvii.  458. 


TUBERCULOSIS.  103 

in  a  concentrated  solution  of  methyl-blue,  the  violet  preparation  being 
secondarily  stained  in  a  like  solution  of  aniline-brown.  If  the  prepa- 
ration is  to  be  permanently  preserved,  it  should  be  dehydrated  in  strong 
alcohol  after  washing  with  water,  and  it  may  then  be  treated  with  oil  of 
cloves  and  mounted  in  Canada  balsam. 

After  the  observer  has  become  thoroughly  familiar  with  the  tubercle 
bacilli  by  means  of  the  method  of  Ehrlich,  much  time  may  be  saved  by 
following  that  of  Baumgarten.1  The  cover-glass  bearing  the  dried  sputum 
is  placed  in  a  very  dilute  solution  of  caustic  potash  (two  drops  of  a  33 
per  cent,  solution  in  a  watch-glass  of  distilled  water)  till  the  layer  of 
sputum  becomes  transparent.  The  cover  is  then  placed  on  a  slide  moist- 
ened with  a  drop  of  water,  tapped  slightly,  and  examined  with  the  micro- 
scope. The  bacilli  are  readily  seen,  and  may  be  differentiated  from  other 
varieties  of  bacteria,  if  necessary,  by  again  drying  the  object  and  exam- 
ining it  in  a  drop  of  a  dilute  watery  solution  of  aniline-violet  or  of  other 
preparations  of  aniline  used  for  staining  nuclei.  The  tubercle  bacilli 
remain  unstained,  while  putrefactive  bacteria  are  tinted. 

The  tubercular  products  of  the  invasion  of  the  body  by  the  bacillus 
tuberculosis  are  regarded  as  primary  or  secondary,  according  as  they  are 
present  at  that  part  of  the  body  which  directly  receives  the  organisms  or 
as  they  are  dependent  upon  the  transfer  of  the  latter  to  parts  remote  from 
the  region  of  their  admission  and  immediate  effects.  This  differing  rela- 
tion is  also  expressed  by  the  terms  local  and  general  tuberculosis.  In 
the  former  the  bacilli  excite  the  growth  of  tubercle  only  at  a  given  part 
of  the  body.  Their  apparent  effects  may  be  wholly  limited  to  this 
region,  and  it  not  rarely  happens  that  the  same  is  quite  distant  from  the 
channels  through  which  the  bacilli  are  admitted.  A  general  tuberculosis 
occurs  when  the  latter  are  disseminated  over  the  body,  and  their  effects, 
especially  the  production  of  numerous  tubercles,  are  found  at  various 
parts.  The  dissemination  may  take  place  at  the  time  of  entrance,  or,  as 
is  more  commonly  the  case,  apparently  occurs  at  some  subsequent  period, 
the  immediate  disturbances  being  localized  at  a  given  portion  of  the  body. 
The  necessary  conditions  being  here  offered  for  the  propagation  of  the 
bacilli,  their  sudden  distribution  in  great  numbers  is  afterward  permitted 
when  favorable  opportunities  arise  for  their  absorption.  Such  conditions 
are  present  when  the  local  tubercular  growths  extend  into  lymphatics  or 
blood-vessels.  The  frequency  with  which  scrofulous  glands  are  tuber- 
culous— that  is,  contain  miiiary  tubercles — is  already  fully  recognized, 
and  a  tuberculosis  of  the  lymphatic  glands  is  essentially  regional.  These 
glands  become  affected  in  consequence  of  disturbances,  the  local  effects  of 
which  may  have  wholly  disappeared,  in  the  region  from  which  they  receive 
their  lymph.  The  cervical  glands  become  permanently  enlarged,  perhaps 
tuberculous,  in  connection  with  persistent  or  recurrent  inflammatory  pro- 
cesses in  the  tonsils  and  pharynx,  the  bronchial  glands  from  similar  bron- 
chial or  pulmonary  affections,  and  the  mesenteric  glands  from  like  intes- 
tinal disturbances.  In  such  instances,  the  direct  reception  of  the  bacilli 
into  the  lymph-current  is  assumed  rather  than  demonstrated  from  a 
knowledge  of  the  possibilities  of  absorption  and  an  appreciation  of  the 
conditions  in  the  glands. 

That  an  actual  growth  of  tubercles  from  the  wall  of  the  intestinal  lymph- 
1  Centralblatt  fiir  die  med.  Wissenschaften,  1882,  xxv.  433. 


104  GENERAL  MORBID  PROCESSES. 

atics  may  take  place  has  long  been  known,  and  Ponfick  lias  recently 
discovered  that  tubercles  may  be  found  growing  from  the  wall  of  the 
thoracic  duct.  The  possibility  of  the  direct  admission  into  the  lymph- 
current  of  the  infective  element  in  tuberculosis  is  thus  apparent,  and  its 
indirect  entrance  into  the  blood-current  is  equally  obvious.  That  the 
bacillus  of  tubercle  may  be  directly  received  into  the  blood-current  is 
likewise  evident  from  the  observations  of  Weigert,  who  found  tubercles 
growing  from  the  walls  of  the  pulmonary  blood-vessels,  venous  as  well 
as  arterial.  This  discovery  of  a  tuberculosis  of  the  blood-vessels  was 
confirmed  by  Klebs,  who  had  found  a  tuberculosis  of  the  azygos  veins. 
The  occurrence  of  multiple  miliary  tubercles  of  the  pulmonary  veins, 
especially  near  the  place  of  entrance  of  smaller  branches,  has  been  asserted 
by  Miigge,1  although  appearances  similar  to  those  described  by  him  may 
be  met  with,  due  simply  to  the  agglomeration  of  white  blood-corpuscles 
and  their  necrosis.  Such  a  condition  simulates  very  closely  the  miliary 
tubercle,  but  is  usually  analogous  to  the  appearances  figured  by  Virchow,2 
and  described  by  him  as  one  of  the  phenomena  of  coagulation.  In  his 
observation  the  white  bodies  were  adherent  to  the  red  clots,  and  were 
with  them  drawn  from  the  pulmonary  artery. 

With  the  admission  into  the  body,  and  the  colonization  of  the  tubercular 
bacilli,  their  effects  may  either  be  progressive  until  the  death  of  the  indi- 
vidual is  occasioned,  or,  with  the  cessation  of  the  growth  of  the  bacilli  or 
a  possible  modification  of  their  noxious  properties,  recovery  may  ensue. 
The  history  of  scrofulous  glands,  as  well  as  that  of  circumscribed  pul- 
monary inflammation  in  scrofulous  persons,  both  presumably  of  a  tuber- 
culous nature,  show  that  the  effects  of  an  invasion  of  the  parasites  may 
be  overcome. 

The  regions  of  the  body  which  are  usually  the  seat  of  a  primary 
tuberculosis  are  unquestionably  the  respiratory  and  intestinal  tracts. 
With  regard  to  the  first  of  these  regions,  the  one  most  frequently 
affected,  there  can  be  no  doubt  that  in  most  instances  the  inhaled  air 
carries  the  bacilli  or  their  spores,  or  both.  Their  constant  presence  in 
the  sputum  of  the  frequent  cases  of  tuberculous  phthisis  suggests  a  ready 
means  for  their  escape  into  the  atmosphere.  The  well  recognized  infec- 
tive qualities  of  the  sputum,  as  demonstrated  by  the  various  experiments 
before  the  bacillus  was  discovered,  demand  the  thorough  disinfection  of 
phthisical  sputa,  since  these  are  in  all  probability  the  chief  source  of  the 
dissemination  of  the  disease. 

The  tuberculosis  of  the  intestine  in  like  manner  is  to  be  regarded  in  the 
main  as  the  result  of  an  absorption  from  its  surface  of  the  specific  agent. 
An  obvious  direct  means  of  the  approach  of  the  bacilli  is  offered  in  the 
sputum,  which,  when  swallowed,  is  likely  to  retain  its  virulent  properties. 
The  frequent  coexistence  of  chronic  pulmonary  and  intestinal  tubercu- 
losis is  thus  most  readily  explained.  To  what  extent  the  presence  of 
the  bacilli  in  the  pearly  distemper  of  rnttle  and  in  the  tuberculosis  of 
other  edible  domesticated  animals,  as  fowls  and  swine,  may  lead  to  an 
infection  of  the  intestinal  wall,  still  remains  an  unsolved  problem.  It  is 
not  yet  determined  at  what  temperatures  the  bacilli  are  destroyed, 
although  their  growth  takes  place  only  between  30°  C.  (86°  F.)  and 

1  Virchou?*  Archi'v,  1879,  Ixxvi.  243. 

2  Die  Cellular  Pathologic,  4te  Auflage,  1871,  184. 


MORBID   GROWTHS.  105 

41°  C.  (105,8°  F.).  The  inoculation  of  pearly  masses  produces  tubercu- 
losis in  certain  animals,  yet  the  effect  of  cooking  in  destroying  the  bacilli 
and  their  spores  is  likely  to  prove  of  great  importance.  Aufrecht's1 
attempts  at  inoculating  rabbits  with  cooked  pearly  masses  proved  unsuc- 
cessful. Schottelius2  publishes  an  interesting  series  of  observations 
relating  to  the  prolonged  use  of  meat  from  cattle  affected  with  the 
pearly  distemper,  and  shows  that  after  a  period  of  years  no  disease  of  the 
nature  of  tuberculosis  occurred  among  the  one  hundred  and  thirty  indi- 
viduals included  in  the  families  concerned.  Whatever  may  be  the  value 
of  this  negative  testimony,  there  is,  as  yet,  no  evidence  011  the  other  side 
which  satisfactorily  determines  the  point  in  question — viz.  that  the  flesh 
of  animals  affected  with  pearly  distemper  produces  tuberculosis  in  the 
human  consumer. 

The  milk  from  cows  thus  diseased  has  likewise  been  regarded  with 
suspicion,  and  the  frequency  of  intestinal  tuberculosis  among  children 
has  been  attributed  to  this  source.  Although  the  theoretical  possibility 
of  the  escape  of  the  bacilli  into  the  milk  of  COWTS  affected  with  pearly  dis- 
temper is  obvious,  their  presence  in  such  milk  is  first  to  be  demonstrated 
under  conditions  which  necessitate  their  origin  from  the  animal.  If 
boiling  the  infective  material  for  three  minutes  destroys  its  virulence,  as 
claimed  by  Aufrecht,  a  ready  means  is  offered  of  destroying  the  tubercle 
bacilli  which  may  be  present,  not  only  in  the  milk  from  animals  affected 
with  pearly  distemper,  but  in  all  milk  which  has  been  exposed  for  a  cer- 
tain time  to  an  atmosphere  which  may  contain  the  bacilli  of  tuberculosis. 
In  the  light  of  our  present  knowledge  extreme  hygienic  precautions  are 
only  demanded  in  those  cases  where  such  a  congenital  or  acquired  basis 
(constitution)  is  present  as  facilitates  the  development  of  tuberculosis. 


Morbid  Growths. 

In  a  system  of  practical  medicine  it  is  obviously  important  to  include 
under  the  head  of  Morbid  Growths  not  only  what  is  spoken  of  by  the 
surgeon  as  a  tumor,  but  also  those  new  formations  of  tissue  which,  in  vir- 
tue of  their  nature,  seat,  manner  of  growth,  and  retrograde  changes,  pro- 
duce an  important  series  of  disturbances  in  the  physiological  processes  of 
the  individual.  The  surgeon  deals  essentially  with  the  swelling,  which, 
producing  irregularities  in  the  outline  of  the  accessible  surfaces  of  the 
body,  is  regarded  as  an  excrescence  or  outgrowth.  It  is  important  for 
him  to  realize  the  nature  of  this  swelling,  that  he  may  follow  a  different 
treatment  for  the  abscess,  the  wen,  the  watery  accumulation,  or  the  fleshy 
mass.  The  last  is  the  tumor  in  the  limited  sense ;  it  is  the  growth  which, 
though  called  morbid,  becomes  so  only  in  consequence  of  its  presence 
being  associated  with  symptoms  whose  existence  and  persistence  interfere 
witli  the  Avell-beiug  of  the  possessor. 

The  physician,  on  the  contrary,  is  more  concerned  with  the  tumor  as  a 
growth  than  as  a  swelling.  The  latter  element  in  deeply-seated  portions 
of  the  body  may  not  be  brought  to  his  attention.  The  growth  takes 
place  in  such  a  manner  as  to  be  productive  of  certain  symptoms  more 
or  less  serious,  among  which  swelling  is  least  obvious.  The  morbid 

1  Op..cit.,  51.  *  Virchou/s  Archiv,  1883,  xci.  129. 


106  GENERAL  MORBID  PROCESSES. 

growth  to  him  becomes  prominent  as  it  displaces  or  replaces  normal 
tissues  by  those  newly  formed,  which  may  or  may  not  be  normal  to  the 
part  in  which  the  growth  is  situated.  His  tumor  is  therefore  a  morbid 
growth,  a  new  formation,  a  neoplasm  or  pseudoplasni,  rather  than  a 
swelling,  a  bunch,  or  an  excrescence. 

In  a  consideration  of  the  general  pathology  of  morbid  growths  the 
first  question  which  suggests  itself  relates  to  the  method  of  origin  of  the 
tumor.  The  tendency  of  the  present  seeks  for  a  local  cause,  and  the 
most  recent  theory,  that  of  Cohuheim,  demands  an  accumulation  of  dor- 
mant embryonal  cells  as  such  a  cause.  Cohuheim  supports  this  view  by  the 
experiments  of  Zahn  and  Leopold,  which  show  that  foetal  cartilage  trans- 
planted into  the  tissues  of  a  mature  animal  may  grow  so  rapidly  as  to 
present  the  characteristics  of  a  cartilaginous  tumor,  while  tissues  trans- 
ferred from  the  animal  after  birth  do  not  increase  in  size,  but  are  usually 
absorbed. 

As  the  active  elements  of  the  growth  are  cells,  and  all  cells  admissibly 
arise  from  pre-existing  cells,  it  follows  that  the  primitive  cells  of  a  tumor 
are  derived  from  those  resulting  from  the  segmentation  of  the  ovum  or 
are  introduced  from  without.  Numerous  experiments  have  been  made 
with  a  view  to  the  inoculation  of  tumors,  the  transplantation  of  living 
fragments  of  the  latter  to  the  living  tissues  of  a  healthy  individual,  for 
the  sake  of  producing  a  tumor,  but  hitherto  almost  invariably  without 
success.  The  alternative  remains  that  the  embryonal  cells  are  those 
whose  derivatives  are  present  in,  and  form  the  essential  element  of,  the 
morbid  growth.  All  tumors  may  thus  be  said  to  have  an  embryonal 
origin.  As  the  segmentation  of  the  ovum  eventually  results  in  the 
production  of  normal  tissues  and  groups  of  tissues  whose  structure  and 
function  are  wholly  different,  so  the  possibility  of  the  production  of 
abnormal  groupings  of  tissue  with  corresponding  irregular  manifestations 
of  function  is  obvious. 

The  cells  of  the  part  from  which  a  tumor  arises  may  be  regarded  as 
indifferent,  those  whose  limitations  of  growth,  like  the  early  embryonal 
cells,  are  only  determined  by  the  changes  they  undergo,  or  their  limits 
of  growth  may  be  already  defined  in  kind,  and  their  like  be  produced  in 
the  formation  of  the  tumor.  The  origin  of  a  tumor  thus  presupposes 
the  existence  of  such  indifferent  cells,  or  the  presence  of  those  whose 
limit  of  transformation  has  already  been  reached.  The  leucocytes  of  the 
body,  whether  found  as  white  blood-corpuscles  or  lymph-corpuscles,  or 
as  the  wandering  cells  of  connective  tissue,  are,  as  Virchow  has  indicated, 
such  indifferent  cells.  Always  present  and  apparently  transitory,  what 
they  are  to  become  can  only  be  determined  from  their  condition  and  sur- 
roundings at  the  time  of  observation.  Although  their  actual  transformation 
into  the  various  cells  of  a  more  permanent  type  is  merely  a  matter  of  infer- 
ence in  the  growth  of  tumors,  the  evidence  presented  by  Ziegler l  leads 
directly  to  the  conclusion  that  their  presence  is  necessary  to  the  new 
formation  of  tissues  whose  growth  is  the  result  of  an  inflammatory  pro- 
cess. These  tissues  may  occur  under  such  restrictions  as  permit  them  to 
be  classified  as  tumors,  and  the  granulomata,  or  tumors  whose  tissue 
resembles  that  of  the  granulations  upon  the  surface  of  a  wound,  repre- 
sent a  well  defined  group  in  structure  as  well  as  method  of  origin. 

1  Op.  tit.,  150. 


MORBID  GROWTHS.  107 

The  production  of  the  cells  of  a  tumor  from  indifferent  cells  is  at 
present  an  assumption,  based  upon  the  frequent  presence  of  the  latter 
within  tumors  and  in  their  vicinity  ;  and  the  obvious  objection  arises 
that  even  if  the  presence  of  these  cells  is  admitted  as  indispensable,  it  by 
no  means  follows  that  they  are  directly  transformed  into  the  more  charac- 
teristic cells  of  the  tumor.  That  they  may  serve  for  the  nourishment  of 
the  amoeboid  cells  of  certain  tumors  is  suggested  by  the  existence  of  both 
in  morbid  growths,  and  the  well-known  property  of  amoeboid  corpuscles 
to  take  in  formed  material,  even  cells,  from  without. 

The  origin  of  tumors  from  cells  whose  limits  of  growth  are  already 
defined  is  rendered  probable  from  the  absence,  entire  or  in  great  part,  of 
indifferent  cells  from  certain  tumors,  and  the  direct  continuity  of  the  latter 
with  a  similar  normal  tissue  of  the  body.  Various  tumors  show  such  an 
intimate  relation,  and  there  is  no  sharply  defined  border-line  between  the 
normal  tissue  and  that  which  represents  the  tumor.  The  occasional 
presence  of  islets  of  well  characterized  tissue  at  points  more  or  less 
remote  from  the  normal  position  of  such  tissue  at  the  time  of  their 
discovery  suggests  a  feasible  source  for  an  eventual  tumor.  Virchow 
long  ago  called  attention  to  isolated  nodules  of  cartilage  within  bones  in 
the  vicinity  of  epiphyseal  cartilages,  probably  detached  from  the  latter, 
which  might  serve  as  the  origin  of  a  cartilaginous  tumor  in  this  region. 
This  inclusion  of  tissue  is  also  suggested  by  the  frequency  of  certain 
tumors  in  certain  regions  where  the  developmental  conditions  are  favor- 
able. Liicke l  mentions  the  frequency  of  dermoid  cysts  near  the  median 
line  of  the  head,  the  vicinity  of  the  eye,  and  the  side  of  the  neck.  Such 
regions  are  those  where  fissures  exist  during  foetal  life,  with  normal  invo- 
lutions of  the  outer  germinal  layer;  which  involutions  may  become  irreg- 
ular, and  eventually  included  or  shut  in,  as  the  fissures  become  closed.  A 
similar  explanation  is  offered  for  the  frequent  occurrence  of  cartilaginous 
tumors  at  the  angle  of  the  jaw,  it  being  thought  probable  that  bits  of 
embryonal  cartilage,  during  the  formation  of  the  ear,  become  included  in 
the  salivary  glands. 

In  like  manner,  Cohnheim  explains  the  frequent  occurrence  of  certain 
epithelial  tumors  at  the  orifices  of  the  body — the  cervix  uteri  and  the 
vicinity  of  the  tracheal  bifurcation — not  through  the  exposure  of  these 
parts  to  injury,  but  because  they  are  regions  in  which  embryonal 
irregularities  of  development  are  likely  to  arise. 

That  congenital,  local  peculiarities  are  an  important  element  in  the 
origin  of  tumors  has  already  been  strongly  advocated  by  Virchow.  Not 
only  are  children  born  with  tumors,  but  instances  of  growths  eventually 
arising  from  birth-marks,  and  the  occurrence  of  certain  tumors  in  the 
same  locality  in  successive  generations  of  the  same  family,  are  suffi- 
ciently familiar. 

Although  certain  tumors  are  admitted  to  be  due  to  congenital  peculiar- 
ities of  tissue,  and  even  to  represent  atypical  growths  from  embryonal  tis- 
sue, the  theory  of  such  an  embryonal  origin  for  all  tumors  seems  unneces- 
sary. The  resemblance  in  symptoms  as  well  as  in  appearance,  and  even  in 
structure,  of  certain  tumors  to  inflammatory  products,  and  their  frequent 
association  with  these,  has  led  to  the  suggestion  of  an  irritant  an  an  exciting 
cause  for  the  tumor,  even  in  the  absence  of  local  peculiarities  of  tissue. 

1  Volkmann's  Sammluny  klinischer  Vortrage,  xcvii.  819. 


108  GENERAL  MORBID  PROCESSES. 

It  is  obvious  that  were  the  embryonal  theory  of  origin,  as  extended  by 
Cohuheim,  universally  applicable,  the  growth  demands  something  more 
than  a  focus  of  embryonal  cells.  An  immediate  cause  for  their  growth 
after  a  dormant  period,  extending  even  into  old  age,  is  required.  Cohn- 
heim  finds  such  in  a  sufficient  supply  of  blood.  He  attributes  the  devel- 
opment or  rapid  growth  of  the  tumor  to  this  feature,  and  supports  his 
view  by  the  usual  appearance  of  exostoses  when  the  skeleton  is  at  its 
period  of  most  vigorous  growth,  and  of  dermoid  cysts  at  a  time  when  the 
formation  of  the  beard  indicates  active  developmental  conditions  in  the 
outer  germinal  layer. 

The  growth  of  ovarian  cystomata  at  and  after  puberty,  and  of  these 
and  mammary  tumors  during  pregnancy,  are  also  explained  on  the  ground 
of  a  more  abundant  supply  of  blood  at  such  periods.  He  and  others  find 
in  physiological  conditions  a  source  for  the  abundant  blood-supply — that 
is,  the  efficient  nutrition  for  the  growth  of  a  tumor.  The  necessity  of 
sufficient  nutrition  in  the  development  of  tumors  is  universally  admitted, 
and  its  source  may  be  looked  for  in  pathological  as  well  as  physiological 
conditions. 

The  existence  of  an  irritant  of  some  sort  often  seems  probable,  and, 
although  its  absence  is  more  frequently  determined  than  its  presence,  it 
is  obvious  that  when  present  it  may  be  overlooked.  Although  traumatic 
irritants  of  considerable  mechanical  severity  exist  in  but  a  small  percent- 
age of  tumors,  their  occasional  influence  in  the  production  of  morbid 
growths  is  not  to  be  denied.  Their  action  may  be  explained  as  producing 
a  congestion  or  as  enfeebling  the  opposition  of  physiological  tissues  to 
pathological  growths.  The  importance  of  an  irritant  as  the  exciting 
cause,  however  its  action  may  take  place,  is  supported  not  only  by  the 
sequence  of  injuries  and  tumors,  but  also  by  the  frequent  occurrence  of 
tumors  in  parts  exposed  to  injury  and  irritation.  Such  exposure  may 
result  from  position,  structure,  or  function.  The  orifices  and  prominences 
of  the  body,  the  retained  testis  in  the  inguinal  canal,  are  notoriously 
liable  seats  of  tumors.  Soft,  friable,  and  slightly  resistant  structures,  like 
mucous  membranes,  are  not  only  the  frequent  place  of  origin  of  tumors, 
but  the  most  exposed  parts  of  such  structures  are  oftenest  affected.  The 
exposure  resulting  from  function  is  manifest  by  the  relation  presented  by 
the  periods  of  greatest  functional  activity  of  the  growth  of  tumors  in  such 
organs  as  the  mammary  gland,  uterus,  and  ovaries. 

The  importance  of  an  irritant  is  still  further  suggested  by  the  associa- 
tion of  tumors  with  inflammation.  The  growth  of  tubercles  and  cancer 
from  serous  membranes  is  frequently  accompanied  by  an  acute  inflamma- 
tion of  the  latter ;  fibrous  tumors  and  chronic  interstitial  inflammations 
often  coexist,  while  elephantiasis  is  usually  preceded  by  recurrent,  erysip- 
elatous  inflammation  of  the  skin. 

The  recent  discovery  of  infective  organisms  as  an  exciting  cause  for 
many  of  the  members  of  an  entire  group  of  tumors,  the  granulomata,  has 
resulted  in  making  prominent  the  etiological  rather  than  the  structural 
features  of  the  tumors  concerned. 

Local  peculiarities  of  tissue,  whether  congenital  or  acquired,  are  thus 
regarded  as  representing  the  beginnings  of  the  growth.  With  the  mul- 
tiplication of  the  cells  their  transformation  may  take  place  or  a  change 
in  their  grouping  may  arise.  The  essential  condition  in  the  production 


MORBID  GROWTHS.  109 

of  the  morbid  growth  is  that  the  formation  of  the  cells  should  take  place 
at  an  abnormal  time  or  place  and  should  progress  in  a  normal  or  abnor- 
mal manner. 

The  growth  takes  place  with  greater  or  less  rapidity  in  one  or  another 
direction  according  to  the  nature  of  the  tumor  and  its  seat.  The  more 
closely  the  tumor  resembles  the  normal  structures  of  the  body,  the  slower 
is  its  growth  ;  the  more  it  differs  in  composition,  the  more  rapid  is  its 
progress.  This  difference  may  arise  from  a  predominance  of  cells  over 
intercellular  substance,  as  in  the  case  of  the  sarcoma,  or  it  may  result 
from  an  atypical  combination  of  tissues,  as  seen  in  the  development  of 
epithelium  and  connective  tissue  in  cancer. 

The  seat  of  the  tumor  is  of  importance  mainly  on  account  of  the  vascular 
supply  of  a  part  and  the  more  spongy  or  yielding  nature  of  certain 
regions.  That  the  more  abundant  the  nutrition  of  certain  regions  of  the 
body,  the  more  favorable  the  opportunities  for  growth,  may  be  admitted 
without  question.  The  spongy  nature  of  tissues  implies  a  predominance 
of  cavities  over  solid  constituents.  These  cavities  are  lined  by  surfaces 
which  represent,  on  the  one  hand,  the  walls  of  lymph-spaces,  on  the 
other  the  free  surfaces  of  the  body  exposed  to  the  air,  as  the  mucous  or 
cutaneous  surfaces  and  the  pulmonary  surface.  The  rapidity  of  growth 
in  the  direction  of  the  least  resistance  is  amply  shown  in  the  projection 
of  tumors  above  the  surface  of  serous  membranes  and  the  frequent  pres- 
ence of  fungoid  excrescences  in  various  parts  of  the  body. 

The  growth  of  tumors  extends  in  all  directions,  but  a  distinction  has 
long  been  drawn  between  the  concentric  or  interstitial  manner  of  growth 
and  the  excentric  or  infiltrating  form.  This  distinction  is  based  upon 
the  presence  of  a  sharply  defined  limitation  of  pathological  and  normal 
tissues  or  upon  the  absence  of  such  a  limitation.  Such  a  distinction  is 
merely  of  relative  importance,  as  certain  tumors  may  grow  in  both 
ways.  This  is  best  observed  in  those  bulging  superficial  tumors  whose 
base  is  irregularly  extended  into  the  continuous  healthy  tissues. 

The  concentric  variety  of  growth  includes  those  tumors  which  have 
commonly  been  described  as  encapsulated,  and  which  are  capable  of 
ready  enucleation  from  their  surroundings  in  virtue  of  a  thin  layer  of 
loose  connective  tissue  lying  between  the  tumor  and  the  contiguous 
tissue.  Such  a  capsule  represents  the  matrix,  the  pia  mater,  in  which  lie 
the  blood-vessels  going  to  and  coming  from  the  tumor,  and  is  often 
nothing  else  than  the  distended  and  hyperplastic  fibrous  tissue  remaining 
after  the  absorption  of  the  muscular  fibres  or  gland-cells  from  the  tissues 
surrounding  the  morbid  growth. 

The  excentric,  peripheral,  or  infiltrating  extension  of  the  tumor  takes 
place  when  the  surrounding  parts  are  invaded  by  the  active  elements  of 
which  the  tumor  is  composed.  The  amoeboid  property  of  the  cells  of 
certain  tumors  is  well  known,  and  the  possibility  is  admissible  that  the 
indifferent  cells  of  the  body,  so  often  accumulated  at  the  periphery  of 
the  growth,  become  impregnated  with  a  formative  function  by  the  con- 
stituents of  the  tumor.  Such  amoaboid  and  wandering  cells  represent  a 
means  through  which  the  growth  of  the  tumor  may  become  extended  in 
its  vicinity  as  well  as  in  more  remote  parts  of  the  body. 

The  extension  in  the  vicinity  may  be  continuous  or  the  reverse, 
the  latter  through  the  formation  of  secondary  nodules,  which  may  event- 


110  GENERAL  MORBID  PROCESSES. 

ually  become  fused  with  the  primary  mass.  The  continuous  growth 
takes  place,  as  has  been  more  particularly  shown  by  Koster,  along  the 
lymph-channels  surrounding  the  tumor,  which  may  become  filled,  dis- 
tended, and  eventually  obliterated  Jby  projections  from  the  neoplasm. 
Both  methods  of  peripheral  growth,  by  secondary  nodules  and  continu- 
ous extension,  represent  an  infection  of  the  surrounding  tissues,  especially 
if  it  be  admitted  that  the  cells  through  which  the  increase  is  accomplished 
are  direct  descendants  of  the  pre-existing  cells  of  the  part.  Not  only 
docs  the  extension  take  place  through  the  lymphatic  vessels  about  the 
tumor,  but  blood-spaces  as  well  as  lymph-spaces  may  be  invaded. 
Thrombi  are  then  found  whose  structure  is  frequently  that  of  the 
tumor,  and  whose  connection  with  the  same  is  direct  through  the  per- 
forated wall  of  the  vessel.  These  features  in  the  growth  of  tumors  lead 
directly  to  the  consideration  of  the  means  by  which  multiple  tumors 
appear  in  remote  parts  of  the  body  after  a  single  tumor  has  appeared 
in  a  given  locality,  and  after  the  removal  of  such  a  primitive  growth. 

The  distinction  between  primary  and  secondary  ttnriors  is  now  so 
obvious  that  one  is  inclined  to  forget  that  the  presence  of  numerous 
tumors  at  various  parts  of  the  body  was  at  one  time  regarded  as  evidence 
of  the  constitutional  or  dyscrasic  nature  of  the  morbid  growth.  Such  a 
multiplicity  seemed  to  indicate  that  the  blood  was  charged  with  the  con- 
stituents of  the  tumor,  which  were  deposited  at  various  parts  of  the 
body. 

Although  certain  multiple  tumors  may  be  present  in  different  local- 
ities without  an  apparent  relation  between  an  antecedent  and  a  subsequent 
growth,  such  tumors  are  usually  limited  to  certain  systems  of  the  body. 
Multiple  bony  tumors  are  found  growing  from  bones,  fibrous  and  warty 
tumors  from  the  skin,  and  h'bro-myomata  from  the  uterus.  Cohnheim's 
theory  of  the  embryonal  origin  of  tumors  may  seem  applicable  in  such 
cases,  but  the  frequent  association  of  the  osteomata  with  chronic  inflam- 
matory conditions,  of  cutaneous  warts  and  fibrous  tumors  with  local  irri- 
tative processes,  makes  such  a  hypothesis  unnecessary. 

Those  tumors  whose  multiplicity  is  of  the  greatest  clinical  importance 
are  the  rapidly  growing  forms  terminating  fatally.  Such  are  those  which 
reappear  in  the  scar  after  the  removal  of  a  cancer,  or  in  the  adjoining  chain 
of  lymphatic  glands  or  at  remote  parts  of  the  body.  The  most  satisfactory 
explanation  of  their  presence,  and  of  the  generalization,  recurrence,  or 
metastasis  of  tumors,  is  derived  from  what  has  already  been  stated  with 
reference  to  the  manner  of  the  growth  of  the  latter. 

It  is  well  known  from  experiments  on  animals  that  various  living, 
normal  tissues  when  transplanted  to  remote  parts  of  the  same  individual 
or  to  other  individuals  may  continue  to  grow.  Cohnheim  claims,  as  has 
been  previously  stated,  that  a  distinction  is  to  be  drawn  in  this  respect  be- 
tween the  tissues  of  the  adult  and  the  foetus,  where  the  genesis  of  tumors 
is  concerned.  This  observer,  in  connection  with  Maas,1  has  found  that 
the  transplanted  material  (periosteum),  although  growing  for  a  while,  dis- 
appears at  the  end  of  five  weeks,  and  it  is  asserted  that  fragments  of 
tumors,  when  transferred,  suffer  a  similar  fate.  Wile,2  on  the  contrary, 

1  Virchoiv's  Archiv,  1877,  Ixx.  161. 

*  The  Pathogenesis  of  Secondary  Tumors,  reprint  from  Philadelphia  Med.   Times,  July, 
Aug.,  and  Sept.,  1882. 


MORBID  GROWTHS.  11  j 

who  has  experimented  with  reference  to  the  fate  of  transplanted  tissues 
and  portions  of  tumors,  reports  that  one  hundred  days  after  the  transfer 
of  periosteum  the  lung  was  found  to  contain  several  centres  of  ossification. 
Pie  regards  the  latter  as  proceeding  from  the  fragments  of  periosteum 
introduced  into  the  jugular  vein,  and  his  results  thus  widely  differ  from 
those  of  Cohnheim. 

Notwithstanding  the  numerous  experiments  which  have  been  made  in 
various  parts  of  the  world  to  excite  the  growth  of  transplanted  bits  from 
tumors,  most  of  them  have  terminated  unsuccessfully.  Although  a  tempo- 
rary growth  of  fragments  of  tumors  has  taken  place  after  transplantation, 
their  eventual  disappearance  has  usually  occurred.  Cohnheim  lays  stress 
upon  this  fact  in  connection  with  his  theory  of  the  origin  of  tumors.  He 
considers  that  the  fragments  of  tissue  and  tumors  disappear  in  consequence 
of  the  inability  of  the  foreign  particles  to  withstand  the  metamorphosis 
of  physiological  tissues.  If  this  opposition  is  neutralized,  the  existing 
germs  of  tumors  become  capable  of  development.  Wile,  however,  found 
that  eight  weeks  after  the  introduction  of  a  bit  of  cancer  into  the  lung  of 
an  animal  the  fragment  had  increased  nearly  twice  in  size.  He  also  refers 
to  the  positive  experiments  of  Newinsky, l  who  transplanted  a  bit  of  can- 
cer from  a  dog  to  the  subcutaneous  tissue  of  another, young  dog,  and  found, 
after  five  months,  not  only  an  ulcerating  cutaneous  cancer  at  the  place  of 
inoculation,  but  also  a  metastatic  nodule  of  the  size  of  a  hazel-nut  in  an 
axillary  lymphatic  gland. 

For  the  present  consideration  it  may  be  borne  in  mind  that  fragments 
of  normal  (foetal)  tissues,  as  shown  by  the  experiments  of  Zahn  and  Leo- 
pold, when  introduced  into  the  organs  of  animals,  may  become  enlarged. 
It  is  also  certain  that  bits  of  tumors,  after  their  introduction  into 
the  tissues  and  organs  of  animals,  have  become  increased  in  size.  What 
their  eventual  fate  might  have  been  does  not  appear ;  and  herein  lies  the 
weak  point  of  the  experiments  with  reference  to  the  production  of  sec- 
ondary tumors.  For  such  experiments  to  be  regarded  as  crucial  it  is 
necessary  that  a  large  number  of  previously  healthy  animals,  after  inoc- 
ulation with  fragments  of  morbid  growths,  should  present  in  various 
parts  of  the  body  well  characterized  tumors  whose  structure  should  be 
like  that  of  the  particles  introduced. 

The  experiments  above  referred  to  are  of  value  in  confirming  the  views 
concerning  the  generalization  of  tumors  which  have  been  generally  admit- 
ted since  Virchow's  discoveries  with  regard  to  the  phenomena  of  embo- 
lism. 

Tumors  are  said  to  become  generalized  when  they  appear  not  only  in 
various  systems  of  the  body,  but  in  various  organs  and  tissues.  They 
are  found  usually  in  considerable  numbers,  and  with  such  differences  in 
size,  shape,  and  appearance  as  to  indicate  different  ages.  Such  tumors 
are  regarded  as  arising  directly  or  indirectly  from  a  common  source. 
This  source  is  called  the  primitive  or  primary  tumor,  and  its  derivatives 
the  secondary  tumors.  The  latter  are  usually  considered  as  the  direct 
descendants  of  the  former,  although  their  relation  may  be  that  of  several 
successive  generations. 

The  primitive  tumor  in  its  growth  may  extend  into  lymphatics  and 
blood-vessels,  as  has  already  been  suggested.     Such  an  extension  may  be 
1  Allgem.  medicinische  Central- Zeitung,  1876,  Ixxi.  875. 


112  GENERAL  MORBID  PROCESSES. 

so  little  obvious  when  the  tumor  is  removed  by  the  surgeon  that  all 
diseased  tissues  are  apparently  separated  from  the  body.  A  recurrence 
of  the  tumor  is  said  to  take  place  when  the  growth  returns  in  the 
cicatrix,  frequently  in  a  multiple  form.  The  explanation  of  such 
a  recurrence  is  based  upon  the  probable  presence,  at  the  time  of  the 
operation,  of  fragments  of  the  tumor  within  the  tissues  forming  the 
base  and  edges  of  the  wound.  During  and  after  the  healing  of  the 
wound  their  growth  is  supposed  to  continue  till  they  become  appar- 
ent as  small  tumors.  The  progress  of  these  recurrent  tumors  is  at 
times  extremely  rapid,  and  they  may  attain  a  considerable  size  in  the 
course  of  a  few  weeks.  Such  nodules  are  secondary  in  point  of  time, 
although  they  were  actually  a  part  of  the  primary  growth. 

Secondary  nodules  in  descent  as  well  as  time  are  those  which  appear 
at  distant  parts,  often  after  the  discovery  of  the  primary  tumor.  Such 
nodules  are  regarded  as  resulting  from  the  transfer  of  particles  of  vari- 
ous size  from  the  primitive  growth,  either  through  the  lymph-vessels 
or  blood-vessels.  If  the  invasion  of  the  body  takes  place  through  the 
former,  the  fragments  may  be  floated  along  to  the  nearest  lymphatic 
gland,  where  it  remains  when  too  large  to  pass  through.  If  it  retains 
the  capacity  of  growth  or  of  stimulating  a  like  growth,  there  results  a 
more  or  less  complete  transformation  of  the  gland  into  a  morbid  tissue 
like  that  from  which  the  fragments  came.  Adjoining  lymph-glands  may 
become  infected  from  the  first,  until  eventually  an  entire  series  becomes 
more  or  less  completely  transformed  into  morbid  growths.  A  like 
invasion  of  the  lymphatic  glands  may  take  place  through  a  continu- 
ous extension  along  the  lymph-vessels;  and  it  is  not  rare  to  find 
the  sub-pleural  or  sub-peritoneal  lymphatics  as  an  elevated  meshwork  in 
consequence  of  the  neoplastic  growth  within  them.  Such  a  method  of 
extension  may  take  place  when  a  cancer  of  the  stomach  or  liver  is  asso- 
ciated with  a  cancer  of  the  pleura,  the  intervening  lymphatics  of  the  dia- 
phragm offering  a  direct  and  continuous  communication. 

With  the  outcropping  of  a  tumor  upon  a  serous  surface  the  possibility 
of  the  detachment  of  particles  is  at  hand.  These  may  become  trans- 
planted to  the  opposed  serous  surface  or  may  be  transferred  to  the  most 
dependent  parts,  and  there  serve  as  seed  for  subsequent  growth. 

The  probability  of  the  embolic  nature  of  many  secondary  tumors 
was  early  suggested  in  the  history  of  embolism.  Rapidly  growing 
tumors  were  known  to  be  capable  of  perforating  the  walls  of  adjacent 
blood-vessels,  especially  veins,  and  to  continue  growing  along  the 
course  of  such  vessels.  The  possibility  of  the  detachment  of  portions 
of  these  tumors  and  their  transfer  along  the  course  of  the  circulation 
was  an  inevitable  inference  from  the  results  of  experimentation  with 
foreign  bodies.  Cancerous  emboli  were  thus  recognized  as  a  possible 
variety,  and  their  distribution  was  subject  to  the  same  laws  as  those 
governing  emboli  otherwise  constituted.  Multiple  nodules  were  fre- 
quently found  in  the  lungs  in  connection  with  tumors  growing  into  the 
inferior  vena  cava,  while  multiple  nodules  in  the  liver  were  usually  asso- 
ciated with  tumors  of  the  gastro-intestinal  canal  or  other  regions  whose 
vessels  formed  a  part  of  the  portal  circulation.  The  readiness  with  which 
portions  may  be  detached  after  death  from  the  soft  masses  projecting  into 
the  interior  of  veins  suggests  the  ease  with  which  particles  may  be  sep- 


MORBID  GROWTHS.  113 

arated  during  life.  The  experiments  already  referred  to  show  that  iso- 
lated fragments  of  tissue  serving  as  emboli  may  grow  in  the  place  of 
their  reception,  and  it  is  presumable  that  the  resulting  growth  takes  place 
under  the  same  conditions  as  those  prevailing  at  the  place  from  which  the 
embolus  started.  The  question  whether  the  secondary  tumor  arises  from 
the  reproduction  of  elements  transferred  from  the  primitive  disease,  or 
whether  these  excite  a  characteristic,  specific  growth  of  the  cells  in  the  place 
of  their  retention,  may  still  be  regarded  as  open.  The  experiments  lavor 
the  former  view,  and  they  alone  are  capable  of  satisfactorily  determining 
the  point  in  question. 

The  secondary  nodules,  whatever  may  be  their  method  of  origin,  pre- 
sent the  peculiarities  of  the  primitive  growth.  If  the  cells  of  the  latter 
are  pigmeuted,  those  of  the  former  show  the  same  peculiarity.  If  the 
structure  of  the  primitive  tumor  contains  bone,  cartilage,  or  squamous 
epithelium,  the  secondary  growths  show  like  characters,  though  they 
may  be  present  in  the  heart  or  other  organs  where  such  tissues  are  not 
present  as  normal  constituents.  So  constant  and  characteristic  is  this  fea- 
ture that  the  structure  of  the  tumor  is  usually  as  well  displayed  in  the 
examination  of  the  secondary  as  of  the  primitive  nodule.  Indeed,  the 
structural  peculiarities  of  the  growth  may  be  more  characteristically  shown 
in  the  former  in  those  instances  where  the  primitive  tumor  has  undergone 
degenerative  changes  obscuring  its  histological  features. 

The  tissues  of  the  tumor  are  subject  to  the  various  changes  which  take 
place  in  the  normal  tissues  of  the  body.  Their  growth  is  attended  with 
a  multiplication  of  cells  and  a  formation  of  intercellular  substance. 
Tumors  whose  growth  is  the  most  rapid  are  those  whose  blood-vessels  are 
the  most  numerous  and  whose  relation  to  the  cells  is  most  intimate.  The 
slower  the  advance  of  the  tumor,  the  more  permanent  is  it  likely  to 
become,  while  the  more  rapid  the  progress,  the  more  transitory  are  its 
elements.  The  growth  may  continue,  and  yet  the  actual  size  of  the  tumor 
may  diminish  through  the  absorption  of  its  degenerated  parts.  The  cells 
of  the  neoplasm  may  undergo  fatty  degeneration,  or  they  may  become 
cornified.  They  may  undergo  the  mucous  metamorphosis  or  the  amyloid 
and  colloid  degenerations.  They  may  take  up  pigment  or  they  may  pro- 
duce the  same,  The  intercellular  substance  varies  in  its  character  as  does 
that  of  normal  tissues.  It  may  be  slimy,  homogeneous,  or  fibrillated.  It 
may  contain  mucin,  chondrin,  or  gelatin,  and  may  be  infiltrated  with  cal- 
careous salts.  Limited  necroses  with  characteristic  cheesy  appearances  are 
of  frequent  occurrence. 

Tumors  may  become  the  seat  of  inflammatory  processes,  indicated  by 
suppuration  and  fever,  which  may  result  in  abscess  or  gangrene,  or  their 
progress  may  terminate  in  the  production  of  scars.  Ulceration  may 
occur  in  consequence  of  the  extension  of  an  inflammatory  process  to  the 
surface,  or  it  may  result  in  the  course  of  the  degenerative  softening  of  a 
tumor.  In  both  cases  the  cutaneous  or  mucous  surface  is  involved  and 
destroyed,  and  the  interior  of  the  tumor  being  exposed  putrefactive  pro- 
cesses, with  fistulse  and  sinuses,  arise,  the  latter  favoring  the  retention  of 
the  product  and  the  persistence  of  the  inflammatory  process. 

Tumors  are  always  pathological,  but  the  resulting  disturbances  vary 
within  wide  limits  and  are  often  of  a  complex  character.  The  familiar 
distinction  between  benignant  and  malignant  tumors  is  based  chiefly 

VOL.  I.— 8 


114  GENERAL  MORBID  PROCESSES. 

upon  this  variance  in  the  nature  of  the  disturbances.  Those  are  benig- 
nant which  closely  resemble  the  normal  structures  of  the  body,  increase 
but  slowly,  and,  if  they  attain  a  large  size,  produce  mainly  mechanical 
disturbances.  They  may  prove  serious,  even  fatal,  if  so  seated  as  to 
interfere  with  the  function  of  important  parts  of  the  body.  Very  large 
and  heavy  tumors  may  prove  burdensome  solely  on  account  of  their 
weight,  while  others  of  similar  character,  elsewhere  seated,  may  interfere 
with  respiration  or  circulation,  and  eventually  with  nutrition.  Tumors 
in  exposed  situations  may  become  important  only  in  virtue  of  their 
liability  to  injury,  while  others  impede  the  function  of  a  part  or  an 
organ  by  pressure  upon  its  nerves  and  vessels  or  by  obstructing  its 
ducts. 

The  malignant  tumors,  on  the  contrary,  differ  in  their  structure 
from  the  normal  tissues  of  the  body.  Their  growth  is  rapid  and 
infiltrating  rather  than  slow  and  concentric.  Such  tumors  usually 
have  a  predominance  of  cells  and  thin  walled  blood-vessels.  The 
former  may  be  little  else  than  nuclei  enveloped  in  an  easily  destruc- 
tible protoplasm,  or  they  may  be  composed  of  multi-nucleated  masses 
of  protoplasm,  and  are  then  known  as  giant-cells.  The  most  malig- 
nant tumors  are  those  which  tend  to  become  generalized  as  well  as  to 
spread  locally.  They  recur  locally,  and  appear  in  the  nearest  lymph- 
glands  and  at  remote  parts  of  the  body.  The  disturbances  produced 
by  the  malignant  tumors  depend  less  upon  their  mechanical  relations 
than  upon  their  tendency  to  destroy  tissues  and  disturb  functions.  AVith 
their  presence  and  progress  in  vital  organs  there  is  associated,  from  their 
manner  of  growth,  a  destruction  of  the  cells  of  such  organs,  as  the  kid- 
neys and  liver,  the  lungs  and  heart.  When  they  are  seated  in  the 
spleen  and  lymphatic  glands,  a  disturbance  in  the  blood-making  process 
must  be  associated.  Their  occurrence  in  the  alimentary  canal  opposes 
the  admission,  digestion,  and  expulsion  of  its  contents,  and  pro- 
duces disturbances  varying  as  to  the  seat  and  peculiarities  of  the  tumor. 
The  progress  of  the  malignant  tumor  is  often  associated  with  ulcera- 
tion,  watery  discharges,  and  hemorrhage.  The  frequent  coexistence  of 
emaciation,  weakness,  ansemia,  and  a  yellowish  discoloration  of  the  skin 
forms  a  group  of  disturbances  which,  included  under  the  name  "cachexia," 
have  long  been  prominent  as  significant  of  malignant  tumors.  At  the 
present  day  this  cachexia  is  regarded  rather  as  the  result  than  the  cause 
of  the  tumor,  whereas  formerly  the  reverse  was  the  case. 

The  modern  classification  of  tumors  is  based  chiefly  on  their  structure, 
in  part  upon  their  method  of  origin,  and  in  part  upon  their  cause. 

With  the  observation  of  the  similarity  of  appearances  in  the  flesh  of 
which  the  external  and  internal  neoplasms  are  composed,  ^:he  suggestion 
readily  presented  itself  to  regard  the  external  tumors  and  the  internal 
growths  as  similar  in  character.  External  forms,  physical  characteristics, 
clinical  peculiarities,  all  proved  insufficient  as  a  means  of  identifying  the 
two,  and  the  step  was  a  short  one  which  led  to  the  minute  study  of  the 
flesh  of  the  tumor  and  a  comparison  of  its  resemblances  and  differences. 
This  comparison  obviously  included  a  knowledge  of  the  structure  and 
peculiarities  of  normal  tissues.  As  histological  studies  advanced,  so  did 
the  pursuit  of  pathological  histology,  and  the  tumors  which  were  once 
designated  as  encephaloid,  mastoid,  pancreatoid,  or  nephroid,  from  real 


MORBID  GROWTHS.  115 

or  fancied  resemblances  to  certain  organs  of  the  body,  became  analyzed 
into  their  microscopic  rather  than  macroscopic  characteristics. 

It  is  unnecessary  to  say  that  the  modern  classification  of  morbid 
growths  owes  its  foundation  and  a  large  part  of  its  superstructure  to 
Virchow,  whose  classic  work,  Die  Krankha/ten  Geschwulste,  showed  the 
direction  which  future  investigators  were  to  pursue  and  the  nature  of 
the  discoveries  likely  to  result. 

The  tumor  represents  the  result  of  the  growth  of  a  tissue  or  tissues 
which  are  like  or  resemble  those  which  form  the  normal  constituents  of  the 
body.  Although  a  new  formation  is  present,  it  is  composed  of  tissues  lying 
within  the  possibilities  of  the  individual.  A  new  formation  of  feathers, 
as  Virchow  suggests,  is  beyond  the  productive  powers  of  human  tissues, 
though  within  those  of  feathered  animals.  A  goose  can  produce  a  tumor 
containing  feathers,  not  one  in  which  hairs  are  found ;  in  the  human 
species  tumors  containing  huirs  may  occur,  not  those,  however,  in  which 
feathers  are  present.  Although  the  cells  of  the  tumors  of  man  may 
deviate  in  their  appearances  from  the  cells  of  normal  tissues,  this  devia- 
tion is  never  so  extreme  that  their  analogue  cannot  be  met  with  in  some 
part  of  the  body. 

As  the  normal  tissues  originate  from  pre-existing  tissues,  so  the  patho- 
logical tissues  of  the  tumor  grow  only  from  the  antecedent  tissues.  The 
matrix  from  which  the  tumor  arises  is  a  normal  tissue.  There  is  pro- 
duced from  it,  as  a  neoplasm,  either  a  tissue  which  follows  the  type  of  the 
maternal  tissue,  a  homologous  tumor,  or  one  which  deviates  in  type  from 
that  of  the  matrix,  a  heterologous  growth.  Although  the  latter  diifers  in 
its  composition  from  that  of  the  matrix,  it  does  not  vary  essentially  from  a 
like  tissue  to  be  found  elsewhere  in  the  body.  It  occurs  where  it  does  not 
belong  either  in  place,  time,  or  quantity.  The  homologous  tumor  appears 
rather  as  a  hypertrophy  of  the  tissue  from  which  it  arises,  and  the  line 
between  this  variety  of  growth  and  a  simple  hypertrophy  is  often  purely 
arbitrary. 

Although  tumors,  in  the  more  limited  sense,  are  solid,  fleshy  masses,  the 
'  new  formation  of  tissues  may  result  in  the  presence  of  a  tumor  within 
which  is  a  cavity  with  various  contents.  Such  a  cavity  is  not  a  mere  hole, 
but  has  a  distinct  wall  of  connective  tissue  lined  with  epithelium  or 
endothelium.  A  distinction  is  thus  drawn  between  cysts  and  growths — 
one  which  is  of  daily  importance  in  the  practice  of  medicine — and  Vir- 
chow's  oncology  includes  the  consideration  of  the  two  varieties  of 
tu  mors. 

Cystic  tumors  are  subdivided  according  to  the  nature  of  their  contents 
and  the  method  of  their  origin.  One  group  is  composed  of  clotted  blood 
within  cavities  resulting  from  the  laceration  of  tissues  or  in  preformed 
spaces.  If  the  cyst  primarily  is  merely  a  rent,  the  wall  becomes  thick- 
ened in  time  from  a  growth  of  the  limiting  tissues,  and  the  blood-clot,  of 
which  the  tumor  was  chiefly  composed,  may  remain  or  become  absorbed. 
If  the  latter  event  occurs,  its  place  of  deposit  may  become  obliterated  by 
a  fusion  of  the  walls  of  the  cyst,  or  may  persist  from  the  subsequent  addi- 
tion of  serum. 

The  cystic  tumor  whose  contents  are  extra vasated  blood  is  the  haema- 
toma,  familiar  instances  of  which  are  met  with  in  the  hsematoma  of  the 
dura  mater,  of  muscle,  of  the  vulva,  and  the  polypoid  haematoma  of 


116  GENERAL  MORBID  PROCESSES. 

the  uterus.  The  latter  is  the  long  retained  and  constantly  enlarging 
blood-clot,  due  to  the  adherence  of  portions  of  the  placenta  after  child- 
birth. 

The  second  group  of  cystic  tumors  has  for  its  contents  a  more  watery 
fluid,  and  to  this  the  term  hygroma  is  applied.  This  watery  fluid  lies, 
for  the  most  part,  within  preformed  cavities,  and  its  accumulation  is  con- 
nected with  a  dilatation  of  these  cavities.  Instances  are  met  with  in  the 
tumors  resulting  from  the  accumulation  of  fluid  in  the  membranes  of  the 
brain  or  spinal  cord,  and  in  the  ventricles  of  the  former  or  in  the  central 
canal  of  the  latter.  These  lead  to  the  congenital  cystic  tumors  of  the  cra- 
nium or  spine,  with  watery  contents.  The  ganglion,  the  house-maid's  knee, 
as  also  the  hydrocele  of  the  tunica  vaginalis,  are  regarded  as  hygromata. 
The  hydrocele  of  the  neck  and  elsewhere  in  the  subcutaneous  or  inter- 
muscular  connective  tissue  is  now  removed  from  the  hygromata  to  the 
tumors  which  arise  from  lymph- vessels.  A  like  transfer  of  other  hygro- 
mata might  be  made  in  accordance  with  the  prevailing  views  concerning 
the  cavities  in  which  the  watery  fluid  is  accumulated. 

A  third  group  of  cysts  contains  material  which  represents  essen- 
tially a  production  from  the  wall,  with  a  difference  of  composition 
dependent  upon  the  nature  of  the  wall.  Such  cysts  give  rise  to  tumors 
through  the  retention  of  their  contents,  and  they  are  called  retention- 
cysts  or  retention-tumors.  In  the  wall  of  the  cysts  is  a  gland-tissue, 
which  may  line  the  surface  or  lie  beneath.  The  glandular  structures 
may  be  cutaneous,  mucous,  or  represent  a  part  of  the  great  glands  of  the 
body,  as  the  liver  and  kidneys.  The  atheromatous  cyst  of  the  skin,  the 
mucous  cysts  of  the  gastro-intestinal  mucous  membrane,  and  the  ovula 
Nabothi  of  the  uterus  are  examples  of  the  retention  of  secretion  within 
glands.  The  dropsical  dilatations  of  the  antrum,  the  vermiform  append- 
age, the  uterus,  the  biliary  and  renal  canals  furnish  instances  of  tumors 
resulting  from  the  retention  of  secretion  on  a  large  scale.  In  the  sub- 
sequent history  of  these  retention-cysts  the  secretion  may  be  modified 
chemically  and  physically ;  the  cells  upon  the  walls  may  be  transformed 
from  columnar  forms  into  flattened  and  scale-like  varieties.  In  time, 
the  original  secretion  frequently  becomes  a  watery  fluid,  resembling  the 
contents  of  the  hygroma  previously  mentioned. 

This  grouping  of  cysts  in  contradistinction  to  fleshy  tumors  omits  the 
consideration  of  a  series  of  cystic  tumors  of  enormous  size,  the  multilocular 
tumors  of  the  ovary.  This  class  represents  a  more  complex  form  of  cystic 
growth — one  whose  tendency  is  toward  the  reproduction  of  cysts,  to  which 
the  term  cystoma  is  applied.  The  cystoma  is  the  result  of  an  active  new 
formation  of  epithelium  and  connective  tissue,  and  is  classified  as  a  variety 
of  the  epithelial  group  of  tumors. 

Morbid  growths,  as  distinguished  from  cysts,  are  divided  by  Virchow 
into  the  simple  and  complex  forms.  The  former  consist  of  a  single  tissue, 
the  histoid  tumors ;  the  latter  of  several  tissues  suggesting  an  organ,  the 
organoid  tumors;  while  still  others,  in  which  the  number  and  grouping 
of  tissues  is  so  complex  as  to  simulate  systems  of  the  body,  even  mon- 
strosities, have  received  the  term  systematoid  or  teratoid  tumors. 

Virchow  claimed  that  the  growth  of  most  tumors  took  place  from  the 
connective  tissues,  and  that  most  of  the  organoid  tumors,  especially  cancer, 
arose  from  the  formative  action  of  the  connective  tissue  in  the  part  where 


MORBID  GROWTHS.  117 

it  first  made  its  appearance.  The  structure  of  cancer  suggested  an  organ, 
as  it  consisted  of  collections  of  cells  resembling  epithelium,  within  spaces 
or  alveoli  whose  walls  were  formed  of  connective  tissue.  The  epithelioid 
cells  of  the  cancer,  as  well  as  the  connective-tissue  corpuscles,  were  con- 
sidered to  arise  from  pre-existing  cells  of  connective  tissue. 

The  first,  most  important,  modification  of  Virchow's  views,  which  has 
led  to  a  more  rational  appreciation  of  the  relation  of  the  various  tumors, 
especially  of  the  epithelial  group,  to  each  other,  arose  in  consequence  of 
the  investigations  of  Thiersch  and  others  with  regard  to  the  origin  of 
certain  cancers.  This  observer l  claimed  that  the  epithelioid  element  of 
cutaneous  cancers  arose  in  all  instances  from  pre-existing  epithelium, 
either  of  the  rete  mucosum  or  cutaneous  glands.  Similar  views  were 
suggested,  with  various  degrees  of  precision,  by  other  authors  concerning 
certain  cancerous  tumors  elsewhere,  but  were  first  applied  to  all  cancers 
with  a  more  exact  formulation  by  "Waldeyer,2  to  whom  the  prevailing 
views  with  regard  to  the  histogenesis  of  morbid  growths  are  due.  Ac- 
cording to  him,  the  essential  (epithelioid)  element  of  all  primitive  cancers 
arises  from  pre-existing  epithelium  ;  consequently,  no  cancer-cell  can  arise 
except  in  organs  where  epithelium  is  normally  present. 

This  comprehensive  statement  was  rendered  possible  by  the  embryo- 
logical  researches  of  Remak  at  the  outset,  and  afterward  by  those  of  His 
and  Waldeyer.  Eemak  showed  that  after  differentiation  of  the  cells  of 
the  ovum  into  the  several  germinal  layers,  those  from  one  layer  could 
not  serve  to  originate  the  cells  belonging  to  another  layer.  The  develop- 
ment of  normal  tissues  takes  place  within  the  limits  defined  by  this  differ- 
entiation. Epithelium  thus  is  not  derived  from  connective  tissue,  nerves, 
or  muscles,  nor  was  the  reverse  known  to  occur.  To  His  is  due  the  exact 
appreciation  of  the  superficial  cells  of  serous  membranes,  which  had  been 
previously  called  epithelium,  and  had  thus  been  confounded  with  the  epithe- 
lial cells  of  mucous  or  cutaneous  membranes  and  of  secretory  glands.  He 
showed  that  these  cells  had  a  wholly  different  origin  from  epithelium,  and 
were  simply  scale-like  cells  of  fibrous  tissue,  to  which  he  applied  the  name 
endothelium.  The  latter  is  now  used  as  the  term  for  the  thin,  squamous 
cells  of  fibrous  tissue,  whether  they  are  found  lining  the  walls  of  the  great 
serous  cavities  or  the  smaller  lymph-spaces,  the  endocardium,  or  the  inner 
coat  of  blood-vessels  and  lymphatics. 

The  importance  of  this  distinction  is  obvious  when  the  occurrence  of 
tumors,  called  cancers,  is  observed  in  parts  which  contain  no  epithelium. 
Aside  from  the  vagueness  of  the  term  cancer,  as  applied  clinically,  tumors 
are  sometimes  met  with,  even  in  parts  where  epithelium  normally  does 
not  exist,  whose  structure  resembles  more  or  less  closely  that  of  cancer 
as  usually  recognized.  Such  tumors  are  to  be  regarded  as  of  an  endo- 
thelial  rather  than  epithelial  character,  and  as  such  their  histogeuesis  falls 
under  the  general  laws  of  the  development  of  tissues. 

AValdeyer3  has  siiggested  that  the  primitive  basis  for  the  development 
of  the  genito-urinary  tract  contains  cells  which  are  equivalent  in  their 
possibilities  of  ultimate  development  to  the  epithelium  of  the  limiting 
germinal  layers — a  suggestion  which  is  of  importance  in  permitting  the 

1  Der  Epithelial  ICrebs,  namentlir.h  der  Haul,  etc.,  18f>o. 

2  Virchnw's  Archiv,  1867,  xli.  470;  1872,  Iv.  67;  Volkmann's  Sammlung  klinisrhcr  Fo«» 
trage,  1871,  xxxiii.  3Eierstock  und  Ei,  1870. 


118  GENERAL  MORBID  PROCESSES. 

epithelial  tumors  of  the  ovary  to  be  brought  under  the  general  embryo- 
logieal  laws  of  development. 

A?  the  growth  of  embryonal  tissues  is  so  denned  that  descendants  are 
like  their  ancestors  in  all  respects,  so  the  development  of  tissues  in  the 
adult  is  regarded  as  defined  with  equal  precision.  Eberth  and  "\\~ads- 
\vorth1  have  shown  that  the  regeneration  of  corneal  epithelium  takes 
place  from  pre-existing  epithelium.  E.  Neumann  and  others  claim  in 
like  manner  the  development  of  muscular  tissue  from  antecedent  mus- 
cular cells. 

The  relation  of  cancer  to  epithelial  tumors  is  regarded  as  similar  to 
that  borne  by  sarcoma  to  tumors  composed  of  connective  tissues.  The 
growth  of  the  epithelial  elements  into  the  neighboring  pans  is  through 
paths  determined  by  pre-existing  or  new-formed  connective  tissue.  The 
active  element  of  the  cancer  lies  more  especially  in  its  epithelioid  cells, 
and  its  growth  takes  place  in  an  atypical  rather  than  a  typical  manner. 
Of  the  various  epithelial  tumors,  there  are  those  like  the  cutaneous  horn 
or  corn,  the  adenoma  or  eystoma,  whose  epithelial  growth  takes  place  in 
accordance  with  normal  methods  of  production.  The  epithelioid  constit- 
uent of  the  cancer,  on  the  contrary,  grows  often  with  great  luxuriance 
and  with  but  little  tendency  to  carry  out  the  normal  mutual  relations  of 
the  epithelium  and  connective  tissue  of  the  part  from  which  it  proceeds. 
The  epithelioid  masses  or  sprouts  are  composed  of  cells  whose  relation  to 
each  other  resembles  that  of  normal  epithelium  in  the  absence  of  an 
intercellular  substance,  while  the  shapes  of  the  cells  correspond  more  or 
less  closely  with  that  of  the  epithelium  in  the  region  from  which  the 
tumor  arises.  The  epithelioid  cells  of  cutaneous  cancers  resemble  those 
of  the  surface,  the  rete,  or  the  glands  of  the  skin.  Cancers  of  the 
stomach  or  uterus  contain  epithelioid  cells  whose  shape  simulates  the 
varieties  in  the  stomach  and  uterus.  Such  resemblances  are  carried  out 
in  the  degenerations  which  the  cells  of  ameer  undergo.  The  horn- 
like, keratoid,  transformation  of  epidermoid  cells  in  cutaneous  cancers, 
the  mucous  degeneration  of  the  epithelioid  cells  of  cancers  of  mucous 
membranes,  are  sufficiently  familiar.  Notwithstanding  these  resem- 
blances, which  are  also  present  in  secondary  tumors  at  remote  parts  of 
the  body,  the  epithelioid  growth  advances  without  limit  and  without 
reproducing  the  normal  type.  Cancer  is  therefore  defined  as  an  atypical, 
epithelial  new  formation. 

Sarcoma,  on  the  other  hand,  whose  clinical  features  correspond  so 
closely  with  those  of  cancer,  simulates,  as  shown  by  Yirchow,  the  con- 
nective tissues.  It  is  composed  of  cells  and  intercellular  substance,  both  of 
which  may  be  as  varied  as  are  those  of  the  connective  tissues.  The  shapo 
of  the  cells  is  as  diverse  and  their  contents  as  various,  while  their  possi- 
bilities of  degeneration  are  alike.  The  cells  of  the  sarcoma  are  not  simply 
cemented  together,  as  are  epithelial  cells,  but  they  are  separated  from  each 
other  by  an  intercellular  substance,  which  corresponds  in  its  appearance 
and  chemical  properties  with  that  of  mucous,  fibrous,  cartilaginous,  or 
osseous  tissue.  The  structure  of  the  sarcoma  differs  from  that  of  these 
tissues  in  presenting  a  predominance  of  evils  over  intercellular  substance, 
while  the  reverse  is  the  characteristic  of  most  varieties  of  connective 
tissue.  In  this  predominant  cell-formation  lies  its  absence  of  type. 

Arehii;  1870,  li.  361. 


MORBID  GROWTHS.  119 

whereas  the  atypical  character  of  the  cancerous  growth  is  manifested 
rather  by  the  irregular  grouping  of  the  cellular  masses  than  by  an 
abundance  of  cells. 

As  the  original  cancer  is  considered  as  possible  only  in  parts  where 
epithelium  is  a  normal  constituent,  so  the  primitive  sarcoma  is  possible 
only  in  parts  where  connective  tissue  is  present.  The  apparent  great  fre- 
quency of  sarcoma  in  recent  times  is  thus  obviously  .explained.  With  an 
agreement  as  to  its  histological  characteristics,  its  possible  place  of  origin 
is  any  of  the  connective  tissues  of  the  body,  and  their  presence  is  uni- 
versal. In  the  manner  of  its  growth,  its  recurrence,  and  generalization 
it  is  subject  to  the  same  laws  which  determine  similar  events  in  the 
history  of  cancer.  Its  degenerations  are  often  the  same,  and  its  symp- 
toms are  due  to  the  action  of  like  causes. 

The  importance  of  distinguishing  between  these  atypical  tumors  is  real, 
in  that  it  is  only  through  the  association  of  causes,  symptoms,  and  results 
with  defined  and  constant  characteristics  that  a  practical  knowledge  of 
tumors  is  to  arise.  The  time-honored  distinction  between  malignant  or 
semi-malignant  and  benignant  growths  is  always  to  be  sought  for,  and 
can  only  be  fully  possessed  when  the  natural  history  of  the  new  forma- 
tions is  known.  With  an  exact  appreciation  of  the  structure  of  a  tumor 
it  becomes  possible  to  study  its  special  pathology.  From  a  knowledge 
of  the  latter  are  to  be  derived  those  features  of  importance  in  determining 
the  relation  of  morbid  growths  to  other  deviations  from  normal  and 
physiological  processes.  An  immediately  practical  benefit  arises  from 
the  Thiersch-Waldeyer  modification  of  Virchow's  theory  of  the  origin  of 
tumors,  in  that  it  permits  with  greater  ease  a  more  accurate  clinical 
diagnosis.  Liicke1  has  been  prominent  in  calling  attention  to  the  sugges- 
tions thus  presented. 

The  diagnostic  value  of  the  theory  above-mentioned  is  rather  negative 
than  positive.  With  rare  exceptions,  a  tumor  cannot  be  epithelial  in 
character  if  its  origin  is  from  an  organ  or  a  part  in  which  epithelium  is 
absent.  The  possible  exceptions  admit  theoretical  explanations  which 
present  considerable  degrees  of  probability,  and  are  also  based  upon  the 
existing  views  of  the  development  of  tissues. 

A  tumor  whose  origin  from  the  connective  tissues  is  determined  par- 
takes of  the  characteristics  of  its  matrix,  and  is  a  connective-tissue  tumor. 
Its  development  from  fibrous  tissue  is  more  likely  to  result  in  a  fibroma ; 
from  fat  tissue,  a  lipoma,  or  a  niyxorna ;  from  cartilage  or  bone,  a  chon- 
droma  or  osteoma. 

Tumors  developing  at  certain  periods  of  life  in  certain  parts  of  the  body 
are  more  likely  to  belong  to  one  than  another  of  the  histogenetic  groups. 
Tumors  of  the  connective-tissue  series  are  stated  by  Liicke  as  more  prev- 
alent before  the  age  of  thirty-five  years,  while  those  of  the  epithelial 
group  are  more  likely  to  occur  after  this  age,  and  cancer  of  the  lip  is  of 
special  frequency  in  old  age.  The  fibro-myoma  is  of  most  frequent 
occurrence  in  the  uterus,  and  rarely  attains  a  large  size  till  the  approach 
of  the  climateric. 

The  rapidity  of  growth  of  tumors  is  also  associated  with  their  genesis. 
It  has  previously  been  stated  that  the  more  rapidly  growing  tumors 
are  those  whose  cells  are  most  abundant  and  in  the  closest  and  most  inti- 
1  Volkmann's  Sammluvg  kliniicher  Vortrdge,  1876,  xcvii. 


120  GENERAL  MORBID  PROCESSES. 

mate  relation  to  blood-vessels.  The  type  of  such  tumors  is  the  sarcoma 
with  its  scanty  intercellular  substance,  while  the  other  (histokl)  tumors  in 
the  same  series,  as  the  fibroma,  lipoma,  chondroma,  etc.,  are  of  relatively 
slow  growth.  Tumors  of  the  epithelial  series  are  of  slow  growth,  from 
the  constantly  increasing  distance  of  the  new-formed  cells  from  the  vas- 
cular connective  tissue  which  provides  their  nourishment.  When,  how- 
ever, the  growth  of  the  epithelium  advances  into  the  connective  tissue, 
pushing  out  in  all  directions  and  coming  in  contact  with  new  series  of  ves- 
sels, the  opportunities  for  nutrition  are  favorable.  In  like  manner,  when 
the  new  formation  concerns  the  connective-tissue  stroma,  as  well  as  the 
epithelial  sprouts,  vascularization  proceeds  with  the  development  of  the 
tumor,  and  favorable  conditions  for  rapid  growth  are  presented.  Large 
epithelial  tumors  may  thus  arise  within  organs,  but,  as  the  surfaces  are 
reached,  the  sources  of  nourishment  become  farther  removed  and  the 
degeneration  of  the  epithelium  favors  its  detachment  and  the  formation 
of  ulcers.  Hence  the  tumors  whose  advance  is  associated  with  ulceration 
belong  rather  to  the  epithelial  than  the  connective-tissue  group. 

The  tendency  of  the  cancerous  tumors  to  become  generalized  through 
the  lymphatics,  and  that  of  sarcomatous  growths  through  the  blood- 
vessels, is  admitted  as  an  important  feature  in  the  differential  diagnosis. 
Although  there  are  numerous  exceptions,  the  rule  is  available.  Its 
explanation  is  based  upon  the  assumed  inability  of  the  larger  epithelial 
cells  of  the  cancer  to  pass  through  the  lymph-glands;  being  detained, 
they  serve  as  new  centres  of  growth.  The  smaller  cells  of  the  sarcoma, 
on  the  contrary,  are  permitted  a  passage  through  the  gland.  The 
numerous  and  thin  Availed  blood-vessels  present  in  the  rapidly  growing 
sarcoma  permit  an  extension  of  the  latter  into  their  interior,  and  thus  a 
ready  opportunity  is  offered  for  the  formation  of  emboli. 

Another  important  modification  in  the  classification  of  tumors  has 
resulted  from  the  recent  discoveries  regarding  the  nature  and  eifects  of 
infective  agencies.  Virchow  grouped  together  under  the  term  granulo- 
mata  certain  growths  composed  of  granulation-tissue  occurring  in  syphilis, 
lupus,  leprosy,  and  glanders.  Their  relation  to  inflammatory  processes 
was  very  intimate,  yet  they  were  recognizable  as  tumors  from  their 
possession  of  many  of  the  characteristics  generally  admitted  as  belonging 
to  such  morbid  growths.  Although  at  times  their  presence  might  be 
regarded  as  evidence  of  an  inflammatory  disturbance,  their  frequent 
appearance  independently  of  general  symptoms  of  the  latter  was  apparent. 
These  tumors,  furthermore,  were  so  frequently  accompanied  by  inflamma- 
tory products  as  to  suggest  a  like  cause  for  both.  Virchowr  stated  that 
the  recognition  of  the  etiology  of  these  tumors  was  indispensable  to  their 
separate  consideration,  and  laid  stress  upon  the  presence  of  a  specific 
virus,  contagious  and  infectious,  in  the  case  of  syphilis.  His  views  con- 
cerning the  etiology  of  leprosy,  though  more  guarded,  yet  carried  the 
suggestion  of  the  importance  of  exact  investigation  concerning  the 
assumed  contagious  character  of  this  disease.  The  contagiousness  of 
glanders  was  not  only  admitted,  but  the  similarity  of  its  manner  of 
origin  and  propagation  to  the  invasion  of  syphilis  was  also  stated.  Not 
only  were  the  resemblances  between  glanders  and  syphilis  recognized, 
but  lupus,  leprosy,  tubercle,  and  scrofula  were  also  admitted  as  present- 
ing a  similar  relation. 


MORBID  GROWTHS.  121 

The  importance  of  recognizing  the  etiology  of  these  tumors  rather  than 
their  anatomy  as  a  basis  of  classification  was  strongly  urged  by  Klebs,1  who 
proposed  the  term  infective  tumors  for  the  group  of  granulomata,  includ- 
ing syphilis,  lupus,  leprosy,  and  glanders ;  and  for  tubercle,  scrofula  and 
the  pearly  distemper  of  animals,  which  Virchow  had  classified  as  lympho- 
mata.  This  group  has  been  still  further  extended  by  the  addition  of  the 
lymphomata  occuring  in  typhoid  fever,  scarlet  fever,  and  diphtheria. 
Ponfick2  has  recently  added  the  disease  actinomycosis  to  the  series,  and 
Cohnheim  suggests  that  certain  of  the  lympho-sarcomata  may  be  similarly 
classified. 

The  growths  thus  included  have  a  common  element  of  structure — the 
granulation-tissue,  with  its  possible  disappearance  through  absorption  or  its 
transformation  into  an  abscess  or  dense  fibrous  tissue.  Such  features  are 
those  common  to  the  granulation-tissue  resulting  from  ordinary  inflam- 
mation. Their  essential  characteristic,  however,  lies  in  the  etiology  of 
this  granulation-tissue,  and  for  many  members  of  the  group  the  cause  has 
been  discovered  to  be  microscopic  organisms.  The  constant  presence  of 
these  is  determined  in  sufficient  numbers,  in  such  distribution,  and  in  such 
relation,  as  to  explain  the  nature  and  occurrence  of  the  tumors. 

The  evidence  recorded  is  not  equally  full  and  exact  for  all  members  of 
this  group.  Neisser3  has  discovered  the  bacillus  of  leprosy,  and  the  dis- 
covery by  Koch4  of  the  bacillus  of  tuberculosis,  scrofula,  and  pearly  dis- 
temper has  already  been  referred  to.  Schiitz  and  Loffler5  have  lately 
announced  their  isolation  of  the  micro-organism  causing  glanders,  and 
Bollinger6  discovered  the  fungus  whose  presence  is  necessary  for  the  exist- 
ence of  actinomycosis. 

In  the  above  affections  the  organisms  are  to  be  regarded  as  the  charac- 
teristic active  agent  in  producing  the  phenomena  of  the  disease  in  which 
they  occur.  The  presence  of  micro-organisms  in  syphilis,  typhoid  fever, 
scarlet  fever,  and  diphtheria  is  admitted,  yet  their  absolute  identification 
and  constant  presence  as  a  cause  of  the  various  manifestations  of  the 
respective  diseases  still  remains  to  be  proved. 

The  classification  of  tumors  herewith  presented  is  essentially  that  of 
Virchow,  with  such  extensions  and  modifications  as  have  arisen  in  conse- 
quence of  the  investigations  and  discoveries  during  the  twenty  years 
which  have  elapsed  since  the  delivery  of  his  memorable  series  of  lectures. 
Cysts  are  mentioned,  as  well  as  growths,  from  the  importance  of  the 
former  in  practical  medicine.  The  frequent  simultaneous  occurrence  of 
cysts  and  growths  in  the  same  tumor  should  be  mentioned,  and  the  cystic 
feature  is  usually  indicated  as  a  qualification. 

CYSTS. 

Cavities,  either  new  formed  or  pre-existing,  with  various  contents. 
The  latter  are  blood,  liquid  other  than  blood,  and  gland-secretion  or 
retained  secretion.  The  wall  varies  in  structure  in  accordance  with  the 
method  of  origin  of  the  cavity. 

1  Prayer  Vierteljahrschr!ft,  1875,  cxxvi.  116.          2  Die  Actlnomykose  des  Menschen,  1882. 
8  Virchow'8  Archiv,  1881,  Ixxxiv.  514.  4  See  page  99. 

5  Deiitxche  medicinische  Wochenschrift,  1882,  Hi.  707. 

6  Centralbluttfiir  die  med.  Wissenschaften,  1877,  xxvii. 


122  GENERAL  MORBID  PROCESSES. 

Hcematoma. 

A  collection  of  extravasated  blood,  usually  within  the  tissues.  Exam- 
ples, hsematoma  of  the  pericranium  (periosteum),  of  the  external  ear, 
muscle,  dura  mater,  ovary,  broad  ligament,  vulva,  anus,  uterus  (from 
retained  placenta),  hsematocele,  dissecting  aneurism. 

Hygroma. 

A  collection  of  transuded  or  exuded  fluid  in  pre-existing  or  new-formed 
spaces.  Examples,  hydrocele,  hydromeningocele,  hydromyelocele,  hydren- 
cephalocele,  ganglion,  inflamed  bursa. 

Retention-  Cyst. 

An  accumulation  of  retained  secretion  in  follicles  or  canals  from  ob- 
struction to  its  escape.  Examples,  atheroma  and  comedo  of  the  skin, 
mucous  cysts  of  the  gastro-intestinal  mucous  membrane,  ovula  Nabothi, 
and  cystic  polypus  of  the  uterus ;  retention-cyst  of  the  antrum,  vermiform 
appendage,  gall-bladder,  and  bile-ducts ;  dropsical  dilatation  of  the  ova- 
rian follicles,  Fallopian  tube,  uterus  (hydrometra),  parovarium  (cyst  of 
the  broad  ligament);  hydronephrosis  and  multilocular  cystic  kidney, 
spermatocele,  ranula,  galactocele. 

The  growths  are  classified  according  to  the  tissues  of  which  they  are 
chiefly  composed  and  from  which  they  originate,  and  according  to  their 
etiology.  There  are  consequently  the  connective-tissue  group;  that  of 
tissues  of  higher  function,  as  muscle,  nerve,  and  vessels ;  and  the  epithelial 
group,  in  which  the  new  formation  of  epithelium  is  the  essential  feature. 
The  teratoid  group  comprises  a  more  complex  massing  of  tissues,  repre- 
senting a  combination  of  those  derived  from  all  the  germinal  layers  of 
the  embryo.  The  infective  group  includes  those  tumors  whose  structure 
is  closely  allied  to  that  of  the  products  of  inflammation,  but  whose  origin 
is  the  direct  result  of  the  introduction  from  without  of  a  microphyte. 

CONNECTIVE-TISSUE  GROUP. 

Each  member  mainly  composed  of  a  more  or  less  typical  growth  of  a 
connective  tissue : 

Myxoma,  Lipoma, 

Glioma,  Chondroma, 

Fibroma  (including  papilloma  Osteoma. 

and  melanoma), 

To  these  are  added  tumors  composed  of  an  atypical  growth  of  a  con- 
nective tissue,  chiefly  manifested  by  a  predominance  of  cells : 

Endothelioma,  Sarcoma. 

The  sarcoma  includes  as  many  varieties  as  there  are  tissues  in  this 
group,  hence, 

Myxosarcoma,  Liposarcoma, 

Gliosarcoma,  Chondrosarcoma, 

Fibrosarcoma,  melanosarcoma,  Osteosarcoma. 


MORBID  GROWIIIS.  123 

GROUP  OF  TISSUES  OF  HIGHER  FUNCTION. 

Myoma,  of  striped  (rhabdorayoma)  Angioma,  of  blood-vessels, 

and  smooth  (leiomyoma)  rnuscu-  Lymphangioma,  of  lymphatics, 

lar  tissue,  Lymphoma  (?),   of    lymph-gland 

Neuroma,  of  nerve  tissue,  tissue. 

EPITHELIAL  GROUP. 

Callus,        "| 

Corn, 

Keratosis,     >  Epidermis. 

Horn, 

Onychoma,  J 

Struma  (?),  ^ 

Adenoma,    V  Epithelium  of  mucous  membranes  or  glands. 

Cystoma,     J 

In  the  above  varieties  the  growth  of  epithelium  is  more  or  less  typical, 
a  simple  hyperplasia,  either  alone  or  combined  with  the  new  formation  of 
fibrous  tissue.  Only  the  last  three  members  of  the  series  are  tumors  in 
the  limited  sense. 

CANCER. 

Cancer  remains  as  an  epithelial  tunior,  representing  the  atypical  growth 
of  cells  resembling  epidermis  or  the  epithelium  of  glands  and  mucous 
membranes,  extending  into  parts  where  epithelium  is  not  found  as  a 
normal  constituent.  A  new  formation  of  connective  tissue  is  usually 
associated  with  that  of  the  epithelial  cells. 

Numerous  varieties"  of  cancer  are  described,  according  to  the  physical 
and  structural  peculiarities  of  the  tumor.  The  scirrhus  and  encephaloid 
of  the  earlier  writers  are  now  transformed  into  fibrous  and  medullary 
cancer.  This  change  in  name  is  due  to  the  stress  laid  upon  the  predomi- 
nance of  the  fibrous  stroma  as  the  usual  cause  for  the  hard,  dense,  scirrhous 
cancer,  while  an  abundance  of  epithelioid  cells  in  relatively  large  alveoli 
is  present  in  the  encephaloid,  marrow-like,  medullary  variety. 

When  the  growth  takes  place  from  the  skin  or  mucous  membranes,  the 
surface  frequently  presents  numerous  and  usually  arborescent  papillae  or 
villi.  The  papillary  cancers  of  the  skin  and  the  villous  cancers  of  mucous 
membranes  are  thus  distinguished. 

Cancerous  growths  of  the  skin  and  transitional  membranes,  often  called 
epithelioma  or  cancroid,  usually  contain  epithelioid  cells  resembling  epi- 
dermis, and  are  therefore  designated  as  epidermoid  or  pavement-celled 
cancer.  The  alveolar  contents  of  certain  cutaneous  cancers  are  cells 
resembling  those  of  the  deeper  layers  of  the  rete  mucosum,  while  those  of 
other  cancers  of  the  skin  resemble  rather  the  epithelium  of  sweat-glands. 
Growths  of  the  former  character  extend  laterally,  ulcerate  early,  and  are 
known  as  superficial  cutaneous'  cancer.  They  form  one  of  the  varieties 
of  the  so-called  rodent  ulcer.  Cutaneous  cancers,  simulating  in  their 
structure  a  reproduction  of  the  epithelium  of  sweat-glands,  represent  a 
variety  of  glandular  cancer.  The  latter  term  is  applied  to  cancerous 
growths  which  arise  in  glandular  organs,  with  suggested  resemblances 
of  their  cells  to  the  gland-cells  of  the  respective  organ.  Cylindrical- 


124  GENERAL  MORBID  PROCESSES. 

celled  cancer  is  frequently  met  with  in  those  parts  of  which  a  cylindrical 
epithelium  is  a  normal  constituent. 

The  degenerations  of  the  epithelioid  cells  and  stroma  suggest  qualifying 
terms.  The  mucous  and  colloid  cancers  are  those  whose  alveolar  contents 
or  stroma  havo  undergone  a  mucous  or  colloid  degeneration.  The  keratoid 
cancer  is  one  which  presents  the  horn-like  transformation  of  its  epider- 
moid  cells.  The  melanotic  cancer  contains  abundant  pigment,  melanin, 
within  its  cells. 

These  differences  in  the  structure  and  appearance  of  the  tumor  are 
frequently  associated  with  certain  modifications  of  growth  and  clinical 
properties.  The  epidermoid  cancers  are  less  likely  to  recur  after  early 
removal ;  the  medullary  cancers  are  of  rapid  growth  and  prone  to  ulcera- 
tion ;  while  the  fibrous  or  scirrhous  forms  are  of  extreme  slowness  of 
growth.  In  general,  however,  the  pathological  importance  of  cancerous 
tumors  is  essentially  the  same  wherever  the  seat  and  whatever  the  pecu- 
liarities of  structure. 

TERATOID  GROUP. 

Includes  those  tumors,  usually  of  congenital  origin  and  apparent  at  birth, 
composed  of  connective  tissue,  epithelium,  nerves,  muscle,  and  vessels. 
These  tissues  are  often  so  grouped  together  as  to  suggest  systems  of  the 
body  and  parts  of  an  individual.  Cysts  are  often  present  which  simulate 
cavities  found  in  the  body,  whether  of  normal  or  pathological  origin. 

In  this  group  are  the  dermoid  cysts  with  their  various  contents,  epi- 
dermis, sebum,  hair,  teeth,  and  bone.  The  solid  teratomata,  with  all 
varieties  of  connective  tissue,  as  fibrous  tissue,  fat  tissue,  cartilage,  bone, 
ueuroglia,  in  addition  to  nerves,  muscle,  and  vessels.  Squamous,  cylin- 
drical, and  ciliated  epithelium  may  be  present  and  line  cavities,  at  times  tubu- 
lar, whose  walls  are  formed  of  skin  or  mucous  membrane.  Other  tumors 
of  this  group  are  commonly  included  under  monstrosities,  and  comprise 
the  varieties  of  duplication  of  parts  of  the  body,  of  which  the  extreme 
instances  are  such  double  monstrosities  as  the  Siamese  Twins,  Ritta  and 
Christina,  the  Spanish  Cavalier,  and  the  like. 

INFECTIVE  GROUP. 

The  chief  characteristic  is  the  cause,  micro-organisms,  which,  intro- 
duced into  the  body,  produce,  through  their  dissemination  and  develop- 
ment, multiple  growths  of  tissue  like  those  resulting  from  persistent 
inflammation.  As  their  structure  corresponds  with  the  productive  results 
of  inflammation,  and  their  cause  is  analogous  to  the  infective  causes  of 
inflammation,  these  morbid  growths  are  closely  allied  to  inflammatory 
disturbances.  Their  classification  among  tumors  is  desirable,  as  they 
represent  circumscribed  growths  whose  appearance,  persistence,  and 
effects  closely  resemble  those  characteristics  of  the  morbid  growths,  in 
the  limited  sense,  in  which  the  new  formation  of  tissue  occupies  a  wider 
range  : 

Granuloma  of  tuberculosis,  scrofula,  leprosy,  glanders,  actinomycosis, 
syphilis,  lupus. 

Lymphoma  of  diphtheria,  scarlet  fever,  typhoid  fever. 


GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS, 
AND  PROGNOSIS. 

BY  HENRY   HARTSHORNE,  M.  D. 


ETIOLOGY. 

RECOGNIZING  pathology  as  simply  morbid  physiology — that  is,  the 
study  of  the  body  and  its  functions  in  states  of  disorder  from  morbid  con- 
ditions— how  these  morbid  conditions  are  produced  is  the  complex  ques- 
tion to  be  answered  by  Etiology. 

Nor  is  this  question  (or  series  of  questions)  by  any  means  only  of 
speculative  or  theoretical  importance.  It  is,  indeed,  eminently  practical. 
What  a  difference,  for  example,  there  must  be  in  the  diagnosis,  prognosis, 
and  treatment  of  an  attack  of  inflammation  of  the  eye,  in  accordance 
with  its  causation  by  ordinary  conditional  influences  (taking  cold),  by  a 
particle  of  steel  imbedded  in  the  cornea,  or  by  syphilis  !  How  great  the 
difference  between  the  wound  made  by  the  teeth  of  an  animal,  in  one  case 
with,  and  in  another  without,  the  presence  of  rabies  in  its  system !  Take 
the  instance  of  what  we  call  fever :  at  a  certain  stage  it  is  almost  the 
same  in  half  a  dozen  diseases.  By  the  causation,  when  known,  of  this 
common  congeries  of  symptoms  we  judge  of  the  essential  nature  of  the 
malady,  and  so  of  its  proper  treatment. 

It  is  a  maxim  in  philosophy  that  every  event  or  effect  must  have  at 
least  two  causes.  In  medical  etiology  we  often  find  many  causes  conspir- 
ing to  produce  one  effect.  These  may  be,  and  commonly  have  been, 
grouped  together  under  two  heads ;  as,  1,  predisposing,  and  2,  exciting, 
causes.  But  under  each  of  these  may  come  a  number  of  agencies  con- 
tributing toward  the  production  or  modification  of  disease.  Thus,  of 
predisposing  causes  we  may  enumerate  inherited  constitution,  habits  of 
life,  previous  attacks  of  disease,  atmosphere,  and  other  immediate  sur- 
roundings. Exciting  causes — say,  of  an  attack  of  apoplexy — may  be,  in 
the  same  case,  mental  shock,  a  stooping  posture,  an  over-heated  room,  etc. 
One  disease  is  very  often  the  next  preceding  cause  of  another.  So  we 
speak  of  the  great  class  of  sequelae  of  acute  or  subacute  disorders ;  as, 
ophthalmia  after  measles,  deafness  following  scarlet  fever,  or  blindness 
small-pox,  abscesses  following  typhoid  fever,  paralysis  diphtheria,  etc. 
But  this  kind  of  causation  is  extremely  common  also  in  chronic  affections. 
What  a  train  of  organic  troubles,  of  kidneys,  heart,  arteries,  brain,  and 
other  parts,  attend  the  affection  to  which  we  give  the  name  of  Bright' s 
disease!  How  complex  the  sequence  often  of  valvular  disease  of  the 
heart,  itself  in  many  instancas  the  effect  of  rheumatic  fever,  with  endocar-  . 

125 


126       GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

ditis  as  a  local  manifestation  of  that  disorder  !  Hardly  any  discovery  in 
pathology  (or  pathogeny,  the  generation  of  diseases)  of  the  last  half  cen- 
tury has  been  more  remarkable  and  fruitful  than  that  of  thrombosis  and 
embolism,  with  their  serious  and  not  rarely  fatal  consequences,  through 
obstruction  of  the  blood-supply  to  different  organs. 

Previous  diseases  constitute  an  often  overlooked  class  of  factors  in  pre- 
disposing to  new  attacks,  and  also  in  determining  their  course  and  results. 
Of  some  affections  one  attack  prepares  the  way  for  another,  as  is  the  case 
with  intermittent  fever,  convulsions,  delirium  tremens,  and  insanity. 
Just  the  reverse  is  true  of  yellow  fever  and  of  all  the  exanthemata,  as 
scarlet  fever,  measles,  small-pox ;  likewise  of  the  analogous  disorders, 
mumps  and  whooping  cough.  The  moot  question  in  this  regard  con- 
cerning syphilis  may  be  left  for  discussion  elsewhere. 

Our  classification  of  the  causes  of  disease  may  be  set  forth  in  simple 
form,  thus : 

1.  Pre-natal  causation — viz.  hereditary  transmission  of  a  proclivity  to 
certain  disorders,  and  also  the  influence  of  circumstances  acting  on  either 
parent  at  the  time  of  conception  or  on  the  mother  during  gestation. 

2.  Conditional  causation — i.  e.  that  belonging  to  variations  of  tempera- 
ture, humidity,  etc.,  affecting  individuals. 

3.  Functional  causation — that  which  is  connected  with  excessive,  defi- 
cient, or  abnormal  exercise  of  any  of  the  functions  of  the  economy. 

4.  Ingestive  causation — e.  g.  bad  diet,  intemperance,  poisoning. 

5.  Enthetic  causation — viz.  that  of  all  contagious,  endemic,  and  epidemic 
diseases.     Closely  allied  to  this  is  epithelic  morbid  influence — namely, 
that  of  the  parasites  producing  certain  affections  of  the  skin,  as  itch, 
favus,  etc. 

6.  Mechanical  causation.     The  effects  of  this  belong  chiefly,  though 
not  exclusively,  to  the  domain  of  surgery. 

Pre-natal  causation  is  of  immense  consequence,  and  its  study  takes  in 
the  whole  scope  of  the  influences  of  species,  race,  family,  and  individual 
parentage.  Darwin's  observations  and  speculations,  and  those  of  other 
evolutionists,  have  not  ignored  the  field  of  human  life  in  considering  the 
struggle  for  existence  and  the  survival  of  the  fittest.  If  we  are  obliged 
to  admit  that  such  a  struggle  and  survival  do  exist  for  men  as  well  as  for 
animals  and  for  plants,  it  is  nevertheless  obvious  that  either  man's  reason 
and  will  introduce  exceptions  to  the  ordinary  laws  of  development  and 
selection  in  nature,  or  else  a  very  peculiar  standard  of  fitness  must  be 
recognized  in  the  survivals  of  humanity.  Many  feeble,  inert,  deformed, 
and  diseased  forms  survive  and  perpetuate  offspring  through  a  long  series 
of  generations,  while  strong  and  admirable  ones  perish,  often  even  destroy- 
ing each  other. 

Leaving  this  theme,  upon  which  biological  science  has  not  yet  pro- 
nounced its  last  word,  we  may  inquire,  What  diseases  are  reasonably 
ascribed  to  hereditary  transmission?  First,  it  must  be  remarked  that 
seldom  is  a  disease  actually  received  directly  from  a  parent.  Putting 
aside  a  few  asserted  instances  of  variola  and  allied  or  analogous  affections 
in  utero,  congenital  constitutional  syphilis  and  (more  rarely)  scrofulosis 
seem  to  afford  almost  the  only  examples  of  this.  Nearly  always  it  is  a 
predisposition  merely  that  is  inherited.  This,  however,  may  be  very 
strongly  marked.  Its  seat  is  evidently  in  that  (as  yet)  occult  law  or  pro- 


ETIOLOGY.  127 

cess  of  individual  organic  development  to  whose  manifestation  we  give 
the  name  of  the  constitution.  In  some  families  all  the  men  grow  bald 
before  forty ;  in  others,  scarcely  so  at  eighty.  Some  may  expect  deafness 
in  middle  life,  others  blindness  in  old  age,  and  others,  again,  have  a  prob- 
ability of  death  from  disease  of  the  heart  at  about  fifty  or  apoplexy  at 
about  sixty  years  of  age.  Such  considerations  enter  into  every  examina- 
tion for  life  insurance,  and  they  are  no  less  important  in  our  prognostica- 
tions of  the  results  of  diseases  in  practice. 

Speaking  more  definitely,  gout  is  undoubtedly  often  hereditary.  That 
is,  a  healthy  childhood  may  be  followed  by  liability  to  gout  in  adult  or 
middle  age,  even  in  the  absence  of  direct  provocatives  to  that  disorder,  but 
much  more  frequently  when  they  are  present.  Gout  affords  an  example 
of  the  general  fact  that  inherited  proclivity  to  special  diseases  shows 
itself  at  nearly  the  same  time  of  life  in  each  generation — scrofula  in  child- 
hood, phthisis  in  adolescence  or  early  maturity,  gout  from  thirty  to  forty, 
apoplexy  after  sixty,  etc.  But  exceptions  to  such  rules  are  not  at  all  rare. 
Gout  also  exemplifies  another  important  fact — viz.  the  occasional  mod- 
ification of  the  transmitted  morbid  tendency  or  "diathesis."  Parents 
who  have  regular  gout — i.  e.  painful  attacks  of  acute  inflammation  of  the 
smaller  joints,  followed  by  deposits  of  urates,  carbonates,  etc. — not  unfre- 
quently  have  children  who  are  subject  to  neuralgia  or  dyspepsia  or  mod- 
ified rheumatic  attacks  (not  sufficiently  recognized  in  practical  treatises), 
to  which  the  name  "  gouty  rheumatism  "  is  most  applicable.  Again,  in 
one  generation  there  may  be  a  marked  tendency  to  insanity ;  in  the  next, 
to  paralysis ;  in  a  third,  to  tubercular  meningitis  during  infancy.1  Or 
some  of  these  successions  may  occur  in  a  reverse  order. 

Constitutional  syphilis  is  undoubtedly  often  conveyed  by  inheritance 
from  either  parent.  Sometimes  the  impression  of  this  diathesis  is  so 
intense  as  to  devitalize  the  foetus  in  utero,  causing  still-birth.  Or  the 
manifestations  of  the  disease  occur  early  in  infancy,  with  symptoms  like 
those  of  the  secondary  or  tertiary  affection  in  the  original  subject  of  it. 
Not  often,  indeed,  is  the  exhibition,  in  some  manner,  of  inherited  consti- 
tutional syphilis  delayed  beyond  the  time  of  childhood. 

Scrofulosis  is  well  known  to  follow  in  the  same  family  through  suc- 
cessive generations,  in  a  manner  apparently  demonstrative  of  hereditary 
derivation.  It  is  true  that  here  we  have  a  problem  not  without  compli- 
cation. Certain  circumstances,  as  poverty  of  living,  dampness  of  locality, 
want  of  fresh  air  in  houses,  etc.,  promote  scrofula  in  children.  Now,  are 
we  sure  that  it  is  from  its  parents  that  each  child,  exposed  to  these  mor- 
bific surroundings,  has  obtained  its  disposition  to  strumous  disorders  ?  or 
may  it  not  be  that  every  time  the  diathesis  is  thus  originated  de  novo  ? 
It  is  to  be  answered  that  decisive  evidence  in  favor  of  inheritance  is  pres- 
ent in  a  number  of  cases  where  the  affection  occurs  so  early  in  infancy  as 
to  be  almost  or  quite  congenital  in  its  beginnings ;  and  in  other  instances 
where  removal  of  the  parents  into  improved  localities,  and  with  better 
living  altogether,  has  not  prevented  the  manifestation  of  the  same  tend- 
ency in  their  offspring  for  two  or  three  generations.  The  inquiry  does 
not  differ  very  greatly  in  its  nature  from  that  concerning  cases  of  enthetic 
diseases — e.  g.  cholera,  yellow  fever,  typhoid  fever ;  as  to  which  the  suc- 

1  For  example,  in  one  family  known  to  me  the  grandmother  had  paralysis,  the  mother 
died  insane,  and  her  three  children  all  died  of  tubercular  meningitis. 


128       GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

cession  of  cases  may  be  such  as  to  allow  hypothetical  explanation,  either 
by  transmission  from  one  individual  to  another  or  by  the  subjection  of  all 
to  a  common  local  infection  or  epidemic  influence.  But  in  both  sorts  of 
cases  crucial  instances  may,  with  care,  be  found  which  determine  at  least 
the  general  etiological  law  for  each  malady. 

Pulmonary  phthisis  has  been  always  considered  to  be,  in  a  marked 
degree,  a  hereditary  disease,  until,  latterly,  the  hypothesis  of  a  tubercular 
virus  has  threatened  to  displace  old  views  about  it.  If,  however,  we 
accept  the  classification  of  cases  of  pulmonary  consumption  approved  by 
several  leading  pathologists,  in  which  a  position  is  provided  for  non-tuber- 
cular phthisis,  we  may  at  least  place  hereditary  vulnerability,  or  proclivity 
to  consumption,  in  this  category,  while  awaiting  the  final  decision  of  science 
upon  the  real  nature  and  origin  of  tubercle.  My  own  conviction  con- 
tinues to  be  positive,  that  tubercular  phthisis  is  often  transmitted  by 
inheritance,  in  the  same  sense  as  other  diseases  are  generally  so — namely, 
by  the  bestowal  upon  offspring  of  a  constitution  especially  liable  to  the 
occurrence  of  the  disorder  at  the  time  of  life  when  it  is  generally  most  apt 
to  appear.  The  investigations  of  Villemin,  Cohnheim,  Schiiller,  Koch, 
Baumgarten,  and  others  have  given  (1882)  much  prominence  to  the  idea 
of  the  possibility  of  the  transplantation  of  tubercle  from  one  human  or 
animal  body  to  another.  Koch's  elaborate  experiments  especially  are 
asserted  to  have  shown  the  existence  of  a  bacillus  tuberculosis,  a  true, 
minute  vegetative  organism,  which  can  be  cultivated  outside  of  the  body, 
in  a  suitable  material,  at  a  temperature  like  that  of  living  blood,  and 
which,  when  inoculated,  produces  tubercular  disease.  The  discussion  of 
this  subject  will  occur  on  a  later  page  as  a  part  of  the  general  topic  of 
the  causation  of  enthetic  diseases. 

Rickets  occupies  a  much  less  prominent  place  in  the  experience  of 
American  practitioners  than  in  that  of  some  countries  abroad,  and  it  is 
therefore  less  easy  here  to  obtain  materials  for  the  study  of  its  etiology. 
Among  those  who  have  had  large  opportunities  for  its  observation,  opinion 
is  divided  very  much  in  the  manner  above  referred  to.  Thus,  Wiltshire 
and  Herring  assert  it  to  be  certainly  hereditary ;  Jenner  denies  this  alto- 
gether, while  Aitken  adopts  the  ground  that  predisposing  causes  are  derived 
from  the  parents  or  the  nurse,  which  are  so  capable  of  influencing  the 
health  of  the  child  as  to  lead  in  course  of  time  to  the  establishment  of 
the  disease. 

Goitre  is  manifestly  a  family  disorder  to  a  large  extent  in  certain  re- 
gions, most  familiarly  in  Alpine  valleys  in  Switzerland.  But  this  local 
feature  takes  us  back  to  the  same  kind  of  question :  Is  it  the  transmission 
of  a  specially  modified  constitution  from  parents,  or  the  direct  action  of 
morbid  local  influences  on  the  children  themselves,  that  produces  bron- 
chocele  and  its  frequent  attendant,  cretinism  ?  Undoubtedly,  goitre  often 
occurs  in  children  of  healthy  parents  brought  from  another  locality  into 
one  where  the  disease  is  common  ;  and,  per  contra,  goitrous  subjects  not 
infrequently  recover  from  the  aifection  when  removed  for  a  length  of 
time  from  the  place  where  it  was  developed  in  them.  We  are,  appar- 
ently, at  least  safe  in  taking  here  a  position  like  that  of  Aitken  con- 
cerning rickets :  viz.  that  predisposing  causes  are  derived  from  parentage, 
whereby,  more  easily  than  in  those  of  different  descent,  certain  influences 
will  develop  goitre  or  cretinism,  or  both  together. 


ETIOLOGY.  129 

As  to  leprosy,  there  seems  no  more  room  for  doubt  that  it  is  often — nay, 
generally — hereditary.  The  obscurity  attending  its  history,  however 
(more  than  one  cutaneous  affection  having  been  from  time  to  time  classed 
under  the  same  name),  will  justify  our  referring  the  reader  for  the  par- 
ticular discussion  of  its  etiology  to  another  part  of  this  work.  (See  DIS- 
EASES OP  THE  CUTANEOUS  SYSTEM.) 

Haemophilia  is  clearly  hereditary  in  certain  families.  Immermann 
asserts  it  to  be  even  a  race-liability  in  the  Jews.-  "Bleeders"  upon  occa- 
sion of  very  small  wounds  of  the  skin,  gums,  etc.  have  been  known  in 
several  successive  generations,  including  (Borner;  Kehrer)  women  at  the 
time  of  parturition,  who  then  are  apt  to  have  dangerous  hemorrhages. 

Cancer  presents  as  unmistakable  examples  of  inheritance  as  any  other 
disease.  Paget  asserts  this  to  be  traceable  in  one  case  out  of  three ;  Sibley, 
in  one  of  nine ;  and  Bryant,  one  of  ten  cases.  De  Morgan  and  others 
have  shown  the  same  thing  to  be  true  of  non-malignant  morbid  growths. 
But,  as  Paget  has  remarked,  when  other  local  disease  or  deformity  is  in- 
herited, it  usually  involves  in  the  offspring  the  same  tissue,  often  the  same 
part  of  the  body,  as  in  the  parent,  but  the  transmitted  cancerous  tendency 
may  show  itself  anywhere :  "Cancer  of  the  breast  in  the  parent  is  marked 
as  cancer  of  the  lip  in  the  offspring.  The  cancer  of  the  cheek  in  the 
parent  becomes  cancer  of  the  bone  in  the  child.  There  is  in  these  cases 
absolutely  no  relation  at  all  of  place  or  texture." 

Cataract  is  believed  by  good  authorities  to  be  promoted  by  hereditary 
tendency.  It  is  of  the  nature  of  a  degeneration.  Possibly,  in  a  greatly- 
prolonged  decay  of  all  the  organs  with  age,  all  eyes  tend  to  become 
cataractous  from  structural  alteration  of  the  crystalline  lens.  Under 
observation  a  quite  different  rate  of  degenerative  change  takes  place 
among  the  organs  of  the  body  in  different  individuals  and  families. 
Thus,  the  lens  becomes  opaque  in  some  at  an  age  when  the  hearing  con- 
tinues good  and  the  muscles  retain  considerable  vigor,  while  in  members 
of  other  families  the  eyes  remain  in  a  sound  condition  at  a  time  when 
other  organs  and  powers  have  failed.  Congenital  cataract  appears  to  be 
altogether  independent  of  any  proclivity  transmitted  from  parents  in  the 
nature  of  an  inheritance. 

Affections  of  the  nervous  system  very  often  show  hereditary  descent. 
Neuralgia  prevails  strongly  in  certain  families.  Particularly,  that  form 
of  cephalalgia  called  sick  headache  is  apt  to  appear,  in  the  periodical 
form,  through  several  generations.  Apoplexy  and  paralysis  are  prone 
to  occur  at  nearly  the  same  time  of  life  under  the  transmission  of  like 
constitutions  by  parentage.  Still  more  often  this  has  been  observed 
of  epilepsy  and  hysteria,  and,  most  of  all  the  neuroses,  in  insanity. 
Monomania  and  melancholia  have  been  in  a  great  number  of  instances 
traced  to  generative  succession — sometimes,  especially  suicidal  monomania, 
through  four  or  five  generations.  Predisposition  to  intemperance,  metho- 
mania,  is  also  a  terrible  inheritance  in  some  families.  Although  the  pro- 
duction of  this  malady  requires  the  provocative  of  indulgence  in  the  use 
of  alcohol  for  its  development,  yet  the  facility  with  which  this  result 
occurs  under  the  same  circumstances  in  different  families  is  too  marked 
to  leave  room  for  doubt  of  its  hereditary  nature. 

Less  certainly,  but  with  much  probability,  we  may  assign  parental 
endowment  as  one  of  the  factors  in  the  causation  of  organic  disease  of 
VOL.  I.— 9 


130      GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

the  heart,  arteries,  liver,  and  kidneys,  as  well  as  of  angina  pectoris, 
asthma,  croup,  dyspepsia,  and  hemorrhoids. 

Is  a  special  proclivity  to  any  of  the  group  of  enthetic  febrile  diseases 
ever  inherited  ?  Dr.  George  B.  Wood  believed  this  to  be  the  case  with 
enteric  or  typhoid  fever.  Few  others  have  shared  this  opinion,  but  it  is 
not  impossible  that  it  has  a  basis  of  truth. 

Reference  has  been  made  already  to  the  difference  between  periodical 
malarial  fevers  (intermittent,  etc.)  and  yellow  fever,  in  that  an  attack  of 
the  latter  does,  and  one  of  the  former  does  not,  protect  the  individual, 
usually,  from  liability  to  the  disease  on  exposure  to  its  cause.  Does  this 
protection  extend  to  offspring  of  parents  who  have  been  "acclimatized  "  to 
yellow  fever  ?  Facts  on  this  point  are  not  easy  to  obtain.  While,  how- 
ever, there  appears  to  be  no  proof  that  a  single  generation  can  ever  suffice 
to  outgrow  (so  to  speak)  liability  to  this  disease,  it  is  well  known  that 
Creoles  in  Louisiana  and  the  West  Indies  are  less  susceptible  to  it  than 
recent  white  residents,  and  that  the  negroes  are  much  less  so,  as  a  race, 
than  the  whites.  Furthermore,  negroes  whose  ancestors  have  long  been 
domesticated  in  our  Southern  States  appear  to  re-acquire  susceptibility  to 
yellow  fever  in  a  degree  more  nearly  like  that  of  white  people  than  is 
observed  in  natives  of  Western  Africa  imported  within  one  or  two  gene- 
rations. 

As  to  autumnal  malarial  fevers  (remittent,  intermittent),  the  black  race 
exhibits  a  sort  of  race-acclimatization,  giving  negroes,  both  in  Africa  and 
in  America,  a  much  less  degree  of  liability  than  is  common  to  all  races 
of  European  descent. 

How  far  any  similar  modification  may  occur  in  the  course  of  genera- 
tions in  regard  to  susceptibility  to  small-pox  and  allied  diseases  remains 
at  present  a  matter  of  speculation.  Some  authors  insist  that  there  must 
be  at  least  a  kind  of  natural  selection,  according  to  which  a  great  epi- 
demic of  variola,  destroying  the  lives  of  many  of  those  most  predisposed 
to  suffer  from  it,  will  leave  the  remaining  population  less  likely  to  be 
attacked  by  it.  The  endeavor  has  even  been  made  to  explain  away  in 
this  manner  much  of  the  diminution  of  mortality  from  small-pox  com- 
monly credited  to  vaccination.  But  the  statistics  of  the  ravages  of  variola 
in  different  countries  before  and  after  the  introduction  of  vaccination 
show  that,  while  we  cannot  deny  that  some  alternation  (of  generations 
respectively  more  and  less  susceptible)  may  occur,  no  such  law  can  com- 
pare in  influence  with  that  of  vaccination  in  the  protection  of  individuals 
subjected  to  it.  Indeed,  the  argument  may  be  inverted ;  thus  :  if  in  the 
days  before  Jenner  small-pox  itself  weeded  out  the  persons  most  liable  to 
it,  or  in  some  way  prepared  a  partial  family-  or  race-protection,  such  a 
protection  ought  to  be  gradually  conferred  upon  a  whole  population 
through  universal  and  persistent  vaccination  carried  on  for  several  gene- 
rations. 

Is  it  possible  for  one  hereditary  constitution  or  diathesis  to  become, 
in  transmission,  not  only  modified,  but  transmuted,  into  another  ?  Some 
of  the  older  pathologists  imagined  this  to  be  the  case  with  syphilis,  to 
whose  past  influence  upon  parents  and  ancestors  they  traced  the  origin  of 
scrofula.  But  no  sufficient  ground  for  such  a  pathogeny  can  be  ascer- 
tained. All  that  appears  to  be  left  after  scrutiny  of  the  facts  is,  that 
syphilis  is  a  depressing  and  perverting  agency,  and  so  may  join  with 


ETIOLOGY.  131 

other  depressing  causes  in  preparing  the  way  for  the  engendering  of 
scrofulosis. 

A  few  points  still  remain  to  be  briefly  mentioned  in  connection  with 
the  hereditary  conveyance  of  proclivity  to  disease.  One  or  several  mem- 
bers of  a  family  will  often  pass  through  life  without  any  manifestation 
of  such  transmission,  while  others,  their  brothers  or  sisters,  give  marked 
evidence  of  it.  Sometimes  a  whole  generation  may  be  passed  over,  and 
yet  the  predisposition  may  be  abundantly  shown  in  that  next  following. 
This  is  closely  similar  to  atavism,  as  it  is  called  in  zoology  and  general 
biology,  according  to  which  traits  occurring  under  admixture  or  variation 
of  animal  or  vegetable  stocks  may  be  absent  in  the  immediate  oifspring 
of  a  couple,  but  reappear  in  their  next  succeeding  descendants,  or  even  a 
still  later  reversion  may  take  place.  Such  instances  are  not  rare,  and 
they  need  to  be  considered  in  the  proper  study  of  the  influence  of  parent- 
age, intermarriage,  etc.  upon  health  and  disease. 

A  practical  question  of  much  importance  (belonging,  however,  rather 
to  sanitary  than  to  medical  science)  is,  how  far  confirmation  or  modification 
of  hereditary  proclivities  may  occur  through  the  eifect  of  the  conditions 
of  marriage  upon  offspring.  Consanguineous  marriages  have  been,  time 
out  of  mind,  held  to  be  very  objectionable.  The  question  has  been  much 
discussed  whether  the  ground  of  sanitary  objection  is  properly  against 
such  marriages  as  per  se  injurious  to  offspring,  or  whether  the  bad  effect 
consists  merely  in  reduplicating  and  intensifying  family  constitutional 
taints.  It  would  not  be  in  place  here  to  go  into  this  controversy.  My 
own  conclusion  is,  that  a  natural  law  of  sexual  polarity  or  affinity 
exists,  according  to  which,  in  all  the  higher  organisms,  reproduction  is 
most  normal  and  gives  the  best  results  when  a  considerable  genetic  differ- 
ence (within  the  limits  of  species)  exists  between  parents.  While,  how- 
ever, this  is  probable,  but  difficult  to  demonstrate,  it  appears  to  be  certain 
that  when  a  father  and  mother  both  possess  morbid  constitutional  predis- 
positions (say,  to  phthisis,  insanity,  or  gout),  their  children  will  be  at 
least  twice  as  likely  to  suffer  from  the  same  as  if  only  one  parent  were 
so  endowed.  Whether  or  not,  then,  the  marriage  of  two  perfectly  healthy 
first-cousins  may  be  expected  (as  several  statisticians  aver  to  have  been 
shown)  to  be  attended  by  defects  of  health  in  their  progeny,  the  union 
of  such  relations  when  their  common  progenitors  were  in  marked  degree 
consumptive,  or  scrofulous,  or  liable  to  insanity,  epilepsy,  etc.,  has  attached 
to  it  so  unfavorable  a  prognosis  for  offspring  as  to  be  rightly  forbidden. 
Morever,  so  few  families  possess  an  absolutely  faultless  health-record  that 
the  chances  of  increasing  existing  morbid  traits  by  intermarriages  are 
quite  sufficient  to  justify  the  commonly  held  objection  against  them. 

We  must  allude  very  briefly  to  the  influence  of  conditions  affecting 
conception  and  gestation  upon  the  health  of  offspring.  Intemperance  in 
parents  has,  in  many  instances,  been  known  to  promote  convulsions; 
infantile  or  epileptic,  and  other  cerebral  or  nervous  disorders  in  children, 
besides  a  general  feebleness  of  constitution.  Even  intoxication  at  the 
time  of  procreation  has  been  asserted  to  mark  a  similar  difference  between 
one  child  and  another  of  the  same  parents. 

All  are  familiar  with  the  (no  doubt  often  quite  imaginary)  accounts  of 
the  effect  on  infants  in  utero  of  powerful  sensory  or  mental  impressions 
upon  the  mother  during  gestation.  Abortion  has,  unquestionably,  been 


132       GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

often  produced  by  violent  nervous  shocks.  Without  deciding  the  question 
whether  "monsters"  are  ever  developed  in  correspondence  with  particular 
experiences  of  the  mother,  we  may  hold  it  to  be  clear  that  all  depressing 
and  disturbing  agencies  may  interfere  with  the  process  of  nutrition  of  the 
fretus,  and  thus  develop  mental  anomalies,  and  that  constitutional  impair- 
ments may  thus  be  greatly  promoted. 

All  inherited  predispositions,  it  is  important  to  remember,  are  aggra- 
vated, and  each  proclivity  changed  to  actuality,  by  those  influences  which 
in  individuals  tend  to  like  effects  upon  health.  Such  become  exciting 
causes  of  various  diseases.  If  these  be  constantly  avoided,  and  all  the 
surroundings  and  the  mode  of  life  of  the  individual  be  maintained  in  a 
manner  most  favorable  to  health,  the  hereditary  tendency  may  remain 
inert  through  a  long  lifetime.  Every  physician  must  have  seen  this  in 
scores  of  instances.  The  application  of  the  principle  through  special 
precepts  belongs  to  personal  hygiene.  But  no  physician  can  rightly 
ignore  the  study  of  this  subject,  or  omit  the  utilization  of  his  acquaint- 
ance with  it  by  preventive  advice  to  members  of  the  families  under  his 
professional  care. 

Our  last  remark  in  connection  with  pre-natal  causation  must  be  upon 
the  effects  of  circumstances  and  modes  of  living  on  masses  of  men,  especially 
in  large  cities  and  populous  countries.  Something  has  been  said  already 
of  race-acclimatization  by  which  there  may  be  acquired  a  lessened  sus- 
ceptibility to  certain  endemic  fevers.1  Almost  a  reverse  action  is  exhib- 
ited in  the  gradual  lowering  of  vital  energy  under  what  has  been  called 
the  "great-town  system."  While  those  having  all  the  comforts  of  life 
and  avoiding  excesses  may  manifest  but  little  of  this  deterioration,  it  is  very 
observable  in  that  mass  of  men,  women,  and  children  who  become  the 
subjects  of  medical  charities.  Closeness  and  uncleanliness  of  living,  with 
more  or  less  exposure  to  dampness  and  extremes  either  of  heat  or  cold, 
with  intemperance  and  syphilis,  are  the  main  causes  of  this  general 
constitutional  impairment.  So  important  is  it  that  it  should  never  be 
forgotten,  not  only  in  our  estimate  of  the  causation  of  diseases,  but  in 
our  anticipation  of  their  results,  and  also  in  our  adaptation  of  measures 
of  treatment,  medical  and  surgical,  to  different  classes  of  patients.  All 
that  it  is  allowable  here  to  suggest  in  this  regard  may  be  summed  up 
(although  very  imperfectly)  in  the  word  hospitalism. 

Conditional  causation  has  been,  to  a  certain  extent,  included  under  what 
has  been  above  said,  as  it  is  the  action,  in  part  at  least,  of  surrounding 
conditions,  that  establishes  a  family-  or  race-proclivity  and  inheritance. 
But  we  must  say  something  more  about  the  direct  action  of  conditions 
upon  individuals. 

Man,  although  organized  with  great  delicacy  of  structure,  is  capable, 
by  the  use  of  his  intelligence,  of  adapting  himself  to  a  wider  variety  of 
external  conditions  than  any  other  animal.  He  is  the  only  truly  cosmo- 
politan being  on  the  earth.  From  the  remote  Arctic  regions  to  the  hottest 
tropical  climates  there  are  tribes  whose  ancestors  have  dwelt  for  centuries 
in  the  same  localities.  Not  that  no  unfavorable  influence  attends  these 
extremes.  The  Esquimaux  are  stunted,  the  Southern  Hindoo  and 

1  It  is  important  (but  not  before  remarked  in  this  article)  that  cholera  does  not  appear 
to  allow  of  any  such  diminution  of  liability  to  it  among  the  natives  of  the  country  in 
which  it  is  endemic. 


ETIOLOGY.  133 

Central  African  are  enfeebled  and  degenerate,  partly  from  climate.  But 
with  man's  numerous  protective  devices,  great  cold  and  great  heat  only 
exceptionally  affect  individual  health.  Freezing  to  death  folloAvs  unusual 
exposures;  the  loss  of  an  extremity  by  sphacelus  from  congelation  is 
more  often  met  with;  heat-stroke  also  is  tolerably  frequent;  and  the 
influence  of  heat  in  producing  cholera  infantum  in  some  large  cities  is 
very  important ;  but  much  the  most  common  kind  of  conditional  morbid 
causation  is  produced  either  by  sudden  changes  of  temperature  or  by  diver- 
sity of  exposure  of  different  parts  of  the  body.  These  are  the  two  usual 
modes  of  "  taking  cold."  When  dampness  accompanies  a  relatively  low 
temperature,  such  an  effect  is  much  more  apt  to  follow  than  in  a  cold  dry 
atmosphere. 

Actual  cold-stroke,  the  analogue  of  heat-stroke,  may  sometimes  happen. 
I  once  saw  such  a  case  in  a  previously  healthy  boy  twelve  years  of  age, 
who,  after  standing  for  an  hour  in  his  night-shirt  on  a  cold  winter 
night,  became  almost  immediately  ill,  fell  into  a  comatose  state,  and  died 
in  about  thirty-six  hours. 

A  simple  rationale  may  be  discerned  for  the  phenomena  of  catching 
cold.  When,  for  example,  a  draught  of  air  blows  for  a  time  upon  the 
back  of  a  person  at  rest  (especially  one  who  has  just  before  used  active 
exertion),  the  local  refrigerant  impression  induces  constriction  of  the 
superficial  blood-vessels.  Hence  follow  two  effects :  one,  the  repulsion 
of  blood  in  undue  amount  toward  interior  organs ;  the  other,  diminution, 
perhaps  arrest,  of  excretion  from  the  skin  of  the  exposed  portion  of  the 
body,  and  consequent  retention  of  some  effete  material,  promoting  eso- 
toxsemia.1  If,  then,  there  be  in  the  body  any  weak  organ — that  is, 
one  whose  circulation  is  partially  impeded  or  whose  nutritive  and  func- 
tional activity  is  low — it  suffers  first  and  most  from  the  impulsion  of 
blood  from  the  surface.  Congestion,  irritation,  and  inflammation  may  fol- 
low, and  we  have  an  attack  of  pneumonia,  pleurisy,  bronchitis,  or  some 
phlegmasia. 

Excessive  heat  with  dryness,  as  under  the  blasts  of  the  Simoon  or  the 
Harmattan  of  Arabia  or  Northern  Africa  (apart  from  insolation,  sun- 
stroke, or  heat-stroke),  may  sometimes  parch  the  body  even  to  a  fatal  degree. 
Much  more  common  is  the  combination  of  high  temperature  with  hu- 
midity. This  has  a  relaxing  effect,  promoting  indolence  of  temperament 
and  predisposing  to  disorders  of  a  catarrhal  nature,  especially  of  the 
digestive  organs,  such  as  were  called  fluxes  by  the  older  writers. 

Cold  climates  are  well  known  to  present  the  greatest  number  of  cases 
of  acute  and  chronic  affections  of  organs  of  the  respiratory  system  ;  warm 
and  hot  climates,  those  of  the  stomach,  liver,  spleen,  and  bowels.  But  we 
must  recollect  what  various  complications  belong  to  climate.  Two  import- 
ant factors,  especially,  must  be  kept  in  view  in  comparing  the  causation 
of  diseases  in  colder  and  warmer  countries — namely,  the  difference  in  the 
articles  of  food  partaken  of  in  each,  and  the  external  sources  of  euthetic 
disorders ;  e,  y.  endemic  and  epidemic  fevers,  etc. 

With  humidity  must  be  considered  variations  in  atmospheric  pressure. 
Physicists  have  long  known  that  while  watery  vapor,  by  itself,  is  heavier 
than  air  which  is  perfectly  dry,  moist  air  is  lighter  than  air  containing 

1  That  is,  blood-poisoning,  originating  within  the  body  itself;  exotoxsemia  being  that 
which  is  enthetic — i,  e.  resulting  from  a  poison  derived  from  without. 


134      GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

little  or  no  moisture.  Hence  the  barometer  falls  as  the  quantity  of  atmo- 
spheric moisture  approaches  saturation.  Other  causes,  however,  also 
affect  barometric  pressure.  With  the  same  degree  of  humidity,  cold  air 
is  denser  and  heavier  than  warm  air,  and  by  its  contraction  lowering  the 
"  column  "  of  atmosphere — the  temperature  of  which  is  reduced — a  flow 
toward  the  upper  part  of  the  column  increases  the  actual  mass  of  air 
pressing  upon  a  particular  place.  Elevation  of  a  locality  above  the 
general  level  of  the  earth  reduces  atmospheric  pressure,  sensibly  as  well 
as  measurably.  So  "  the  difficult  air  of  the  iced  mountain-top "  has 
become  proverbial. 

These  variations  are  familiar,  though  all  their  effects  upon  human 
health  have  been  by  no  means,  as  yet,  fully  studied.  Most  difficult  to 
determine  and  analyze  are  the  influences  of  changes  of  pressure,  chiefly 
hygrornetric,  upon  the  course  of  diseases  and  upon  the  result  of  severe 
surgical  operations.  Among  the  few  important  series  of  observations 
bearing  on  this  topic  have  been  those  of  Dr.  S.  Weir  Mitchell  on 
neuralgia,1  and  Dr.  Addiuell  Hewson  on  the  prognosis  of  major  opera- 
tions,2 in  connection  with  the  state  of  the  weather.  The  former  ascer- 
tained a  marked  relation  between  the  approach  of  a  wave  of  low  baro- 
metric pressure  and  attacks  of  irregularly  periodic  neuralgia ;  the  latter 
proved,  by  the  statistics  of  the  Pennsylvania  Hospital  for  a  number  of 
years,  that  the  most  favorable  time  for  amputations  or  other  capital  oper- 
ations is  when  the  barometer  is  high,  or  at  least  on  the  ascent. 

Electrical  atmospheric  states  and  vicissitudes  have,  quite  probably, 
a  practical  consequence  beyond  what  is  usually  ascribed  to  them  in  con- 
nection with  health  and  disease.  But  their  effects  are  so  difficult  to  dis- 
entangle from  those  of  other  meteorological  causes  that  we  must  be  con- 
tent at  present  without  attempting  their  exact  specification.  The  same 
observation  may  be  made  with  reference  to  ozone. 

Elevation  of  site  has  importance,  not  only  in  regard  to  climatic  hygiene, 
but  also  to  its  therapeutic  use,  particularly  in  the  treatment  of  phthisis, 
goitre,  and  some  affections  of  the  nervous  system.  But  in  our  brief  and 
general  survey  of  Etiology  this  topic  must  be  left  without  discussion, 
since  no  disorder  appears  to  be  traceable  to  elevation  alone,  beyond  the 
temporary  prostration  on  exertion,  with  hemorrhages  from  the  nose, 
lungs,  etc.,  often  produced  in  those  who  climb  to  great  mountain-heights 
or  ascend  rapidly  in  balloons.  It  has  been  shown  by  ample  experience 
that  considerable  populations  may  live  in  ordinary  health  through  long 
periods  at  altitudes  more  than  10,000  feet  above  the  level  of  the  ocean. 

Depression  below  the  surface  of  the  earth  has  never  become  a  part  of 
human  experience  beyond  the  limit  of  a  few  hundred  feet.  Miners  living 
underground  in  a  few  places  in  Europe  have  been  found  to  exhibit  com- 
paratively feeble  health,  but  the  privation  of  sunlight,  the  confined  atmo- 
sphere, and  the  dampness  of  such  unnatural  abodes  will  suffice  to  account 
for  these  effects. 

Under  functional  causation  of  disease  we  may  include  all  excessive, 
deficient,  or  abnormal  exercise  of  any  of  the  organs  of  the  body.  To 
simple  excess  may  be  ascribed  the  scrivener's  or  bank-officer's  paralysis 
of  the  muscles  of  the  hand  used  in  continuous  writing ;  brain  exhaus- 

1  American  Journal  of  Medical  Sciences,  April,  1877,  p.  305. 
*  Pennsylvania  Hospital  Reports,  1868. 


ETIOLOGY.  135 

tion  from  mental  labor  or  anxiety,  unrelieved  by  sufficient  sleep;  and 
sexual  impotence,  temporary  or  lasting  (or  sometimes  even  general  paral- 
ysis), from  inordinate  sexual  or  sensual  indulgence. 

Deficiency  of  functional  exercise  is  observed  to  produce  disability,  as 
when  the  muscles  of  a  limb,  for  instance,  are  for  a  long  time  restrained 
from  use.  Surgeons  meet  with  this  inconvenience  (unless  assiduously 
guarded  against)  when  a  fractured  limb  is  kept  long  at  rest  in  a  fixed  posi- 
tion. Atrophy  of  the  mammae  in  single  women  of  retired  lives  is 
common ;  atrophy  of  the  testicles  in  unmarried  men  much  less  so.  These 
changes,  however,  are  physiological,  not  pathological ;  upon  alteration 
of  conditions — e.  g.  marriage — the  atrophy  will  disappear  altogether. 

Abnormal  functional  action  as  a  cause  of  morbid  results  is  seen  when 
the  eyes  are  injured  by  reading,  writing,  or  doing  any  delicate  work  in  a 
bad  light ;  for  instance,  late  twilight.  Also,  in  a  secondary  or  accessory 
manner,  when  a  near-sighted  person,  having  the  action  of  the  muscles  of 
convergence  in  excess  of  his  accommodation,  or  a  long-sighted  (hyperopic) 
person,  whose  accommodation  is  in  excess  of  convergence,  suffers  from 
asthenopia,  perhaps  with  headache,  distress,  nausea,  etc.  Another  example 
of  abnormal  functional  exercise  and  its  effects  is  that  of  self-abuse,  where 
the  unnatural  mechanical  imitation  of  the  physiological  act  of  sexual 
coition  induces  disturbances  of  the  nervous  and  circulatory  systems, 
besides  debility  from  excess. 

Ingestive  causation  is  a  sufficiently  fit  designation  for  all  errors  of 
diet,  as  well  as  misuse  of  medicines,  and  poisoning.  Starvation  or  inanition 
belongs  to  the  same  category  by  negation.  Gluttony  and  intemperance 
are  major  members  in  the  ingestive  series,  while  haste  in  taking  food, 
without  mastication,  and  the  use  of  heavy  bread,  unripe  fruit,  and  other 
indigestible  articles,  account  for  many  cases  of  dyspepsia  and  some  of 
colic,  cholera  morbus,  diarrhoea,  etc.  With  young  children,  especially, 
no  more  frequently  acting  cause  of  disorder  exists  than  dietetic  misman- 
agement, most  of  all  during  the  period  of  dentition,  and  earlier,  when, 
from  absence  or  insufficiency  of  mother's  milk,  they  have  to  be  artificially 
fed.  Then  the  supply  of  good  fresh  cow's,  goat's,  or  ass's  milk  may  carry 
them  well  through  infancy,  while  a  regimen  of  arrowroot  or  gum-arabic 
and  water,  or  stale,  half  sour  milk,  may  either  starve  or  sicken  them  to 
death.  On  the  subject  of  poisons  and  of  misuse  of  medicines  we  have  no 
occasion  here  to  make  special  remark.  Only  it  may  be  mentioned  that 
the  possibility  of  either  is  always  to  be  remembered  by  the  physician  in 
making  up  his  mind  in  regard  to  the  origin  of  symptoms  observed. 

Euthetic  causation  is  a  large  subject,  including  all  origination  of  disease 
by  the  introduction  of  morbid  materials  from  without  the  body.1  Medical 
opinion  has  generally  accepted,  and  facts  fully  sustain,  the  recognition  of 
three  groups  of  enthetic  disorders,  viz. :  those  which  are  personally  con- 
tagious; such  as  are  locally  epidemic;  and  epidemic  diseases.  Of  the 
first  group  it  will  suffice  to  mention,  as  an  example,  syphilis ;  of  the 
second,  intermittent  fever;  of  the  third,  influenza. 

Were  all  maladies  whose  causation  is  evidently  of  external  origin 
capable  of  the  same  clear  discrimination  as  these,  we  should  have  no 
difficulty  with  the  present  topic.  But,  in  fact,  no  subject  connected  with 

1  Simon  has  proposed  the  term  exopathic  to  indicate  the  origin  of  such  maladies ; 
autopathic  disorders  being  those  which  originate  within  the  body  itself. 


136       GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

the  history  of  disease  has  become  surrounded  by  more  intricate  contro- 
versy. Many  times  the  same  facts  are,  or  appear  to  be,  explicable  in  two 
or  three  different  ways.  What  some  hold  to  be  proofs  of  contagion  from 
person  to  person,  others  are  ready  to  account  for  by  the  subjection  of  a 
number  of  persons  or  of  a  whole  community  to  either  a  common  local 
or  a  widespread  migrating  (epidemic)  influence.  It  is  sometimes  impos- 
sible, in  the  nature  of  things,  to  obtain  an  absolute  demonstration  of  the 
truth  of  one  or  another  of  these  theories  without  such  experiments  upon 
human  beings  as  are  impracticable. 

While  endeavoring  to  ascertain  the  limits  of  our  present  knowledge 
upon  these  questions,  let  us  first  notice  what  are  the  most  positive  facts 
concerning  them,  some  of  which  are  common  to  the  whole  group  or  class 
of  what  have  been,  since  Liebig,  often  called  zymotic,1  but  latterly  more 
often  enthetic,  diseases. 

These  diseases  may  be  enumerated  as  follows : 

1.  Only  produced  by  contact  or  inoculation. 

Primary  Syphilis,  Vaccinia, 

Gonorrhoea,  Hydrophobia. 

2.   Contagious  also  by  atmospheric  transmission  through  short  distances. 

Variola,  Scarlatina, 

Varioloid,  Rotheln, 

Varicella,  Mumps, 

Measles,  Whooping  Cough, 

Diphtheria,  Typhus, 

Relapsing  Fever. 

3.  Endemic,  occasionally  epidemic. 

Malarial  Fevers  (Intermittent,  Remittent,  and  Pernicious  Fever), 
Dengue,  Yellow  Fever. 

4.  Other  zymotic  or  enthetic  diseases. 

Influenza,  Tropical  Dysentery, 

Cerebro-spinal  Fever,  Typhoid  Fever, 

Erysipelas,  Cholera, 

Puerperal  Fever,  Plague. 

As  all  observers  are  agreed  in  regard  to  the  personal  transmission  of 
the  first  named  of  these  series  (variola,  etc.),  we  need  to  give  attention  here 
only  to  the  other  groups ;  except  merely  to  say  that  the  easily  demonstra- 
ble existence  of  a  morbid  material  (virus)  in  the  instances  of  primary 
syphilis,  gonorrhoea,  variola,  and  vaccinia  presents  a  very  cogent  ana- 
logical argument  for  the  presumption  that  all  clearly  contagious  (even 

1  The  term  zymotic  has,  with  many  authors,  fallen  into  disrepute,  chiefly  because  Liebig's 
hypothesis  concerning  the  chemico-physical  action  of  ferments,  as  well  as  of  contagia,  has 
lost  ground  in  comparison  with  the  vital  or  disease-germ  theory.  Yet  the  analogy  between 
fermentation,  putrefaction,  and  the  action  of  a  virus  on  an  animal  organism  persists ; 
whatever  may  be  the  theory  of  their  explanation,  something  appears  to  be  common  or 
similar  in  all  these  processes. 


ETIOLOGY.  137 

though  non-eruptive)  maladies,  such  as  mumps  and  whooping  cough, 
must  also  have  a  morbid  material  as  their  essential  cause ;  and  also  in 
favor  of  the  supposition  that  a  morbid  material  may  probably  be  the 
"causa  sine  qua  non"  of  each  of  the  other  maladies  which  are  known  to  be 
endemic  or  epidemic.  A  few  theorists  only  have  argued  in  favor  of  any 
other  view  than  this.  Sir  James  Murray  and  Dr.  Craig  of  Scotland,  and 
Dr.  S.  Littell  of  Philadelphia,  have  sustained  an  electrical  hypothesis, 
and  Oldham  and  others  have  advocated  one  connected  with  changes  of 
bodily  temperature,  or  ozone,  etc.,  for  the  origination  of  certain  endemic 
and  epidemic  diseases.  But  all  the  facts  point  toward  the  existence  of 
material  causes,  specific  for  each  of  these  disorders,  and  many  observations 
and  much  ingenuity  of  reasoning  have  been  brought  to  bear  upon  the 
question  as  to  their  intimate  nature. 

Are  these  materise  morborum  merely  inorganic  elements  or  compounds 
entering  human  bodies  and  acting  there  as  chemical  poisons?  Against 
such  a  supposition  we  have,  as  almost  decisive  objections,  not  only  the 
absence,  under  the  most  searching  analysis,  of  any  chemical  peculiarity  in 
the  air  of  malarious  or  otherwise  infected  regions,  but  also  the  cling- 
ing of  many  endemic  and  epidemic  causes  (as  known  by  their  effects)  to 
particular  localities,  notwithstanding  the  recognized  law  of  the  diffusion 
of  gases  which  must  antagonize  such  concentration.  Therefore,  we  may 
rule  out,  as  highly  improbable  at  least,  the  hypothesis  of  the  inorganic 
gaseous  nature  of  malaria,  as  well  as  of  the  essential  causes  of  yellow 
fever,  cholera,  plague,  and  the  other  analogous  diseases. 

By  the  once  general  use  of  the  term  zymotic,  there  is  suggested  a 
line  of  thought  which  has  been  quite  prevalent  since  the  prominence  of 
Liebig's  teachings  in  chemical  physiology,  until  recently.  That  great 
chemist  did  not  imagine  that  a  true  zymosis  or  fermentation  occurs  under 
the  action  of  a  virus  upon  the  human  economy.  His  thought  was  more 
clearly  expressed,  in  the  phraseology  of  the  late  Dr.  Snow  of  London,  as  the 
theory  of  continuous  molecular  change.  Its  most  striking  physical  instance 
or  analogue  is  the  extension  of  flame  from  a  burning  body  to  combustible 
matter  within  its  reach.  Sugar  formation  from  starch  by  diastase,  and 
the  change  of  albumen  into  peptone  by  pepsin,  are  familiar  examples,  in 
organic  materials,  of  the  propagation  of  molecular  movement  in  special 
directions  and  with  characteristic  results.1  It  does  not  seem  to  be  more 
than  a  short  step  from  these  to  the  processes  which  we  study  in  fermenta- 
tion, putrefactiou,  septicaemia,  and  the  multiplication  of  small-pox  conta- 
gion, from  the  smallest  inoculation,  in  the  human  body.2 

But  here  comes  in  a  new  hypothetical  factor,  introduced  by  the  aid  of 

1  In  anticipation  of  the  argument  concerning  the  necessity  of  the  action  of  minute  living 
organisms  to  produce  fermentation,  putrefaction,  and  specific  diseases,  emphasis  may  be 
here  laid  upon  the  fact  that  the  above  named  changes,  and  many  others  like  them,  are 
produced,  in  the  absence  of  such  organisms,  by  chemical  agents  formed  in  the  body,  or 
even  (as  when  sulphuric  acid  changes  starch  to  sugar)  by  inorganic  substances.  Pasteur 
considers  that  the  yeast-cell  secretes  a  sort  of  diastase  which  changes  starch  or  cane-sugar 
into  glucose,  on  which  the  cell  then  lives,  decomposing  the  glucose  into  alcohol,  carbonic 
acid,  etc.  Koch  and  others  now  assert  that  a  bacillus  produces  the  souring  of  milk,  and 
another  the  butyric  acid  fermentation. 

*  The  assertion  of  some  advocates  of  the  "germ  theory  of  disease,"  that  only  living  organ-- 
isms reproduce  their  kind,  loses  weight  as  an  argument  in  view  of  the  natural  history  of 
Binall-pox  and  analogous  diseases;  unless  it  be  proved  that  every  particle  of  contagious 
matter  is  (at  one  time  at  least)  a  living  organism. 


138     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

the  microscope,  although  anticipated  conj ectu rally  before  actual  discoveries 
in  this  field  were  made  certain.  So  prominent  is  this  subject  in  the  dis- 
cussions of  the  present  time,  under  the  expression  "  the  germ  theory  of 
disease/'  that  we  are  justified  in  giving  attention  to  it  here  somewhat  at 
length. 

Stahl  proposed  a  purely  chemical  theory  of  fermentation  early  in 
the  seventeenth  century.  Not  much  later  Hauptmaun  suggested 
the  probable  causation  of  epidemic  diseases  by  minute  living  organisms. 
Linnaeus l  revived  this  hypothesis  in  the  eighteenth  century.  These  two 
topics  of  inquiry,  with  the  intermediate  one  of  putrefaction,  then  received 
much  attention,  at  first  apart,  but  afterward  with  recognition  of  their 
analogies.  When  Fabroui,  Cagniard  de  la  Tour,  Schwann,  and  Kiitzing 
had,  with  the  aid  of  the  microscope,  made  familiar  the  life-history  of  the 
yeast-fungus2  (Saccharomyces  cerevisise),  more  close  consideration  still  was 
given  to  these  remarkable  changes  in  organic  materials  and  forms,  dead 
and  living. 

Starting  from  the  physical  basis  of  inorganic  chemistry,  Liebig  followed 
the  series  up  from  the  so-called  catalytic3  action  by  which  the  presence 
of  a  substance,  itself  apparently  unchanged,  induces  reaction  between  two 
or  more  other  bodies,  to  those  Avhich  occur  within  plants  and  animals,  as 
examples  of  vital  chemistry.  Such  is  the  influence  of  diastase  or  inver- 
tin,  which  in  the  seeds  of  plants  brings  on  the  conversion  of  starch  into 
sugar  and  of  cane-sugar  into  glucose  and  levulose.  Such  is  the  agency 
of  ptyaliu  in  the  saliva,  of  pepsin  in  the  gastric  juice,  and  of  pancreatin 
or  trypsin  in  the  secretion  of  the  pancreas,  in  the  processes  of  digestion. 
From  these  it  appears  to  be  an  easy  transition  to  those  changes  wThich 
occur  in  organic  matter  no  longer  living,  as  in  the  fermentation  of  vege- 
table juices  and  the  putrefaction  of  animal  tissues.4  Liebig  endeavored  to 
explain  these  also  in  the  same  manner  as  the  chemico-vital  processes ; 
and  he  then  went  farther  to  apply  the  same  generalization  to  the  propa- 
gation of  disease,  by  what  is  called  virus,  in  the  instances  of  contagious, 
endemic,  and  epidemic  maladies. 

But,  meanwhile,  observation  and  speculation  gave  almost  equal  prom- 
inence to  the  importance  of  minute  living  organisms  in  the  apparent  insti- 
gation of  all  these  evidently  analogous  changes  of  fermentation,  putre- 
faction, suppuration,  septicaemia  (Piorry,  1835),  infection,  and  contagion. 

Upon  this  side  the  leading  investigator  for  many  years  has  been  Pas- 
teur. As  long  ago,  however,  as  1813  Astier,  and  in  1840  Heiile  of 
Berlin,  and  near  the  same  time  Sir  Henry  Holland  of  London  and  Dr. 
J.  K.  Mitchell  of  Philadelphia,  gave  expression  to  opinions  of  a  similar 
kind,  based  upon  many  important  facts  before  very  much  overlooked. 
By  exact  experimentation,  moreover,  Schwann,  Helmholtz,  Schroeder, 
and  Dusch  ascertained  that  the  agent  or  agents  causative  of  fermentation 
and  putrefaction  can  be  detained  by  heated  tubes,  by  animal  membranes, 

1  Linnaeus  accepted  the  asserted  observation  by  Rolander  of  acari  in  the  stools  in  dysen- 
tery.    The  great  naturalist  deviated  somewhat  here  from  his  usual  carefulness  and  accu- 
racy, as  that  observation  was  not  afterward  verified. 

2  Leiiwenhoek,  however,  had  observed  and  described  it  in  1680. 

3  The  idea  expressed  by  this  term  was  especially  favored  by  Berzelius  and  Mitscherlich. 
*  It  is  noticeable,  however,  although  generally  forgotten,  that  the  one  set  of  changes 

and  assimilations  (namely,  those  of  digestion)  are  formative  actions  of  life,  and  the  others 
destructive,  in  the  direction  of,  or  subsequent  to,  death. 


ETIOLOGY.  139 

and  by  cotton  wool,  anticipating  the  later  observations  of  Pasteur,1  Tyn- 
dall,  Chauveau,  and  others  to  the  same  or  similar  effect.  These  results  of 
experiments  are  commonly  understood  to  prove  the  particulate  character  of 
the  agents  so  studied.  What  may  be  called  an  era  in  the  practical  appli- 
cation of  etiological  inquiry  dates  from  the  introduction  by  Lister  (about 
I860)  of  the  principles  of  antiseptic  surgery,  based  upon  the  theory  that 
disease-germs,  derived  from  the  atmosphere  or  other  external  sources, 
are  the  essential  causes  of  suppuration,  septicasmia,  pyasmia,  gangrene,  etc. 
following  injuries  or  operations. 

So  far  from  this  inquiry  being  yet  terminated,  while  experiments  and 
observations  have  become  more  and  more  numerous  and  elaborate,  opin- 
ions continue  to  differ ;  and  we  must  yet  await  the  time  when,  by  suc- 
cessively excluding,  one  after  another,  all  the  sources  of  error,  a  truly 
scientific  conclusion  may  be  obtained. 

Roughly  speaking,  it  may  be  said  that  parties  in  the  debate  are  chiefly 
ranged  upon  two  sides — those  who  favor  the  probability  that  only  chem- 
ical, not  vital,  action  is  to  be  traced  in  fermentation,  putrefaction,  suppu- 
ration, infection,  and  contagion ;  and  those  who  regard  minute  organisms, 
discovered  or  undiscovered,  as  causative  of,  and  indispensable  to,  all  these 
processes. 

Without  intention  of  injustice  to  other  able  investigators,  the  principal 
names  so  far  associated  with  the  former  of  these  views  may  be  thus 
mentioned:  Panum  (1856),  Robin,  Bergmann,  Liebig,  Colin,  Lebert, 
Vulpian,  Ouimus,  B.  W.  Richardson,2  Beale,3  Senator,  Roseuberger,  Hil- 
ler,  Nsegeli,  Schottelius,  Harley,  Jacobi,  Curtis,  and  Satterthwaite.  Of 
those  maintaining,  in  some  form  and  with  more  or  less  positiveness,  the 
disease-germ  theory,  the  most  conspicuous,  especially  as  observers,  have 
been  Tuchs  (1848),  Royer  (1850),  Davaine,  Branell,  Polleuder,  Pasteur, 
Tyndall,  Lister,  Mayrhofer,  Ortel,  Letzerich,  Nassiloff,  Hueter,  Toussaint, 
Hansen,  Salisbury,  Klob,  Hallier,  Basch,  Virchow,  Neisser,  Eberth, 
Tommasi  Crudelli,  Klebs,  Talamon,  Schiiller,  Tappeiner,  Colmheirn, 
Koch,  Baumgarteii,  Buchner,  Aufrecht,  Birch-Hirschfeld,  Greenfield, 
and  Ogstou.  Besides  these  the  elaborate  studies  of  microphytes  by 
Cohii,  and  those  of  Coze  and  Feltz,  Waldeyer,  Recklinghausen,  and 
others  upon  septic  poisoning,  have  been  of  acknowledged  importance ; 
and  the  experimental  labors  of  Burdon  Sanderson  in  England,  and  Stern- 
berg,4  H.  C.  Wood,  and  Formad  in  the  United  States  (under  the  aus- 
pices of  the  National  Board  of  Health),  possess  great  value.  But  the 
scientific  caution  of  these  last  inquirers,  like  that  of  Magnin,  has  pre- 
vented them  from  formulating,  as  yet,  positive  and  final  opinions  upon 
the  subject.  It  is  not  saying  too  much  to  assert  nearly  the  same  of 

1  Pasteur's  experiments  with  long-drawn  bent  tubes  had  especial  significance. 

2  Dr.  Richardson  lias  long  contended  for  the  doctrine  first  proposed  by  Panum,  that  a 
peculiar  chemical  agent,  (called  by  Bergmann  xepsin]  is  the  cause  of  blood-poisoning  from 
virulent  absorption   or  inoculation.     Latterly,  attention  has  been  called  by  Selmi  and 
other  observers  to  the  existence  of  complex  compounds  called  ptomaines  in  decomposing 
animal  substances — e.  y.  the  human  body  after  death — these  having  considerable  resem- 
blance in  their  toxic  action  to  tlie  poisonous  vegetable  alkaloids. 

3  Opposed  at  least  to  the  ordinary  form  of  the  germ  theory  of  disease. 

4  Sternberg's  observations  and  experiments  (following  those  of  Pasteur)  with  the  inocu- 
lation of  animals  with  saliva,  proving  that  even  when  taken  from_  perfectly  healthy  men 
this  may  be  fatally  poisonous  to  animals,   possess  remarkable  interest.     They  do  noi 
seem,  however,  to  be  decisive  either  way  in  regard  to  the  germ  theory  of  infection. 


140     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

several  of  those  mentioned  above,  as  inclining  to  one  or  the  other  side 
of  the  controversy.1 

It  would  appear,  then,  that  the  data  for  a  final  conclusion  have  not  yet 
been  made  certain.  Several  hypotheses  are  conceivable,  and  capable,  each, 
of  plausible  support : 

1.  The  purely  chemical  theory  of  Liebig,  Gerhardt,  Bergmaim,  Snow 
of  London,  and  B.  "W.  Richardson. 

2.  The  bioplastic  hypothesis  of  Beale,  according  to  which  germinal 
matter  may  be  detached   from  a   living    body  and   planted,   while  yet 
retaining  vitality,  upon  another,   and  there  may  undergo  changes  more 
or   less   morbid,  and   destructive  of  the   body   by  which    it   has   been 
received.      This  theory  of  migrating  or  transplanted  bioplasts  has  re- 
ceived very  little  support  besides  that  of  its  distinguished  author. 

3.  That  the  minute  organisms  discovered  so  constantly  upon  diseased 
parts  of  plants  and  animals  (e.  g.  ergot  of  rye,  Peronospora  wfcstans  of 
potato-rot,   Botrytis  Bassiaiia  of  silk-worm  niuscardiue,  Panhistophyton 
of  silk-worm  pebrine,  JSmpusa  muscce  of  the  fly,  Achorion,  Tricophyton, 
Oidium,  and  Leptothrix  of  human  affections  of  the  skin  and  mucous  mem- 
branes) are  incidental  or  accidental  only2 — acting,  as  JL  Owen  observes, 

1  Billroth  and  Cohnheim  are  among  those  who  have  changed  their  opinions  on  this 
subject  after  prolonged  investigation. 

2  This  possibility  lias  not  been  as  yet  altogether  ruled  out  in  regard  to  Koch's  Bacillus 
tuberculosis  ;  concerning  which  active  discussion  has  been  going  on  during  the  past  year 
or  two  (1882-83).     A  very  large  number  of  observers  confirm  the  statement  that  the 
bticilli  are  found  in  most  specimens  of  tubercle.     Several,  also,  have  repeated  with  success 
Koch's  inoculation  experiments,  in  which  tubercle  appeared  to  be  propagated  by  care- 
fully isolated  bacilli.     But  many  facts  still  stand  in  the  way  of  the  conclusion  that  the 
bacillus  is  the  causa  sine  qua  non  of  tuberculosis.     First,  examples  of  the  production  of 
phthisis  by  apparent  contagion  or  infection  are  few.     Although  Dr.  C.  T.  \Villiams  found 
bacilli  in  the  air  of  the  wards  of  the  Hospital  for  Consumptives  at  Brompton,  yet  of  the 
experience  of  that  hospital  Dr.  Vincent  Edwards,  for  seventeen  years  its  resident  medical 
officer,   reports  as  follows:  "Of  fifty-nine  resident  medical    assistants  who  lived  in  the 
hospital  an  average  of  six  months  each,  only  two  are  dead,  and  these  not  from  phthisis. 
Three  of  the  living  are  said  to  have  phthisis.     The  chaplain  and  the  matron  had  each 
lived  there  for  over  sixteen  years.     Very  many  nurses  had  been  in  residence  for  periods 
varying  from  months  to  several  years.     The  head-nurses,  says  the  writer,  sleep  each  in  a 
room  containing  fifty  patients.     Two  head-nurses  only  are  known  to  have  died — one  from 
apoplexy ;  the  other   head-nurse  was  here  seven    months,  was  unhappily  married,  and 
some  time  afterward  died  of  phthisis.     Of  the  nurses  now  in  residence,  one  has  been  here 
twenty-four  years,  two  twelve  years,  one  eight  years,  one  seven  years,  one  six  and  a  half 
years,  and  one  five  years.     No  under-nurse,  as  far  as  I  am  aware,  has  died  of  phthisis. 
All  the  physicians  who  have  attended  the  in-and-out  patients  during  the  past  seventeen 
years  are  living,  except  two,  who  did  not  die  from  phthisis." 

Against  the  inoculation  and  inhalation  experiments  of  Villemin,  Tappeiner,  Koch,  Wil- 
son Fox,  and  others,  by  which  the  specific  character  of  tubercle  has  been  said  to  be 
proved,  must  be  placed  those  of  Sanderson,  Foulis,  Papillon,  Lebert,  Waldenburg,  Schotte- 
litis,  Wood  and  Formad,  Robinson,  and  others,  by  which  tubercles  have  been  induced  by 
the  injection,  inoculation,  or  inhalation  of  various  non-tubercular  materials.  In  answer 
to  the  argument  from  these,  it  is  asserted  by  Koch  and  his  supporters  that  "  there  is  no 
anatomical  or  morphological  characteristic  of  tubercle,"  its  only  sufficient  test  being  its 
inoculabiiity.  This  is  almost  begging  the  question  ;  at  all  events,  it  leaves  it,  for  the 
present,  unsettled.  Moreover,  tubercular  deposits  do  not  always  contain  bacilli,  as  has 
been  shown  by  Spina,  Sternberg,  Formad,  Prudden  (N.  Y.  Medical  Record,  April  14  and 
June  Hi.  1883).  The  last  named  made,  in  one  well  marked  case,  six  hundred  and  ninety- 
five  sections  from  ninety-nine  tubercles  in  different  portions  of  a  tuberculous  pleura,  all 
of  Koch's  precautions  being  observed  in  the  examination.  Belfield  (Lectures  on  Micro- 
O/v/iuu'.v//!.s  find  Disease)  admits  the  possibility  that  tuberculosis  may  be  produced  by  either 
of  several  causes.  It  has,  at  least,  not  yet  been  demonstrated  that  the  tubercular  tissue  is 
more  than  a  nidus  or  favorable  "  culture-ground  "  for  the  bacilli,  or  that,  in  the  presence 
of  a  constitutional  predisposition,  they  may  not  merely  promote  a  more  rapid  destruction 
ul  the  invaded  organs  or  tissues. 


ETIOLOGY.  141 

most  commonly  as  natural  scavengers  in  the  consumption  of  effete  organic 
material ;  but  that  they  may  become  noxious  under  two  sorts  of  circum- 
stances— viz.  when  their  numbers  are  enormously  increased,  as  is  known 
to  be  the  case  with  trichinae  in  the  human  body,  and  also  when  they  are 
brought  in  considerable  number  into  contact  with  bodies  already  diseased, 
or  at  least  suffering  under  depression  of  vital  energy. 

4.  That  such  organisms  are  the  essential  and  direct  causes  of  enthetic 
maladies  by  invading  the  human  and  other  living  bodies  as  parasites, 
consuming  and  disorganizing  their  tissues,  blood  corpuscles,1  etc.     Pasteur 
considers  the  abstraction  of  oxygen  an  important  part  of  their  action. 

5.  That  these  microbes,  microphytes,  or  mycrozymes  act  not  as  parasites, 
but  as  poison-producers,  secreting  a  sort  of  ferment  which  is  the  specific 
morbid  material  (Virchow) ;  or,  when  multiplying  in  excess  of  their  food- 
material,  they  may  die,  and  their  dead  bodies,  like  other  decaying  organic 
matter,  may  become  poisonous.     This  possibility,  although  not  distinctly 
suggested  (so  far  as  I  know)  hitherto,  appears  to  me  to  be  not  unworthy 
of  consideration.     That  the  numbers  of  micro-organisms  present  have 
some  important  relation  to  morbid  conditions  has  long  since  been  inferred 
from  familiar  facts. 

6.  That  they  are  not  generators,  but  carriers,  of  disease-producing 
poisons ;  their  vitality  giving  to  the  latter  a  continuance  of  existence  and 
capacity  of  accumulation  and  transportation  not  otherwise  possible. 

Briefly,  the  following  is  a  summary  of  the  most  generally  accepted 
classification  of  those  microscopic  organisms2  whose  role  in  the  causation 
of  diseases  is  now  under  discussion  ;  chiefly  following  Colin  and  Klebs  : 

Orders :  Hyphomyceta?,  Algse,  Schizomycetse. 

Hyphomyceta3,  genera :  Achorion,  Tricophyton,  Oidium. 

Algoe,  genera:  Sarcina,  Leptothrix. 

Schizomycetoe,  or  Bacteria,  genera:  Micrococcus,  Rod-bacterium,  Bacil- 
lus, Spirillum.3 

Micrococci  (Sphrerobacteria  of  Cohn)  are  asserted  (under  certain  condi- 
tions) by  Letzerich,  Wood,  and  Formad 4  to  be  causative  of  diphtheria ; 
Ogston  has  found  them  in  ordinary  pus;  Rindfleisch,  Recklinghausen, 
Waldeyer,  Birch-Hirschfeld,  and  others  report  them  to  be  always  present 
in  the  abscesses  of  pyamia;  Buhl,  Waldeyer,  and  Wagner  state  their 
occurrence  in  intestinal  mycosis ;  Eberth,  Koster,  Maier,  Burkhardt,  and 
Osier,  in  ulcerative  endocarditis;  Orth,  Lukomsky,  Fehleisen,  and 
Loeffler,  in  erysipelas;  Coats  and  Stephen  in  pyelo-nephritis ;  Friedlander, 
in  pneumonia;  Eklund  (Plax  scindens)  in  scarlet  fever;  Keating*  and 

'  Against  this  view  stands  especially  the  objection  that,  as  Cohn,  Burdon  Sanderson, 
and  others  have  fully  shown,  bacteria  and  other  SchizomycetiB  obtain  their  nitrogen,  not 
from  organized  tissues,  but  from  ammonia,  and  their  carbon  and  hydrogen  from  the 
results  of  decomposition  in  organic  tissues.  (See  B.  Sanderson,  in  Brit.  Med.  Journal,  Jan. 
16,  1875.)  Pasteur  has  regarded  the  relation  of  these  organisms  to  oxygen  as  important; 
some  of  them  requiring  it  for  their  existence  (aerobic),  and  others  not  (anaerobic).  He 
has  defined  fermentation  as  "life  without  free  oxygen." 

.  *  For  further  details  concerning  these  the  reader  is  referred  to  the  works  of  Magnin, 
Belfield,  and  Gradle  on  The  Bacteria,  and  on  the  Germ  Theory  of  Disease. 

3  Cohn  also  separates  vibrio  and  spirochaete  as  genera  distinct  from  spirillum.    They  may, 
however,  be  regarded  rather  as  species  of  that  genus.     Some  recent  authors  included  bac- 
terium and  bacillus  under  one  genus,  bacillus;  against  which  simplification  there  seems  to 
be  no  valid  objection. 

4  Bulletin  of  National  Board  of  Health,  Supplement  No.  17,  Jan.  21,  1882. 
6  The  Medical-  Nem,  Philadelphia,  July  29,  1882. 


142     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 


Le  Bel,  in  measles ;  Leyden  and  Gaudier,  in  cerebro-spinal  meningitis ; 
Carmona  del  Valle,  in  yellow  fever ;  Prior,  in  dysentery  ;  Gaff'ky,  Leis- 
tikow,  Bokai,  and  Bockhardt,  in  gouorrhosa ; l  besides  other  similar  ob- 
servations by  numerous  writers. 

Bacterium  termo  is  regarded  by  leading  authorities  as  the  special  fer- 
ment or  causative  agent  of  putrefaction2  (Billroth,  Cohn). 

Bacillus  includes,  hypothetically  at  least,  several  species;  as  Bacillus 
subtilis,  the  innocent  hay-fungus ;  Bacillus  anthracis,  the  microbe  of 
malignant  pustule  (anthrax,  milzbrand,  charbon)  and  the  splenic  fever 
of  sheep ;  Bacillus  typhosus  (Klebs,  Eberth,  Meyer)  of  typhoid  fever ; 
Bacillus  lepra  (Hansen,  Neisser,  Cornil,  Koebnerj  of  leprosy ; 3  Bacillus 
rnalarise,  reported  as  having  been  demonstrated4  by  Klebs  and  Tommasi 

Crudeli,    Marchand,   Ceri,    and    Ziehl ; 
Bacillus  tuberculosis  (Koch,  Baumgar- 
c?a»jV*ten,  1882);    the  bacillus  of  malignant 
**••*•  /•  oetlema  (Gaffky,  Brieger,  Ehrlich);  that 
•,«{  *    of  syphilis  (Aufrecht,  Birch-Hirschfeld/ 
•  /    ,  /  Morrison) ;  of  glanders  (Loeffler,  Schuetz, 
•;%;*/    Israel,  Bouchard);  of  pertussis  (Burg- 
?    •    \  er) ;  besides  the  Actinomycosis  of  Israel, 
**.'  Ponfick,6  Bellinger,  and  others.     Koch 

Micrococci:  a,  zooglcea  form;  b,  microooc-    ,                                   i       /i  r,n.->\   i  i 

cus  from  urine,  in  rosary  chain;  c,  rosary    has    V6iy  recently   (188o)    06611    reported 
solution  of  sugar  of    A_  i j; i  ;„  77 iii._  i :n.._ 


FIG.  1. 


FIG.  2. 


to  have  discovered  in  Egypt  the  bacillus 
of  cholera. 

Spirillum  (Spirochseta  of  Ehrenberg)  has  its  best  ascertained  example 
in  the  minute  forms  first  observed  by  Obermeier,  and  afterward  by 
many  other  observers,  in  the  blood  of  patients  suffering  with  relapsing 

fever.  They  have  been 
found  present  in  the  blood 
only  during  the  febrile 
paroxysm,  disappearing 
in  the  intermission  and 
through  convalescence. 

Hastening  to  close  our 
consideration  of  this  sub- 


ject, we  may  note,  with- 
out much  argument,  a  few 
of  the  points  of  difficulty 

Bacteria:  a,  zooglcea  of  Bacterium  termo;  b,  pellicle  of  bacteria    nppri;no,    vpf    +n    Up    mr,™ 
from  surface  of  beer;  c,  Bacterium  lineola,  free;  d,  zooglcea    "«W*IUK    j  ui 

form  of  B.  lineoia.  ful]y  illuminated  by  care- 

1  Steinberg's  careful  experimentation  seems  to  show  the  identity  of  Neisser's  gonococ- 
cus  with  the  Micrococcns  urese,  commonly  found  in  decomposing  urine. 

2  Others  have  referred  putrefaction  to  vibriones,  less  precisely  described. 

3  Dr.  H.  D.  Schmidt  of  New  Orleans,  an  experienced  pathologist,  reported  (Chicago 
Medical  Journal  and  Examiner,  April,  1882)  that  critical  examination  of  numerous  speci- 
mens of  tissues  from  three  cases  of  leprosy  under  his  care  failed  to  verify  the  existence 
of  bacilli  as  characteristic  of  that  disease. 

4  Not  certainly,  however,  as  shown  by  Sternberg  (Bulletin  of  Nat.  Board  of  Health,  Sup- 
plement No.  14,  July  23,  1881).     Dr.  Salisbury  of  Ohio  in  1866  made  a  series  of  observa- 
tions, on  the  basis  of  which  he  asserted  the  discovery  of  a  genus  of  malarial  microphytes, 
which  he  referred  to  the  family  of  PalmellnK. 

The  oval  and  spherical  organisms  described  by  Richard  and  Laveran  as  found  in  the 
blood  of  malaria]  patients  resembled  micrococci  rather  than  bacilli. 

5  More  recently  described  by  him  as  micrococci.  6  Die  Actlnomykose,  1881. 


ETIOLOGY. 


143 


ful  observation  before  any  form  of  the  germ  theory  can  take  its  place 
as  an  established  doctrine  in  etiology  : 

1.  The  absence  of  the  characters  belonging  to  definite  organisms1  in 
the  easily-studied  virus  of  small-pox  and  vaccinia  stands,  a  priori,  against 


FIG.  3. 


FIG.  4. 


Bacillus  malarix  of  Klebs  and  Tommasi 
Crudeli. 


Bacteria  from  gelatin  solution,  inoculated 
from  swamp-mud,  X  1500  (Steinberg). 


the  probability  of  such  organisms  being  essential  to  the  causation  of  other 
enthetic  diseases. 

2.  Analogy  in  nature,  showing  the  commonly  beneficial  action  of  nutri- 
tive processes  in  re-appropriating  the  products  of  organic  decay  on  a  large 
or  on  a  small  scale,  makes  the  scavenger  theory  of  the  general  function 
of  minute  cryptogamic  organisms  more  probable,  per  se,  than  that  which 
holds  many  of  them  to  be  destructive  parasites  or  poison-producers  in 
the  bodies  which  they  may  inhabit.     Few  well  known  parasites  are  capa- 
ble of  causing  death  in  higher  animals  or  in  man. 

3.  These   microbes   are   among   the    minutest   objects   which   can    be 
studied  under  the  microscope.     Bacteria  average  about  Q^O  of  an  inch 
in   their   longest  diameter;    micrococci   and   spores  (Dauersporen,   Bill- 
roth)  are  yet  smaller.     Much  care,  therefore,  as  well  as  skill,  must  be 
exercised  in  making  observations  upon  them.2     Huxley  asserted  a  few 

1  The  particulate  character  of  variolous  and  vaccine  virus  has  been  already  alluded  to, 
as  asserted  to  have  been  shown  by  Chauveau  and  others.     Yet  it  is  not  absolutely  demon- 
strated that  filtration  may  not  produce  an  important  chemical  alteration  in  some  kinds  of 
highly  unstable  organic  material  subjected  to  it.    Cohn  figures  a  Micrococcus  vacciniae  in 
his  article  on  Bacteria  (Microscopical  Journal,  vol.  xiii.,  N.  S.,  pi.  v.,  Fig.  2).     Beale  denies 
(Microscope  in  Medicine,  4th  ed.)  the  existence  of  any  organisms  in  vaccine  virus.     Lug- 
ginbuhl,  Weigert,  Klebs,  Pohl-Pincus,  and  others  have  asserted  their  existence,  but,  espe- 
cially in  the   absence  of   any  successful   culture   experiments,   it  does   not  seem  to  be 
proved. 

2  A  very  interesting  discovery  was  made  by  Tyndall,  to  the  effect  that  while  one  boiling 
of  a  liquid  would  sterilize  it  for  the  time  by  destroying  all  the  bacteria  present,  their  spores 
might  still  retain  vitality  and  be  afterward  developed.    By  repeated  exposure  to  a  boiling 
temperature,  taking  these  spores  in  their  developing  stage,  they  were  destroyed,  and  com- 
plete sterilization  was  effected. 


144     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 


years  ago  that  a  distinguished  English  pathologist  had  mistaken  for  move- 
ments of  minute  living  organisms  the  "  Brownian  movements "  seen  in 
the  particles  of  many  not  living  substances  under  a  high  magnifying 
power.  One  observer,  at  least,1  considers  that  the  forms  designated  as 
bacteria  and  micrococci,  etc.  are  either  forms  of  coagulated  fibrin  or 
granules  from  morbidly-altered  blood-corpuscles  (zoogloea  of  Billroth, 
Wood,  Formad,  and  others).  Koch  denies  the  validity  of  the  observa- 
tion of  organisms  in  tubercle  by  Klebs  and  Schiiller,  while  insisting  upon 
his  own  demonstration  of  a  bacillus  tuberculosis.  Authorities  must,  by 
mutual  confirmation  or  correction,  remove  these  obscurities. 

4.  Bacteria  and  micrococci  have  been  abundantly  discovered  (Kolaczck ; 
J.  G.  Richardson)  in  healthy  bodies  upon  the  various  mucous  membranes 
and  in  the  blood.     The  correctness  of  such  observations  has  been  denied, 
but,  so  far  at  least  as  the  mucous  membranes  are  concerned,  it  has  been 
well  established  by  Nothnagel,  Sternberg,  and  others.     Bacteria  have 
sometimes  been  found  in  countless  numbers  in  fecal  discharges. 

5.  Bacteria  become  most  numerous  in  materials  of  a  septic  or  infectious 
character  after  their  period  of  toxic  intensity  has  passed  by. 


FIG.  5. 


FIG.  6. 


Vibrios  in  gelatin  culture-fluid,  X  1000  (Sternberg).    Protococcus  from  slides  exposed  over  swamp-mud, 

X  400  (Sternberg). 

6.  Suppuration  can  be  produced  (Uskoff,  Orthmann)  without  the 
presence  of  minute  organisms  of  any  kind.  Bacteria  have  been  found 

1  R.  Gregg,  AT.  Y.  Me.d.  Record,  Feb.  11,  1882.  Sternberg,  however,  has  replied  to  him 
(N.  Y.  Med.  Record,  April  8,  1882,  p.  368).  The  latter  admits  a  doubt  as  to  whether  the 
granules  seen  within  the  leucocytes  by  Wood  and  Formad  in  diphtheritic  material,  and 
believed  by  them  to  be  micrococci,  are  such,  or  are  merely  granules  formed  or  set  free  by 
disorganization  of  protoplasm  within  the  leucocytes.  This  uncertainty  well  illustrates 
the  difficulty  of  these  investigations. 

A  chemical  test  much  relied  upon  is,  that  bacteria  resist  the  action  of  acids  and  alka- 
lies, which  destroy  granular  material  of  animal  origin ;  also,  that  all  these  organisms  are 
deeply  stained  by  aniline  dyes  and  by  haematoxylin.  The  most  decisive  test,  however,  is 
cultivation  in  a  liquid  sterilized  by  heat.  Koch  prefers  a  process  of  dry  culture  for  the 
bacillus  of  tubercle. 

Gradle  (Lectures  on  the  Germ  Theory  of  Disease,  Chicago,  1SS3,  p.  28)  says  that  the  abso- 
lute criterion  of  the  life  of  bacteria  is  their  power  of  multiplication. 


ETIOLOGY. 


145 


under  Lister's  antiseptic  dressings  without  suppuration  following.  Paul 
Bert  destroyed  all  the  microbes  in  a  septic  liquid,  and  yet  found  it  to 
retain  its  poisonous  quality.  Rosenberger  (1881)  has  made  similar 
observations. 

Panum,  Coze,  and  Seltz,  Bergmann  and  Schmiedeberg,  Hiller,  Vul- 
pian,  Rosenberger,  dementi,  Thin,  and  Dreyer  have,  by  various  elab- 
orate investigations,  proved  that  fatal  septic  poisoning  can  be  produced 
in  animals  by  the  products  of  organic  decomposition,  without  the  pres- 
ence of  living  organisms.  Zweifel's  experiments  seem  to  have  shown 
that  normal  blood,  when  deprived  of  oxygen,  in  the  absence  of  micro- 
organisms, may  acquire  septic  properties. 

As  stated  by  Belfield,1  many  experiments  by  Schmidt,  Edelberg, 
Kohler,  Nencki,  and  others,  have  shown  that  septicaemia  may  be  induced 
by  the  injection  into  the  blood  of  free  fibrin  ferment  and  other  sub- 
stances, in  the  absence  of  minute  organisms.  To  such  an  affection  some 
authors  now  give  the  name  saprsemia,  to  distinguish  it  from  bacterial 
infective  disorders. 

Griffiui  ascertained  that  mixed  saliva,  filtered  through  porous  plates,  and 
thus  containing  no  microbes,  will  still  produce  septicaemia  in  animals,  when 
subcutaneously  injected.  Colin  (1876)  has  denied  the  collusiveness  of 
the  experiments  of  Chauveau,  which  nave  been  held  to  prove  the  par- 
ticulate  nature  of  variolous  and  vaccine  virus.  Moreover,  it  is  well 
known  that  eggs  with  shells  unbroken  are  tainted  when  placed  near  others 
which  are  unsound. 

7.  While  Klebs  and  Koch  maintain  the  definite  specificity  of  each 
minute  microphytic  organism,  Nsegeli  and  Billroth  assert  their  mutual 


FIG.  7. 


FIG.  8. 


Bacilli  trom  swamp-mud,  X  1000  (Sternberg). 


Bacilli  from  septtemic  rabbit,  X  1000 
(Sternberg). 


convertibility.  Burdon  Sanderson  avers2  that  "the  influence  of 
environment  on  organisms  such  as  bacteria  is  so  great  that  it  seems 
as  if  it  were  paramount."  Buchner,  Grawitz,  Greenfield,  Pasteur, 
Wernich,  Thorne,  Willems,  Law,  Wood,  and  Formad  report  experi- 
ments making  it  appear  that  modification  by  culture  is  possible  with 
bacilli  and  micrococci,  converting  an  innocent  into  a  malignant  parasitic 
organism,  or  a  death-producing  microbe  into  one  capable  only  of  causing 

1  Leiturfs  on  the  Relation  of  Micro-organisms  to  Disease,  1883. 
*Brit.  Med,  Journal,  Jan.  16,  1875. 
VOL.  I.— 10 


146     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 


a  transitory  and  not  dangerous  local  affection  ;  which  nevertheless  secures 
to  the  animal  thus  treated  immunity  when  subsequently  exposed  to  the 
deadly  infection.  Most  interesting  have  been  the  successes  with  such 
culture-inoculations  obtained  by  Buchner,  Greenfield,  and  Pasteur 
with  anthrax  in  sheep ;  by  Pasteur  also  in  chicken  cholera ;  and  by 
Willems  and  Law1  with  the  lung-plague  of  cattle. 

In  none  of  these  cases  is  there  reported  any  morphological  change 
whatever  in  the  bacillus  (Grawitz)  or  micrococcus  (Wood  and  Formad) ; 


FIG.  9. 


FIG.  10. 


Bacilli  from  human  saliva,  X  1000  (Sternberg). 


Bacillus  anihracis  (Sternberg). 


the  change  in  the  effects  noted,  and,  in  the  case  of  the  micrococci  of 
malignant  diphtheria,  the  acquired  capacity  of  reproduction  through 
several  generations,  are  all. 

8.  The  immunity  against  subsequent  attacks  on  exposure  (similar  to  the 
protection  given  by  vaccination)  continues  to  be  without  full  explanation 
upon  any  theory.  But  it  is  especially  difficult  to  reconcile  it  with  the 
hypothesis  of  the  infection  being  caused  by,  and  dependent  upon,  the 
presence  of  peculiar  microphytes.  Why  should  not  these,  whether  as 
parasites  or  as  poisons,  always  produce  the  same  effects? 

.9.  The  view  entertained  by  Thome,  Wood,  and  Formad,  that  a  com- 
mon benignant  affection,  such  as  ordinary  sore  throat,  may  be  converted 
into  a  violent  infectious  disease — e.  g.  malignant  diphtheria — by  modifica- 
tion of  innocent  micrococci  into  those  with  lethal  characters,  through  local 
or  bodily  conditions,  is  sufficiently  contravened  by  the  great  frequency  of 
such  conditions  compared  with  the  decided  relative  rarity  of  such  malig- 
nant epidemics  or  endemics. 

10.  Throughout  all  the  investigations  which  have  been,  and  are  likely 
to  be,  conducted,  there  remains  the  extreme  difficulty,  if  not  impossibility, 
of  total  separation  between  the  microbes  themselves  and  the  matter  of  the 
vehicle  in  which  they  exist — the  membrane,  urine,  blood,  virus,  artificial 
culture-material,  or  whatever  it  may  be.  All  the  effects  ascribable  to  the 
disease  germs  may  be,  with  no  more  difficulty,  attributed  to  the  toxic  action 

1 N.  Y.  Med.  Record,  June  18,  1881,  p.  679.  Exposure  to  the  air  for  a  considerable 
period  seems  to  be  the  agency  chiefly  relied  upon  for  what  may  be  called  the  dynamic 
modification  of  these  microphytes.  When  cultivated  in  the  depth  of  a  liquid,  so  that 
air  is  excluded,  they  are  supposed  to  acquire  a  habit  of  obtaining  oxygen  by  decomposing 
organic  substances,  and  thus  act  destructively  upon  the  cell-elements  of  living  bodies. 
Analogous  differences  have  long  since  been  observed  in  the  study  of  fermentation  between 
surface  and  sedimentary  yeast. 


ETIOLOGY. 


147 


Bacillus  tuberculosis,  within  and  outside  of  pus-corpuscles 
(Sternbcrg). 


of  a  portion,  however  minute,  of  the  soil  in  -which  they  have  lived, 
whose  modifications  must  be  concomitant  with  those  which  they  undergo. 
It  appears  necessary,  there- 
fore, at  the  present  time,  FIG.  11. 
to  regard  this  whole  ques- 
tion as  still  undecided,  with 
a  predominance  of  proba- 
bility, however,  in  favor 
of  the  view  that  these  mi- 
nute organisms,  or  some 
of  them,  have  a  direct  and 
important  relation  of  some 
kind  to  the  causation  of 
specific  endemic,  epidemic, 
and  contagious  diseases. 
Altogether,  the  strongest 
arguments  are  on  the  side 
of  the  view  that  the  mi- 
crococci,  bacilli,  etc.  cause 
diseases,  not  as  parasites, 
living  upon  their  victims, 
but  as  poison-producers 
infecting  them.1  The 
germ  theory  continues  to 
be  in  the  position  of  a 
probable  hypothesis,  not  in  that  of  an  established  doctrine  of  etiological 
science. 

Practically,  the  result  is  nearly  the  same  as  if  it  were  altogether  settled, 
since  it  is  admitted  on  all  sides  that  the  presence  of  microphytes  (bacteria, 
micrococci,  spirilla)  coincides  with  those  conditions  under  which  originate 
several  of  the  most  malignant  diseases.  Measures  which  prevent  the 
appearance  or  promote  the  destruction  of  these  minute  organisms  are  at 
least  often,  and  to  a  great  degree,  preventive,  if  not  curative,  of  such  dis- 
orders; and  the  glory  of  Jenner's  discovery,  by  which  the  ravages  of 
small-pox  have  been  made  (potentially  at  least)  controllable,  seems  not 
unlikely  to  be  paralleled  by  the  achievements  of  Pasteur  and  others  in 
a  similar  preventive  mastery  over  other  maladies  of  men  and  animals. 
There  is,  therefore,  no  branch  of  inquiry  in  connection  with  medical  science 
more  worthy  of  being  assiduously  encouraged  and  extended.  The  pres- 
ent may  almost  be  said  to  be,  in  the  history  of  medicine,  an  era  of  rnyco- 
pathology. 

For  an  exhaustive  study  of  Etiology  attention  would  now  have  to  be 
given  to  the  modifying  influences  affecting  the  occurrence  and  character 
of  diseases  in  connection  with  age,  sex,  and  temperament.  But,  as  neither 
of  these  is  ever,  per  se,  causative  of  any  malacly,  and  they  merely  deter- 
mine some  modification  of  the  action  of  morbid  causes  when  these  occur, 
want  of  space  must  be  our  justification  for  leaving  them  to  be  considered, 
in  this  work,  in  connection  with  the  special  causation  of  the  different  dis- 

1  This  comports  much  the  best  with  the  general  natural  history  of  parasites  on  the  one 
hand,  and  of  venoms,  ptomaines,  etc.  on  the  other.  Gautier,  Ogston,  and  others  have 
expressed  the  opinion  that  microphytes  may  produce  ptomaines. 


148     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

eases  which  will  be  hereafter  described.     A  larger  treatment  of  our  present 
subject  belongs  rather  to  hygiene  than  to  practical  medicine. 


MEDICAL  DIAGNOSIS. 

FOR  the  purposes  of  the  medical  practitioner  all  professional  studies 
unite  to  the  end  of  furnishing  pi'eparation  for  the  diagnosis  and  treatment 
of  diseases.  At  the  bedside  the  cardinal  questions  are,  How  does  the 
present  condition  of  our  patient  differ  from  health  ?  and,  What  ought  we 
to  do  to  bring  about  his  recovery  ? 

Diagnosis  involves  three  main  directions  of  inquiry  :  1,  as  to  the  gen- 
eral bodily  state  of  the  patient ;  2,  morbid  changes  in  particular  organs, 
tissues,  or  functions  ;  3,  as  to  what  name  properly  designates  the  disorder, 
according  to  accepted  nomenclature. 

Pathology  can  never  be  out  of  view  in  connection  with  either  the 
theoretical  or  the  practical  study  of  diagnosis.  But  it  is  most  closely 
regarded  when  the  last  of  these  questions  is  before  us,  since  the  names  of 
diseases  generally  have  a  more  or  less  distinct  reference  to  their  patho- 
logical nature.  Yet  clinical  observation  always  suggests  the  early  use  of 
provisional  terms  for  recognized  groupings  of  morbid  phenomena ;  and 
sometimes  these  clinical  designations  remain  for  a  long  time  in  use  because 
of  the  imperfection  of  pathology. 

We  ascertain,  in  practice,  the  nature  of  a  given  case,  first,  by  consid- 
ering its  symptoms.  These  are  those  obvious  evidences  of  deviation  from 
health  which  the  patient  himself  is  aware  of,  or  which  the  physician 
readily  discerns  or  elicits  by  simple  inquiry  or  examination. 

Secondly,  taking  the  clue  furnished  by  symptoms,  a  closer  inspec- 
tion is  made,  with  the  intent  of  finding  what  is  the  actual  state  of  import- 
ant organs,  as  the  heart,  lungs,  liver,  spleen,  kidneys,  and  alimentary 
canal. 

Lastly,  when  these  means  fail  to  remove  all  obscurity,  or  when  special 
scientific  investigation  is  practicable,  instruments  of  precision  are  em- 
ployed, as  the  thermometer,  sphygmograph,  opthalmoscope,  sesthesi- 
ometer,  or  aspirator;  or  by  the  microscope  and  chemical  analyses  still 
more  minute  examination  is  made  into  the  particulars  of  the  morbid 
processes  present  and  their  results. 

We  may  subdivide  diagnosis,  then,  into :  1,  symptomatology ;  2, 
organoscopy  or  physical  diagnosis ;  3,  instrumental  diagnosis. 


Symptomatology. 

SEMEIOLOGY  (from  ayfiicov,  a  sign)  is  a  term  much  in  use,  with  essen- 
tially the  same  meaning  as  symptomatology,  but  less  conveniently  dis- 
tinctive, since  it  does  not  so  well  indicate  the  contrast  between  obvious 
signs,  or  symptoms,  and  those  more  recondite,  obtained  by  the  methods 
of  physical  diagnosis. 

Signs  of  disease  cannot  be  recognized  as  such  except  by  one  who  is 


MEDICAL  DIAGNOSIS.  149 

familiar  with  the  appearances,  actions,  and  manifestations  which  belong- 
to  health.  Nor  can  they  be  understood,  so  as  to  infer  what  they  mean, 
without  knowledge  of  normal  physiology  on  the  one  hand,  and,  on  the 
other,  of  the  natural  history  of  diseases.  Physiology  constitutes  the  etymo- 
logical grammar,  symptomatology  the  vocabulary,  and  diagnosis  the 
syntax  of  practical  medicine.  Just  as  grammatical  knowledge  will  not 
enable  any  one  to  read  or  speak  a  language  without  acquaintance  with 
its  words,  so  clinical  observation  is  necessary  to  the  physician  over  and 
above  all  the  knowledge  he  may  have  of  physiology  and  pathology. 
He  must  learn  to  know  diseases  by  sight,  or  at  least  by  personal  contact 
and  observation. 

Every  one  has,  of  course,  a  general  familiarity  with  the  state  and 
actions  of  his  own  and  other  bodies  in  health,  yet  a  more  exact  know- 
ledge of  the  movements  of  respiration,  circulation,  secretion,  etc.,  as  well 
as  the  form,  size,  and  relative  location  of  all  the  organs  of  the  body,  is 
needed.  Physiology  and  medical  anatomy  furnish  such  information. 
The  more  thorough  this  knowledge  is  appropiated,  the  better  fitted  the 
student  is  for  practical  diagnosis.  For  its  application,  however,  cultiva- 
tion of  all  the  perceptive  powers  is  very  important.  Some  men  have  a 
genius  for  quick  and  clear  discernment  of  symptoms  and  for  their  inter- 
pretation, as  well  as  for  that  of  physical  signs.  But  all  can  much  improve 
their  senses,  and  their  sagacity  in  using  them,  by  experience.  For  this, 
if  for  no  other  reason,  scientific  training,  in  field  or  laboratory  studies, 
affords  the  best  introduction  to  the  work  of  the  medical  student  and 
physician.  The  traits  most  needed  for  success  in  diagnosis  are  exactness 
and  comprehensiveness.  First,  to  be  sure  precisely  what  each  sign  is  that 
comes  under  observation ;  next,  to  overlook  no  existing  symptoms  or 
physical  signs;  and,  last,  so  to  combine  them  into  a  mental  map,  diagram, 
or  picture,  as  to  make  a  coherent  and  rational  whole.  This  nosogram 
may  then  be  compared  with  the  descriptions  of  standard  authorities,  to 
find  its  place  (if  it  has  one)  in  technical  classification.  First,  however, 
ascertain  the  thing,  the  morbid  state  or  combination  of  states;  afterward 
the  name,  or  morbid  species,  when  practicable.  It  is  always  to  be 
remembered  that  complication  of  diseases,  or  at  least .  the  existence  of 
some  irregular  manifestations  along  with  those  which  are  characteristic, 
is  more  common  than  the  occurrence  of  purely  typical  cases.  The  por- 
traits of  most  diseases  in  the  books  are  averages,  like  the  composite  class- 
photographs'of  Douglas  Galton.  Not  nearly  every  case  will  correspond 
with  such  an  average  in  all  respects.  Moreover,  so  great  is  the  possible 
variety  of  alterations  among  the  different  organs  of  the  body  that  the 
chances  of  two  instances  of  disease  being  precisely  alike  in  every  par- 
ticular are  hardly  greater  than  those  in  favor  of  every  move  being  the 
same  in  two  games  of  chess  with  the  same  opening. 

In  an  essay  like  the  present  it  is  not  easy  to  decide  upon  the  best 
manner  of  treating  the  subject  before  us.  Too  much  or  too  little  may 
be  said.  With  advanced  readers  the  whole  history  of  symptoms  and 
physical  signs  might  be  left  to  the  special  discussions  occurring  in  articles 
upon  different 'diseases.  But  it  may  be  taken  for  granted  that  those  who 
consult  the  present  work  will  do  so  either  at  a  comparatively  early  stage 
of  their  studies  or  when  time  has  made  desirable  a  renewal  of  what  may 
have  been  once  known  and  then  forgotten.  Since,  then,  it  is  impossible 


150     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

to  anticipate  what  may  be  the  exact  needs  of  either  class,  a  somewhat 
elementary  statement  of  main  facts  appears  justifiable  here. 

Following  the  natural  method,  we  may  suppose  a  call  to  visit  a  patient. 
Arriving  in  his  presence,  the  first  question  (mostly  left  out  of  view  and 
rarely  expressed)  may  be,  Is  it  a  case  of  real  or  only  imaginary  indispo- 
sition? Army  medical  officers,  more  than  most  others,  can  appreciate 
the  possibility  of  this  inquiry  sometimes  disposing  of  the  whole  case. 

Supposing  it  to  be  real,  is  it  an  illness  or  an  accident  or  other  injury? 
Is  it  severe  or  of  trifling  account  ?  Acute  or  chronic  ?  We  observe  the 
position  of  the  patient,  lying  quietly  in  bed,  sitting  up,  or  walking  rest- 
lessly about  the  room.  Then  the  countenance  is  observed — pale  or 
flushed,  tranquil  or  excited  in  expression.  We  feel  the  forehead,  touch 
the  cheek  and  hand.  Is  the  skin  hot  or  cold,  dry  or  moist  ?  The  pulse 
is  felt ;  the  breathing  also  is  counted. 

Of  the  patient  himself  or  of  another  (in  serious  acute  cases  better  of 
his  care-taker,  in  another  apartment)  we  ask  questions  whose  answers  give 
us  the  general  history  of  the  case.  When  not  before  known  these  should 
include  his  antecedent  personal  history,  even  extending  to  that  of  the 
family,  as  far  as  can  be  learned.  What  tendencies  have  they,  or  has  he 
or  she,  shown  by  previous  attacks  and  their  results  ? 

So  we  come  to  the  present  attack  :  When  did  it  begin,  and  how  ?  What 
have  been  its  prominent  symptoms  since?  Questions  are  then  to  be  put- 
concerning  the  heat  of  the  body,  appetite,  complaint  of  pain,  sleep,  move- 
ment of  the  bowels,  discharge  of  urine  :  in  the  female,  menstruation  ;  if 
married,  pregnancy  or  parturition,  how  often  and  when  occurring  last. 
Thus  the  practitioner  is  enabled  to  get  a  clue  to  the  diagnosis,  to  be 
followed  out  through  his  own  observation  and  closer  examination.  If 
the  patient  be  a  child  and  the  attack  be  acute  and  febrile,  an  early  question 
must  be  as  to  its  having  passed  or  not  through  the  different  diseases  of 
childhood — viz.  the  exanthemata,  mumps,  and  whooping  cough,  and  also 
what  exposure  to  any  of  these  it  may  have  been  recently  subjected  to. 

Going  farther  into  particulars,  let  us  review  some  of  the  possible 
developments  obtained  in  the  above  questioning  of  symptoms. 

When  lying  in  bed  the  decubitus  may  be  significant,  as,  upon  the  back 
with  the  knees  drawn  up  in  peritonitis ;  with  the  hands  pressing  the 
abdomen  in  colic;  tossing  to  and  fro  in  the  delirium  of  fever  or  of  early 
cerebral  inflammation ;  on  one  side  constantly  in  acute  inflammation  of 
the  liver  or  in  pleurisy.  Or  the  patient  may  be  obliged  to'  be  propped 
in  a  sitting  posture  (orthopnoea)  from  heart-disease,  asthma,  or  ascites,  or 
leaning  forward  upon  the  back  of  a  chair  or  a  pillow  with  aneurism  of 
the  aorta.  More  remarkable  still  may  be  the  subsultus  tendmum  of  low 
fever,  the  opisthotonos  of  tetanus,  the  respiratory  spasms  of  hydrophobia, 
or  the  clonic  movements  of  epileptic,  hysterical,  or  occasional  convulsions. 

In  the  face  we  see  pallor  in  syncope  and  in  anemia  in  any  of  its  vari- 
eties and  with  varied  associations ;  a  general  redness  in  some  cases  of 
apoplexy  and  in  remittent  fever;  flushing  of  the  forehead  and  eyes 
especially  in  yellow  fever ;  dusky  redness  in  typhus,  and  a  more  purple 
hue  in  typhoid  fever ;  yellowness  in  jaundice,  in  some  cases  of  remittent 
and  in  most  of  yellow  fever ;  sallowness  in  cancer ;  a  bright  central  glow 
upon  each  cheek  in  early  pneumonia  or  the  hectic  of  phthisis ;  a  bine 
or  ashen  appearance  in  the  collapse  of  cholera,  and  blackish-blue  in 


MEDICAL  DIAGNOSIS.  151 

cyanosis  or  carbonic  acid  poisoning ;  bronzed  in  Addison's  disease ;  puffy 
about  the  eyelids  in  Bright' s  disease ;  the  surface  swollen,  yet  resistant  to 
the  touch,  in  myxredema.  The  eyes  (one  or  both)  glare  prominently  in 
exophthalmic  goitre ;  squint  in  advanced  cerebro-meuiugitis ;  roll  to  and 
fro  often  in  the  prostration  of  cholera  iufantum  and  in  convulsions ;  are 
clear  and  bright  in  phthisis ;  yellowish  in  hepatic  disorder ;  dull  and 
clouded  in  low  fevers ;  without  expression  in  imbecility  and  general 
paralysis. 

Contraction  of  the  pupil  is  observed  in  inflammation  of  the  retina  or 
of  the  brain,  narcotism  from  opium  (until  near  death)  or  eserine,  or  apo- 
plectic effusion  near  the  pons  varolii.  Dilatation  of  the  pupil  is  seen  in 
most  cases  of  hydrocephalus  and  of  apoplexy ;  in  nerve-blindness  (arnau- 
rosis),  glaucoma,  cataract,  and  narcotism  from  atropia,  duboisia,  or  hydro- 
cyanic acid.  Inactivity  of  the  pupil  (Argyll  Robertson)  under  changes 
of  light  and  darkness  is  common  in  locomotor  ataxia.  Different  states 
of  the  two  pupils  under  the  same  light  show  disorder,  either  ophthalmic 
or  cerebral  in  site,  or  may  indicate  pressure  on  the  cervical  sympathetic 
ganglia,  as  from  aortic  aneurism. 

In  elderly  persons  we  ought  always  to  look  for  the  arcus  senilis,  which 
is  a  sign  of  a  tendency  to  fatty  degeneration.  It  is  a  ring,  or  part  of  a 
ring,  with  ill-defined  edges,  best  seen  by  lifting  or  depressing  an  eyelid,  at 
the  junction  of  the  cornea  and  sclerotic  coat  of  the  eye.  In  some  quite 
healthy  old  persoas  there  may  be  seen  at  the  same  junction  a  clearly- 
defined  circular  line  of  calcareous  nature.  This  must  be  distinguished 
from  the  true  fatty  arcus  senilis. 

Of  the  face  we  may  also  notice  the  pinched  nose,  hollow  eyes,  and  fell- 
ing jaw  of  the  facies  Hippocratica,  presaging  death ;  the  square  forehead 
of  the  rickety  child  (not  common  in  this  country) ;  ulcers  on  the  forehead, 
scars  at  the  mouth-corners,  or  copper-colored  eruptions  in  syphilis ;  the 
full,  flabby  lips  of  scrofula.  In  peritonitis  or  gastritis  the  mouth  is  apt 
to  be  drawn  up  with  a  peculiar  expression  of  suffering  and  nausea.  Very 
striking  is  the  characteristic  one-sided  appearance  in  facial  palsy,  from  lesion 
of  the  seventh  nerve.  There  may  be  a  smile,  a  frown,  or  other  expres- 
sion on  the  sound  side  of  the  face,  while  the  paralyzed  side  is  quite 
immovable.  As  the  seventh  nerve  (portio  dura)  supplies  the  orbicularis 
muscles,  its  paralysis  (so  often  temporary)  may  cause  inability  to  close  the 
eye  upon  the  affected  side.  Ptosis,  or  inability  to  open  the  eye,  involv- 
ing the  levator  palpebra3,  which  is  innervated  by  the  third  nerve  (motor 
oculi)  is  more  significant  of  cerebral  lesion. 

Even  the  ears  may  have  language,  as  when  their  lobes  are  full  and 
glistening  red  in  the  gouty  diathesis,  or  wrinkled  in  prolonged  cachexise, 
or  when  they  are  running  with  discharges  in  the  struma  (scrofula)  of 
childhood.  The  hair  becomes  dry  and  lustreless  in  phthisis,  and  falls 
out  during  convalescence  from  many  acute  diseases. 

If  we  look  at  the  gums  in  a  case  of  lead-poisoning,  we  may  expect  to 
find  a  blue  line  along  their  edges.  Scurvy  is  betokened  by  a  swollen, 
spongy,  and  easily-bleeding  state  of  the  gums.  Many  scorbutic  cases, 
however,  lack  this  so-called  pathognomonic  feature.  It  may  be 
remarked,,  by  the  way,  that  absolutely  pathognomouic  signs  of  particular 
diseases,  never  absent  and  exclusively  seen  in  them,  are  very  few.  Albu- 
minuria,  for  example,  is  not  always  present  in  Bright's  disease,  and  is 


152     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

also  met  with  in  a  number  of  other  affections.  Sugar  in  the  urine  may 
follow  inhalation  of  chloroform  or  an  attack  of  cholera,  as  well  as  diabetes 
mellitus.  Rice- water  discharges  may  be  absent  in  the  collapse  of  cholera, 
and  patients  may  die  with  yellow  fever  without  black  vomit.  Still,  these 
symptoms  have  great  diagnostic  value,  and,  taken  with  others  associated 
with  them,  may  often  enable  us  to  attain  to  a  diagnosis  of  much  import- 
ance. 

Perfect  teeth  in  an  adult  in  this  country  are  rather  the  exception  than 
the  rule.  In  the  notched  incisors  of  inherited  syphilis,  however,  there  is 
something  quite  distinctive.  The  notches  in  Hutchiuson's  teeth  are 
vertical,  not  horizontal. 

Old  as  medicine  is  the  examination  of  the  tongue  in  disease.  It  may 
be  protruded  with  difficulty,  as  in  low  fevers,  in  apoplexy,  and  in  cere- 
bral paralysis  (bulbar  sclerosis,  glosso-labio-pharyngeal  paralysis)  or  thrust 
to  one  (the  paralyzed)  side  in  herniplegia.  It  is  pallid  in  anaemia;  yellow 
in  bilious  disorder ;  red  in  glossitis  (then  swollen  also),  in  scarlet  fever, 
and  in  gastritis ;  furred  in  indigestion,  gastro-hepatic  catarrh,  and  the  early 
stage  of  various  febrile  attacks ;  dry,  brown,  cracked,  or  fissured  in  typhus 
or  typhoid  fevers  and  in  the  typhoid  state  of  malarial  remittent  fever ; 
bare  of  epithelium  in  advancing  phthisis  and  in  imperfect  convalescence 
from  severe  acute  diseases.  Coldness  of  the  tongue  is  one  of  the  worst 
signs  in  the  collapse  of  cholera. 

As  we  examine  the  throat  internally  we  look  for  signs  of  faucial  inflam- 
mation in  redness  and  swelling,  with  or  without  enlargement  of  the  ton- 
sils, or  relaxation  and  elongation  of  the  uvula,  or  ulceration,  or  the  gray 
or  brown  membranous  deposit  of  diphtheria.  In  the  mouth  of  a  child 
we  may  find  the  little  white  vesicular  patches  called  aphthoo,  the  curd-like 
exudations  of  thrush,  or  possibly  the  much  worse  grayish  ulcerations  of 
caucrum  oris,  or  the  rarer  ashen  sloughs  of  gangrene  of  the  mouth. 

Outside  of  the  throat  we  must  remember  the  significance  of  glandular 
swellings  or  scars  of  suppurated  glands  in  children ;  nor  overlook,  if 
present,  stiffness  of  the  muscles,  or  torticollis,  or  goitrous  enlargement  of  the 
thyroid  gland.  Observation  should  be  made  also  of  the  site  of  the  carotid 
artery  on  each  side,  and  of  the  jugular  veins,  since  aortic  regurgitatiou 
may  be  indicated  by  violent  action  of  those  arteries  or  tricuspid  regurgita- 
tion  by  pulsation  of  the  veins  in  the  neck. 

Long  before  vaso-niotor  physiology  had  any  place  in  science  the  pulse 
was  known  to  afford  valuable  indications  in  disease.  Either  of  the  acces- 
sible arteries  will  answer  instead  of  the  radial ;  its  convenience  merely 
makes  the  wrist  the  common  place  of  comparison.  By  careful  examina- 
tion of  the  pulse  something  may  be  learned  of  several  of  the  factors  con- 
cerned in  its  production.  These  factors  are — 1,  the  muscular  force  of  the 
walls  of  the  heart ;  2,  the  state  of  the  cardiac  valves ;  3,  the  muscularity 
of  the  arteries ;  4,  the  elasticity  of  the  arterial  coats ;  5,  the  state  of  the 
capillary  circulation ;  6,  the  qualities  of  the  blood ;  7,  the  condition  of 
the  nervous  system  as  to  excitability  or  apathy. 

A  feeble  heart  must  induce  a  feeble  pulse.  Moderate  debility  may  be 
attended  by  slowness  of  the  pulse,  but  usually  a  weak  circulation  is 
marked  by  frequent,  small  beats,  like  the  vibrations  of  a  short  pendulum. 
A  strong  heart-beat  (other  things  being  equal)  is  relatively  slow,  with  a 
proportionate  pause  after  the  second  sound. 


MEDICAL  DIAGNOSIS.  153 

Valvular  lesions  produce  various  effects  upon  the  pulse.  Most  notable 
are  the  irregularity  connected  often  with  mitral  insufficiency  and  the  jerk- 
ing pulse  (Corrigan)  of  aortic  regurgitation. 

Believing,  as  the  present  writer  does,  in  the  existence  of  a  true  arterial 
systole  following  and  supplementing  the  ventricular  contraction,1  it  must 
be  urged  that  a  vigorous  muscularity  in  the  arteries  promotes  strength  in 
the  pulse — not  by  resistance,  but  by  auxiliary  propulsion  of  the  blood. 
Another  condition  altogether  is  tonic,  spasmodic  contraction  of  the  arteries. 
This  is  not  often  met  with  pure  and  simple,  but  a  measure  of  it  is  seen  in 
the  corded  or  wiry  pulse  of  acute  enteritis  or  peritonitis. 

Deficient  elasticity  of  the  arteries  is  not  easily  separated  in  observation 
from  muscular  relaxation.  When  arteries  undergo  degeneration  (ather- 
omatous,  fatty,  or  calcareous),  their  middle  coat  suffers  the  deterioration 
of  both  elastic  and  muscular  tissues,  these  being  substituted  by  materials 
either  more  or  less  yielding,  and  always  less  resilient,  than  the  natural 
fabric  of  the  vessels. 

The  influence  of  the  condition  of  the  capillary  circulation  upon  that  of 
the  arterial  system  and  the  heart  is  manifest  in  inflammations.  By  reflex 
excitation  the  arteries  are  made  to  contract  actively  and  impel  the  blood 
more  forcibly  than  in  the  normal  state  toward  the  centre  of  impeded 
nutrition  (stasis).  This  has  been  abundantly  proved  by  the  comparison 
of  the  amount  of  blood  flowing  through  the  arteries  of  a  sound  limb  and 
those  of  its  fellow,  when  the  latter  is  the  seat  of  a  violent  acute  inflam- 
mation. 

Blood-states  also  affect  the  pulse  by  the  differences  in  direct  stimulation 
to  which  the  heart  and  arteries  are  subjected  according  to  the  qualities  and 
composition  of  the  blood.  It  is  probable  that  the  fover-pulse  of  typhus, 
typhoid,  the  exanthemata,  septicaemia,  and  pyaemia  has  its  origin  in  mor- 
bid conditions  of  the  blood,  acting  in  a  twofold  manner — directly  upon 
the  heart  and  arteries  themselves,  and  mediately  through  the  vaso-motor 
ganglia. 

Lastly,  the  nervous  system  stands  in  an  important  relation  to  the  action 
of  the  heart  and  arteries,  and  thus  to  the  pulse.  In  a  nervous,  excit- 
able person,  changes  in  the  rate  of  the  pulse  may  take  place,  with  slight 
significance,  which  in  a  different  constitution  might  be  of  serious  import. 

To  understand  the  language  of  the  pulse  care  must  be  taken  in  several 
respects : 

1.  Both  wrists  should  be  felt.     Sometimes  there  is  an  abnormal  varia- 
tion in  the  course  of  the  main  radial  trunk  which  may  pass  over  the 
thumb.     Again,  an  aneurism  may  cause  a  great  difference  between  the 
two  radial  pulses,  or,  possibly,  an  embolus  may  occlude  one  of  the  radial 
vessels,  annulling  its  pulsation.  . 

2.  Other  arteries  also,  especially  the  carotids,  should  be  examined — 
in  all  obscure  cases  at  least.    Visibly  beating,  distended,  and  tortuous  tem- 
poral arteries  are  occasionally  met  with.     They  are  not  pathognomonic  of 
any  one  malady,  although  often  referred  to  the  gouty  diathesis.     They 

1  This  view,  although  advocated  by  Sir  Charles  Bell,  Legros  and  Onimus,  Hermann  of 
Zurich,  and  others,  is  opposed  to  the  most  prevailing  vaso-motor  physiology.  Several 


complications  and  some  contradictions  in  pathological  discussion  at  the  present  time 
would  be  cleared  up  by  the  abandonment  of  the  now  commonly-held  stopcock  theory  of 
arterial  function,  which  has  really  nothing  whatever  to  support  it  except  the  misinterpre 


154     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

may  attend  irregular  malarial  attacks,  or  may  be  connected  simply  with  a 
hypersemic  state  of  the  brain. 

3.  The  heart's  impulse  should  always  be  compared  with  the  arterial 
pulsation.  The  former  may  be  strong  and  regular,  while  the  latter  L« 
small,  feeble,  or  intermittent.  Something  must  then  be  wrong,  either  in 
the  aortic  valves  or  in  the  arterial  system. 

5.  On  account  of  possible  nervous  agitation,  the  pulse  should  usually 
be  examined  more  than  once,  during  each  visit  to  the  patient. 

6.  Sex,  age,  position  of  the  body,  and  time  of  day  must  all  be  taken 
account  of.     In  men  the  average  rate  of  the  pulse  is  between  65  and  75 
per  minute;  in  women,  between  70  and  80.     The  pulse-rate  of  early 
infancy  varies  from  100  to  120,  and  is  very  easily  hurried.     That  of  old 
persons  is  commonly  between  60  and  70,  until,  at  a  very  advanced  age, 
with  debility,  its  frequency  may  be  increased,  especially  upon  exertion. 
Lying  down,  we  find  the  slowest  pulse  ;  sitting,  somewhat  more  rapid ; 
and  most  so  in  the  standing  position.     In  health  the  time  of  day  makes 
no  constant  difference  apart  from  the  effects  of  food  and  exercise.     In 
disorders   attended   by  fever  there  are   important  changes   to   be   reg- 
ularly observed.     Excepting  the  variable  paroxysms  of  remittent  and 
intermittent,  which  are  a  law  unto  themselves,  in  febrile  affections  the 
pulse  may  be  expected  to  be  slowest  in  the  morning  and  most  excited  in 
the  early  part  of  the  night.     A  diminution  of  this  difference  is  a  favor- 
able sign.     Sleep  generally  slows  the  pulse  decidedly.     The  ordinary 
statement  is,  that  the  pulse  is  always  slower  during  sleep,  but  I  have 
several  times  found  that  in  states  of  exhaustion  without  fever  it  may  be 
considerably  more  rapid  while  the  patient  is  asleep.     Nothing  is  more 
sure  to  increase  the  strength  and  rapidity  of  the  pulse  than  high  temper- 
ature. 

7.  Very  important  is  the  relation  between  the  pulse  and  respiration. 
Normally,  four  pulsations  occur  to  each  respiratory  act.     In  pulmonary 
affections,   while  the  circulation  is  often  disturbed  pari  passu  with  the 
breathing,  it  may  be  quite  otherwise.     Great  acceleration  of  the  rate  of 
breathing,  with  little  increase  in  the  rapidity  of  the  pulse,  should  lead  us 
to  suspect  disease  involving  the  respiratory  organs.     Conversely,  a  much 
hurried  or  otherwise  perturbed  pulse,  with  little  or  no  change  in  the 
breathing,  points  toward  the  heart  as  either  functionally  or  organically 
the  seat  of  disorder. 

'  Let  us  further  consider,  briefly,  the  kinds  of  pulse  to  be  met  with  and 
interpreted  in  practice. 

A  natural  pulse  is  always,  per  se,  a  good  sign.  Yet  in  the  history  of 
a  disease  usually  so  well  marked  as  yellow  fever  some  fatal  cases  have 
been  recorded  (walking  cases)  in  which  the  pulse,  almost  to  the  last, 
was  natural. 

Strength  of  the  pulse,  to  a  certain  degree,  belongs  to  it  normally.  But 
this  is  often  exaggerated,  and  we  may  have  the  strong,  hard,  full,  per- 
haps bounding,  pulse  of  an  inflammatory  affection  (of  the  brain,  for  ex- 
ample, or  of  the  joints  in  acute  rheumatism)  in  a  person  of  vigor.  A 
bounding  pulse  often  accompanies  mere  palpitation  of  the  heart,  whose 
source  may  be  the  sympathetic  influence  of  indigestion  or  nervousness. 
A  similar  pulse  is  apt  to  be  constantly  present  in  hypertrophy  of  the 
heart.  In  this  case  it  is  made  more  forcible  as  well  as  more  rapid  by 


MEDICAL  DIAGNOSIS.  155 

active   exertion;  while  palpitation,    without  organic  trouble,   is  usually 
diminished  by  moderately  active  exercise. 

A  full  pulse  is  not  always  strong,  nor  is  a  small  pulse  necessarily  weak. 
Mention  has  been  made  already  of  the  tense,  corded  pulse  met  with  in 
acute  peritonitis,  and  sometimes  in  enteritis.  Gastric  inflammation,  with 
nausea,  may  exhibit  a  depressed  pulse,  weak  and  but  little  accelerated. 
Under  still  other  circumstances  we  may  find  a  full  pulse  which  is  soft, 
easily  compressible,  even  gaseous.  Most  frequently  a  feeble  pulse  is 
rapid,  and  a  very  rapid  pulse  is  weak.  Slowness,  in  marked  degree, 
attends  apoplexy,  opium  narcotism,  and  fracture  of  the  skull  com- 
pressing the  brain.  Functional  disturbance  of  the  heart  may  occasion- 
ally exceed  in  effect  these  causes  of  retardation.  I  have  met,  under  such 
circumstances,  with  a  pulse  of  20  in  the  minute;  one  of  18  has  been 
recorded.  A  few  apparently  healthy  persons  have  habitually  a  pulse 
with  but  40  or  50  beats  in  the  minute. 

Quickness  in  each  beat  may  occur,  while  a  long  interval  makes  the  rate 
per  minute  slow.  The  jerking  pulse  of  aortic  regurgitation  is  the  most 
remarkable  example  of  this.  Galabin  asserts  that  without  imperfection 
of  the  valves  of  the  aorta  a  decidedly  abrupt  pulse  may  attend  great 
lowering  of  arterial  tension.  Something  of  the  same  kind  may  be  noticed 
in  the  temporarily  excited  pulse  of  very  nervous  subjects  under  agitation. 

Dicrotism,  or  reduplication  of  the  pulse-beat,  is  not  uncommon  in 
typhus  and  typhoid  fever.  Here  relaxation  of  the  heart  as  well  as  of 
the  blood-vessels  appears  to  allow  a  momentary  interruption  in  the  suc- 
cession of  the  arterial  upon  the  cardiac  systole.1 

Intermittence  and  irregularity  of  the  pulse  are  not  exactly  the  same 
thing.  Occasional  intermittence  may  be  merely  a  nervous  symptom  or  a 
muscular  twitch  of  the  heart,  like  the  twitches  now  and  then  occurring 
without  significance  in  voluntary  muscles.  Persistent  intermittence,  with 
feebleness  of  the  pulsations  (these  being  generally  somewhat  rapid),  is 
among  the  signs  of  dilatation  of  the  heart. 

It  is  possible  for  intermittence  of  the  radial  pulse  to  accompany  regu- 
larity in  the  heart-beat.  This  usually  results  from  narrowing  (stenosis) 
of  the  aortic  valvular  outlet  from  the  left  ventricle.  Only  a  certain 
number  of  impulses  fairly  reach  the  more  distant  arteries.  This  symptom 
may  result  also  from  fatty  degeneration  of  the  heart. 

Absence  of  pulse  in  one  radial  vessel,  while  it  is  present  in  the  other, 
shows  the  presence  of  an  obstacle  to  the  circulation  on  one  side,  which 
may  be  an  aneurism,  or  an  embolus  plugging  the  artery. 

Irregularity  of  the  pulse,  a  total  derangement  of  its  rhythm,  while  not 
often  important  in  young  children,  is  a  serious  symptom  at  other  times  of 
life.  In  one  disease  most  common  in  childhood,  acute  hydrocephalus, 
the  pulse  in  the  first  stage  is  apt  to  be  hard  and  rapid,  in  the  middle 
stage  slow  and  tolerably  full,  in  the  third  rapid,  feeble,  and  often  irreg- 
ular. Mitral  disease  frequently  presents  considerable  irregularity  of  the 
pulse ;  and  so  does  dilatation,  even  without  mitral  lesion.  Brain  trouble, 
especially  late  in  life,  whether  structural  or  functional,  may  produce  the 

1  An  exceptional  phenomenon,  noticed  by  a  few  observers,  is  the  recurrent  pulse ; 
t.  e.  a  pulsation  felt  below  the  finger,  whose  pressure  interrupts  the  flow  of  blood  through 
an  artery.  It  may  be  explained  by  supposing  unusual  fulness  of  the  vessels  (local,  if 
not  general)  with,  at  the  same  time,  relnxation  of  their  walls;  bearing  in  mind,  also,  the 
manner  of  anastomosis  of  the  radial  and  ulnar  branches  which  favors  recurrence. 


156     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

same  symptom.  B.  \V.  Richardson  lias  pointed  this  out  as  one  of  the 
effects  of  the  excessive  use  of  tobacco,  even  in  young  persons. 

The  pulse  of  continued,  relapsing,  and  remittent  fevers  is,  during  the 
febrile  exacerbation,  rapid  (100  to  120) ;  in  the  earlier  part  of  the  attack 
full,  but  only  moderately  hard,  or  even  soft  and  yielding.  As  the  attack 
passes  its  height  and  critical  defervescence  occurs,  the  pulse  grows  slower, 
unless  great  prostration  has  supervened ;  in  which  case  it  increases  in 
rapidity,  while  it  fails  more  and  more  in  fulness  and  resistance. 

The  pulse  of  the  moribund  state  is  nearly  always  small,  very  rapid 
(130-150),  and  thready,  without  force  or  fulness.  It  may  become  imper- 
ceptible before  death.  A  pulse  of  140  beats  in  the  minute  is  alwrays 
alarming;  if  much  beyond  that  rate  the  case  is  desperate.  A  pulse 
of  more  than  150  beats  in  the  minute  is  very  difficult  to  count  accu- 
rately. 

Exophthalmic  goitre  is  attended  characteristically  by  a  full,  somewhat 
rapid,  and  bounding  pulse,  the  cardiac  impulse  being  also  proportionately 
violent  and  extended.  Exercise  much  increases  this  hyper-pulsation. 

Pulsation  of  the  jugular  veins  is  ordinarily  explained  by  tricuspid  regur- 
gitation,  a  portion  of  the  blood  .being  sent  back  to  the  vena  cava  with  an 
impulse  reaching  to  the  jugulars.  In  some  instances,  however,  as  the 
writer  has  repeatedly  observed,  jugular  pulsation  takes  place  without  any 
abnormality  in  the  action  or  condition  of  the  heart,  from  a  local  inflam- 
mation (as  tonsillitis)  causing  a  marked  exaggeration  of  the  muscular  con- 
tractility resident  in  the  larger  veins. 

Retardation  of  the  flow  of  blood  through  the  veins  is  manifest  during  the 
collapse  of  epidemic  cholera.  On  pressing  the  blood  back  in  a  vein  upon 
the  hand,  for  example,  and  then  lifting  the  finger,  instead  of  the  move- 
ment being,  as  in  health,  too  swift  to  be  seen,  it  is  so  slow  as  to  be  easily 
followed. 

Capillary  movement  may  be  estimated  in  a  similar  manner.  If  it  be 
very  sluggish,  pressure  upon  the  cheek,  forehead,  or  hand  will  cause  a 
pallor  which  remains  for  some  seconds,  instead  of  disappearing  at  once 
when  the  pressure  is  withdrawn.  This  is,  it  may  be  noticed,  entirely 
different  from  the  pitting  upon  pressure,  without  much  if  any  change  of 
color,  in  local  oedema  or  general  anasarcous  effusion.  The  tache  m6ningi- 
tique  of  Trousseau  is  a  pink  or  rose-red  line  left  for  a  time  after  draw- 
ing the  finger  across  the  forehead  or  abdomen  in  cases  of  acute  hydro- 
cephalus  (tubercular  meningitis). 

Respiration  must  be  watched  carefully  in  all  cases  of  disease.  Nor- 
mally, in  the  adult,  while  at  rest,  from  16  to  18  respiratory  movements 
occur  in  each  minute.  The  number  is  somewhat  greater  in  women,  and 
is  considerably  increased  in  children,  at  birth  being  about  40  in  the 
minute.  Men  breathe  most  by  the  diaphragm  ;  in  women  there  is  a 
greater  lifting  of  the  ribs.  In  either  sex  a  disorder  attended  by  pain  in 
breathing  may  modify  this  proportion.  If  pleurisy,  for  example,  be 
present,  the  ribs  will  be  but  slightly  lifted,  abdominal  breathing  taking 
predominance.  When  peritonitis  makes  every  movement  of  the  abdomen 
painful,  costal  respiration  is  maintained  almost  alone.  Likewise,  a  uni- 
lateral pleurisy  or  pneumonia  will  check  the  respiration  on  the  affected 
side,  with  an  increased  movement  on  the  sound  side.  This  difference  is 
less  manifest  to  the  eye  than  to  the  ear  in  auscultation.  In  all  febrile 


MEDICAL  DIAGNOSIS.  157 

affections  respiration   is  hurried  proportionately  with  the  pulse,  unless 
some  complicating  local  disorder  disturbs  the  relation. 

Dyspnoea  may  be  produced  by  many  different  causes,  whose  possibility 
must  be  remembered  in  its  interpretation  as  a  means  of  diagnosis.  In 
asthma  violent  efforts  are  made  to  compel  the  entrance  of  air  into  the 
lungs  by  the  intercostal  muscles  and  diaphragm,  aided  by  all  the  accessory 
muscles  of  respiration,  including  the  steruo-cleido-mastoid  and  others  of 
the  neck.  Expansion  of  the  nostrils  may  occur  in  sympathy  with  these 
efforts.  Yet  the  amount  of  resistance  may  be  shown  by  a  partial  sink- 
ing-in  of  the  lower  ribs,  as  well  as  by  the  patient's  distress.  These  last 
signs  are  sometimes  very  marked  in  the  collapse  of  one  or  both  lungs  now 
and  then  occurring  in  whooping  cough. 

Croup  induces  a  similar  struggle  for  breath,  although  the  obstruction 
is  differently  located.  Early  in  the  croupal  attack  a  hoarse  sound  may 
accompany  each  inspiration  and  expiration.  Later,  when  the  danger  to 
life  from  apnoea  becomes  more  imminent,  a  hissing  or  whistling  sound 
succeeds.  This  last-mentioned  kind  of  sound  results  temporarily,  also, 
from  the  spasmodic  obstruction  to  breathing  in  laryngismus  stridulus. 

Besides  the  affections  of  the  lungs  Avhich  impede  respiration  (as  pneu- 
monia, hydrothorax,  etc.),  we  may  have  dyspnoea  induced  by  extra-pul- 
monary causes,  such  as  dilatation  of  the  heart,  aneurism  of  the  aorta, 
mediastinal  cancer,  pleuritic  effusion ;  also  by  abdominal  dropsy,  extreme 
elephantiasis,  etc.  Mention  need  hardly  be  made  here  of  respiratory 
obstruction  from  defective  or  injurious  qualities  of  the  air,  threatening 
or  producing  asphyxia. 

Sighing  respiration  takes  place  in  heart  disease  not  infrequently.  A 
peculiar  modification  of  the  breathing  movements  has  been  associated 
especially  with  fatty  degeneration  of  the  heart.  From  the  distinguished 
authors  who  first  described  it  this  is  called  the  Cheyne-Stokes  respiration. 
Intervals  of  suspension  of  breathing  occur,  after  which  short,  shallow 
inspirations  begin,  and  gradually  increase  for  a  time  in  depth  ;  then  they 
grow  shorter  and  shallower  again,  until  apnoea  is  reached.  Such  a  cycle 
may  occupy  from  half  a  minute  to  a  minute  and  a  half,  with  from  fifteen 
to  thirty  increasing  and  decreasing  respirations  in  all.  It  "has  been  shown 
by  several  observers  that  this  type  of  respiration  is  not  peculiar  to  fatty 
degeneration  of  the  heart.  It  has  been  met  with  in  cases  of  cardiac  dila- 
tation, aortic  atheroma,  cerebral  hemorrhage,  tubercular  meningitis,  and 
urremia. 

Sometimes  a  kind  of  dyspnoea  common  in  advanced  disease  of  the 
heart,  especially  in  mitral  lesion  with  dilatation,  has  been  confounded  with 
this.  Here  the  breathing  is  constantly  labored  (orthopncea) ;  but  the 
patient  from  time  to  time  dozes  off  into  an  imperfect  sleep,  in  which  the 
breathing  almost  entirely  ceases.  Then  he  is  awakened  with  a  start  of 
distress,  perhaps  out  of  a  painful  dream.  This  succession  of  dozing 
apnoea  and  waking  dyspnoea  belongs  to  a  late  stage  of  heart  disease,  and 
usually  ends  in  death. 

Stertorous  respiration  is  familiar  in  apoplectic  coma,  as  well  as  in  that 
of  brain  compression  from  injury  or  from  opium  or  alcoholic  narcotism. 
In  ursemic  coma  true  stertor  is  less  apt  to  be  observed ;  sometimes  the 
respiration  in  this  condition  has  a  hissing  sound. 

Along  with  the  movements  of  respiration  we  may  notice  that  the  breath 


158     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

is  hot  and  has  a  heavy  odor  in  the  early  stages  of  all  febrile  disorders. 
Disagreeable  breath  is  common,  however,  in  persons  not  ill,  from  bad 
teeth  or  from  indigestion.  It  is  worst  of  all,  putrid,  in  gangrene  of  the 
lung.  Certain  cases  of  chronic  or  subacute  bronchitis  (as  well  as  of 
ozfena)  also  have  very  offensive  breath.  Coldness  of  the  breath  is  a  very 
bad  sign ;  it  is  observed  sometimes  before  death  in  the  collapse  of  cholera. 

Hiccough  (singultus)  is  a  spasmodic  affection  of  the  diaphragm.  It  is 
innocent,  though  annoying,  in  most  cases,  resulting  from  indigestion  or 
from  nervous  disorder;  in  children,  occasionally,  from  long  crying. 
When  it  takes  place  in  cases  of  general  prostration  it  betokens  threaten- 
ing depression  or  exhaustion  of  vital  energy. 

The  voice  is  mostly  altered  by  serious  disease.  It  may  be  feeble  and 
whispering,  from  debility;  hoarse,  from  laryngeal  inflammation  and 
tumefaction;  thick,  from  cerebral* oppression ;  lost  (aphonia),  in  some  cases 
of  chronic  laryngitis  and  in  paralysis  of  the  vocal  muscles.  The  manner 
of  articulating  wyords  is  often  changed  in  disorders  of  the  nervous  system. 
A  marked  example  of  this  is  the  monotonous  scanning  speech  of  cerebro- 
spinal  sclerosis. 

Cough  is  an  extremely  variable  symptom,  always  to  be  understood  in 
connection  with  the  attendant  circumstances.  Usually,  however,  the 
character  of  the  cough  itself  is  more  or  less  distinctive.  A  dry,  hard 
cough  may  be  merely  sympathetic  or  nervous,  or  it  may  belong  to  the 
first  stage  of  acute  bronchitis.  A  hacking  cough,  with  little  expectora- 
tion, is  not  infrequently  observed  for  a  time  in  incipient  phthisis.  Pneu- 
monia has,  if  any,  a  short  and  rather  sharp  cough.  Progressing  bron- 
chitis is  recognized  by  the  deepening  and  greater  or  less  loosening  of 
the  cough.  In  advanced  phthisis  there  are  distressing  spells  of  deep, 
laborious  coughing,  especially  in  the  night  or  in  the  morning  after  sleep. 
Croup  is  known  (whether  sporadic  or  in  the  form  of  laryngeal  diphtheria) 
by  the  barking  cough  of  the  early  stage  and  its  whistling  character  toward 
the  fatal  end.  Nearly  the  same  sort  of  hissing  or  whistling  sound  in 
breathing  has  been  mentioned  already  as  occurring  in  laryngismus  stridulus. 
Paroxysms  of  coughing,  with  or  without  whooping,  are  pathognomonic 
of  pertussis. 

Expectoration  often  affords  important  signs.  Briefly,  it  may  suffice  to 
say  here  that  it  is  mucous,  whitish,  or  colorless  in  early  bronchitis ;  more 
or  less  yeltewish  and  muco-purulent  in  severe  and  protracted  bronchitis ; 
rusty,  from  admingliug  of  the  coloring  matter  of  blood,  in  pneumonia, 
early  and  middle  stages;  bloody  and  muco-purulent  in  early  and  of  heavy 
roundish  (nummular)  masses  in  late  pulmonary  phthisis ;  putrid,  rotten, 
in  gangrene  of  the  lung. 

Continuing  our  survey  of  obvious  symptoms,  we  must  now  take  account 
of  the  conditions  of  the  general  surface  of  the  body.  Temperature  is  of 
great  consequence.  Most  precisely  determinable  by  the  thermometer,  the 
touch,  when  educated,  will  give  very  useful  indications  of  its  changes. 
It  is  difficult,  and  not  commonly  desirable,  to  separate  variations  of 
moisture  from  those  of  temperature.  Reserving  for  another  place  the 
special  consideration  of  medical  thermometry,  it  may  be  here  said  that 
the  skin  is  hot  and  dry  in  the  typical  condition  of  fever,  whatever  its 
special  associations.  Heat  and  moisture  of  the  skin  are  more  often  met 
with  together  in  the  fever  of  acute  articular  rheumatism  than  in  any  other 


MEDICAL  DIAGNOSIS.  159 

affection.  As  a  rule,  perspiration  lessens  febrile  heat.  Copious  (colliqua- 
tive)  sweating  is  habitual  in  many  wasting  diseases,  notable  in  pulmonary 
phthisis.  It  is  then  a  sign  of  great  general  relaxation  of  the  system. 

Coldness  of  the  surface  attends  prostration,  either  from  temporary  col- 
lapse or  from  positive  exhaustion.  The  skin  is  perceptibly  cold  in  the 
algid  stage  of  cholera.  It  may  be  so  in  very  severe  cases  of  sporadic 
cholera  morbus.  In  the  chill  of  intermittent,  while  the  patient  has  the 
subjective  sensation  of  coldness,  his  temperature  is  seldom  reduced,  and  is 
often  higher  than  natural,  although  lower  than  during  the  febrile  exacer- 
bation. 

The  color  of  the  skin  is  pallid  in  anaemia,  phthisis,  dropsy,  etc.,  and  in 
syncope ;  ashen  or  livid  in  cholera  collapse  and  in  the  cold  stage  of  per- 
nicious malarial  fever ;  yellow  in  jaundice,  remittent,  and  yellow  fever ; 
sallow  in  chlorosis,  cancer,  and  chronic  dyspepsia ;  purple,  almost  black 
(especially  the  lips  and  ends  of  the  fingers),  in  asphyxia ;  dark,  as  if 
stained  with  ink,  after  long  use  of  nitrate  of  silver;  bronzed  in  Addison's 
disease ;  bright  red  in  scarlet  fever,  etc.  The  eruptions  of  this  and  other 
exanthemata,  and  of  the  different  cutaneous  diseases,  will  be  best  con- 
sidered in  the  special  articles  treating  them  of  in  this  work. 

Odor  is  perceptible  and  peculiar  (though  not  easily  described)  in  some 
bad  cases  of  typhus  fever  and  of  small-pox ;  less  often  in  aggravated 
chlorosis.  Lunatics  and  paralytics  (especially  when  assembled  together 
in  institutions)  often  give  off  a  noticeable  smell.  Most  distinct,  however, 
is  the  cadaverous  odor,  sometimes  perceptible  for  hours  before  death. 
Corroborative  of  this,  in  summer,  is  the  flocking  of  flies  around  the  bed 
of  a  dying  patient.  In  a  hospital  ward  this  selection  amongst  a  number 
of  patients  may  be  quite  observable. 

Emphysema,  from  the  presence  of  air  in  the  connective  tissue  under  the 
skin,  is  rarely  met  with  except  as  the  consequence  of  an  injury  or  of  local 
gangrene. 

(Edema  is  local  watery  effusion,  which  may  have  various  causes  and 
significance.  Anasarca  must  have  a  general  causation,  either  connected 
with  the  state  of  the  blood  or  with  disorder  of  the  heart,  kidneys,  or  liver, 
or  of  more  than  one  of  those  organs  at  once.  Pitting  on  pressure  is  the 
sign  of  watery  effusion.  Soft  crackling  under  the  touch  distinguishes 
emphysema.  A  firm  enlargement  of  the  surface  of  the  face  and  upper 
part  of  the  body  occurs  in  myxoedema. 

Swellings  of  all  kind  must  be  carefully  observed,  and  their  nature  in- 
quired into — whether  they  be  inflammatory  or  other  chronic  enlargements 
of  joints,  tumors,  fibrous,  fatty,  or  cancerous,  aneurisms,  hernial  protru- 
sions, or  of  any  other  character.  In  protracted  disease  of  the  liver  (cir- 
rhosis) it  is  not  uncommon  to  find  the  superficial  abdominal  veins  dilated 
and  tortuous. 

Abdominal  enlargement  may  result  from  adipose  accumulation  (obesity), 
distension  of  the  bowels  with  wind  (meteorism),  ascites,  ovarian  cysts, 
cancerous  or  other  tumors,  aneurism  of  the  aorta,  abscess,  retention  of 
urine,  or  pregnancy.  By  the  methods  of  physical  diagnosis,  along  with 
careful  inquiry  into  the  history  of  each  case,  we  are  to  make  out  the  dis- 
tinctions amongst  these  different  conditions. 

Emaciation  always  marks  either  defect  of  nutrition  or  morbid  excess 
of  tissue-waste.  It  is  counterfeited  in  the  sudden  collapse  of  malignant, 


160     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

cholera,  and  exaggerated  in  appearance  during  the  analogous  condition  of 
cholera  infantum.  On  recovery  from  these  states,  especially  the  latter, 
roundness  and  fulness  of  the  face  and  limbs  may  return  much  too  soon 
for  the  actual  restoration  of  fat  and  flesh.  A  young  child  may  be  plump 
and  chubby  to-day,  seemingly  wasted  with  acute  illness  to-morrow,  and, 
if  soon  relieved,  the  next  day  almost  as  rotund  as  ever. 

Continued  diarrhoea,  phthisis  pulmonalis,  mesenteric  disease,  cancer, 
and  aneurism  of  the  aorta  are  among  the  most  frequent  causes  of  great 
emaciation.  Sometimes,  as  in  progressive  pernicious  anaemia,  we  are  struck 
with  the  comparatively  slight  degree  of  wasting  of  the  body  while  the 
disease  is  advancing  toward  death. 

In  myxoedema  there  is  a  swelling  or  general  enlargement,  especially  of 
the  upper  portions  of  the  trunk.  This  is  not  anasarcous,  but  depends 
upon  a  morbid  change  in  the  connective  tissue  throughout  the  body. 

Articular  enlargements  may  be  (particularly  in  the  knee  in  children) 
scrofulous,  or  gouty  (in  the  smaller  joints),  rheumatic,  with  evidences  of 
inflammation,  acute  or  chronic ;  or,  what  is  not  well  named,  rheumatoid 
arthritis.  In  this  last  aifection  there  is  a  gradual  swelling  and  stiffening, 
with  but  little  inflammation,  of  several,  sometimes  all,  the  joints  of  the 
extremities.  Locomotor  ataxia  is  in  some  cases  attended  by  a  degenera- 
tive alteration  in  one  or  more  of  the  larger  joints. 

The  limbs  may  furnish  to  the  eye  many  expressive  signs  of  disease  or 
disability.  In  the  listlessness  of  one  arm  and  hand,  while  the  other  can 
perform  various  movements,  we  see  reason  to  suspect  hemiplegia.  If 
the  fingers  are  rigidly  contracted,  as  well  as  powerless,  we  have  this 
diagnosis  confirmed,  whether  the  rigidity  be  early  or  late  in  its  stage. 
We  must  then  look  for  a  similar  condition  of  the  lower  extremity  on  the 
.same  side.  Paraplegia  and  general  paralysis  have  their  more  extended 
(bilateral)  indications  in  like  manner.  Characteristic  also  are  the  wrist- 
drop,  from  paralysis  of  the  extensors  of  the  hand,  in  lead-palsy ;  weak- 
ness or  incapacity  of  the  flexors  and  extensors  in  writer's  cramp ;  the 
hand  fixed  helplessly  in  the  position  for  writing  in  paralysis  agitans 
(advanced  stage) ;  the  main  en  griife,  with  shrunken  muscles  and  drawn 
tendons,  of  progressive  muscular  atrophy  (wasting  palsy).  In  the  legs  at 
first  and  chiefly,  but  in  time  also  in  the  arms,  increase  of  bulk  M-ith  loss 
of  power  in  the  muscles  shows  the  existence  of  pseudo-hypertrophic  mus- 
cular paralysis. 

Gouty  fingers  have  their  joints  not  only  swollen,  but  distorted  by 
deposits  of  urates  and  carbonates.  Clubbed  finger-ends,  in  the  adult, 
are  seen  mostly,  with  incurvation  of  the  nails,  in  advancing  consumption. 
The  nails  are  sometimes  striated  after  attacks  of  gout,  the  lines  disappear- 
ing gradually  during  the  interval.  In  many  acute  diseases,  transverse 
ridges  are  noticeable  on  the  nails,  marking  the  date  when  their  growth 
was  arrested  and  subsequently  resumed.  'These  are  specially  remarkable 
after  attacks  of  relapsing  fever. 

A  tendency  to  dropsical  effusion  is  generally  first  shown,  besides  a 
puffiness  of  the  face,  in  the  feet  and  ankles,  the  shoe  or  slipper  marking 
off  the  enlargement  above  its  margin.  Often  this  has  no  other  cause 
than  debility,  with  a  watery  condition  of  the  blood.  Varicose  veins, 
with  old  and  resultant  ulcers,  are  also  among  the  possible  things  to  be 
found  in  examination  of  the  legs  and  feet. 


MEDICAL  DIAGNOSIS.  161 

Movements  of  the  hands  are  incessant  and  jerking  in  chorea;  perpetually 
trembling  in  delirium  tremens,  and  often  in  one  arm  and  hand  only,  in 
paralysis  agitans ;  with  tremor,  seen  in  voluntary  motions  alone,  in  mul- 
tiple cerebro-spinal  sclerosis.  More  unusual  is  the  rhythmical  closing 
and  opening  of  the  hand,  successively,  of  athetosis. 

In  the  walk  of  patients  able  to  be  upon  their  feet  there  may  be  much 
significance.  A  hemiplegic  subject  will  circumduct  the  feeble  limb  after 
the  other ;  one  suffering  with  paraplegia  will  shuffle  the  feet  slowly  along 
the  floor ;  the  hysterical  paralytic  drags  the  lame  limb  behind  the  other ; 
the  patient  with  spastic  spinal  paralysis  rises  on  his  toes  in  walking, 
with  his  legs  held  close  together ;  the  shaking  paralytic  rather  trots  for- 
ward, with  the  body  bent ;  and  the  subject  of  locomotor  ataxia  lifts  his 
feet  and  kicks  out  forward  or  sideways,  then  bringing  down  the  heels 
with  a  stamp  at  each  step.  In  progressive  muscular  atrophy  and  advanced 
pseudo-hypertrophic  muscular  paralysis  a  waddling  or  rolling  gait  is  seen. 
Choreic  patients  are  very  irregular  in  their  walk,  as  in  all  other  move- 
ments. Hip  disease  (coxalgia)  shows  itself  in  a  child  by  its  lifting  the 
pelvis  and  limb  of  the  affected  side  and  bending  the  knee,  so  as  to  touch 
only  the  toes  to  the  ground.  Club-foot  and  other  deformities  require  no 
description  in  this  place. 

Sensibility  of  the  extremities  and  of  other  parts  of  the  surface  of  the 
body  needs  to  be  examined  into,  with  all  its  possible  variations  (hyper- 
sesthesia,  anaesthesia,  analgesiae,  etc.),  especially  when  the  nervous  appa- 
ratus is  for  any  reason  supposed  to  be  involved.  Motions  of  an  unusual 
character  must  likewise  be  carefully  noticed.  "  Westphal's  symptom  "  is 
regarded  as  having  considerable  diagnostic  value.  It  is  otherwise  called 
the  tendon-reflex,  with  its  modifications.  When  a  person  in  health  is  seated 
with  one  leg  crossed  over  the  other  or  with  the  legs  dangling  over  the 
edge  of  a  high  bench  or  table,  and  a  sudden  blow  is  struck  upon  the 
tendon  of  the  patella,  the  leg  and  foot  will  be  spontaneously  jerked  for- 
ward. In  locomotor  ataxia,  even  from  an  early  period,  this  tendon-reflex 
is  abolished.  In  spastic  spinal  paralysis  (lateral  spinal  sclerosis)  it  is 
exaggerated.  Quite  analogous  to  this  is  the  ankle-clonus.  This  is 
obtained  by  firmly  flexing  the  foot  and  then  tapping  sharply  upon  the 
tendo  Achillis.  The  foot  is  then  involuntarily  extended  and  flexed 
several  times  in  succession.  There  is  more  doubt  in  regard  to  the 
associations  of  this  symptom  than  as  to  the  knee  movement,  but  it  has 
been  clinically  shown  to  be  exaggerated  in  spastic  spinal  paralysis. 

At  our  first  acquaintance  with  a  case  of  disease,  while  making  inquiry 
into  its  nature,  the  genital  organs  must  not  be  forgotten.  Not  that  we 
need  always  make  examination  of  them,  but  any  pointing  in  symptoms 
toward  them  must  be  borne  in  mind,  so  as  to  guide  us  in  or  toward 
further  procedures  in  diagnosis.  In  making,  in  obscure  cases,  a  diag- 
nosis by  exclusion,  we  are  sometimes  driven  to  a  scrutiny  of  the  genital 
system. 

We  have  now,  however  incompletely,  touched  upon  the  greater  number 
of  obvious  signs  or  symptoms  which  a  view  of  a  patient  would  furnish 
without  making  minute  inquiry  of  himself  or  others  concerning  his  or 
their  knowledge  of  the  illness.  Such  are  the  objective  signs  of  disease, 
which  must  be  still  more  exactly  and  extensively  discerned  and  under- 
stood by  means  of  the  processes  of  physical  and  instrumental  diagnosis. 

VOL.  I.— 11 


162     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

But  the  subjective  symptoms  also,  and  all  those  observed  and  described  by 
the  patient  and  his  or  her  friends,  must  receive  very  careful  attention. 
Much  practical  skill  may  be  shown  by  the  kind  of  questions  asked  and 
the  use  made  of  the  answers  given. 

First,  as  to  the  alimentary  apparatus  : 

Taste  is  very  commonly  altered  in  disease,  being  sour  in  indigestion, 

bitter  in  disorders  of  the  liver,  saltish  in  haemoptysis,  rotten  in  ranffreue 

/•  ,i      i  r  J 

of  the  lungs. 

Dryness  of  the  mouth  is  the  rule  in  fevers.  Sometimes  the  saliva  is 
viscid  and  adherent.  Increased  flow  or  salivation  was  formerly  frequent 
in  practice  under  large  doses  of  mercurials.  Jaborandi  or  its  alkaloid 
pilocarpin  will  generally  produce  it.  Iodide  of  potassium  occasionally 
has  the  same  effect  in  less  degree. 

Loss  of  appetite  nearly  always  attends  serious  diseases  of  any  kind. 
Excessive  craving  for  food  (bulimia)  is  rare.  Tapeworm  accounts  for 
it  in  some  instances.  Desire  for  strange  articles  of  food,  as  slate-pencils, 
ashes,  etc.,  is  met  with  in  some  instances  of  chlorosis  and  of  hysteria. 
A  return  of  natural  appetite  is  one  of  the  best  signs  toward  the  close  of 
any  acute  attack  of  illness. 

Thirst  is  seldom  absent  in  fever.  It  is  also  usually  present  in  the 
state  of  collapse,  as  from  cholera,  pernicious  intermittent,  or  the  shock  of 
severe  (especially  railroad)  injuries. 

Dysphagia  or  difficulty  of  swallowing  may  result  from  simple  debility, 
as  in  the  moribund  state ;  inflammation  of  the  fauces,  tonsils,  or  pharynx ; 
stricture  of  the  resophagus ;  obstruction  by  a  foreign  body  or  by  a  cancer- 
ous or  aneurismal  tumor ;  retro-pharyngeal  abscess ;  paralysis  of  the 
muscles  of  the  throat,  such  as  sometimes  follows  diphtheria.  Soreness 
of  the  throat  is  present  in  some,  but  not  in  all  of  these  examples  of  dys- 
phagia,  being  most  marked  in  the  inflammatory  condition  of  pharyngitis, 
tonsillitis,  scarlet  fever,  and  diphtheria.  Ulceration  of  the  throat  should 
always  be  carefully  looked  for,  and  if  present  investigated  to  ascertain 
whether  it  is  simple,  diphtheritic,  or  syphilitic.  We  must  be  careful 
not  to  mistake  a  mere  local  accumulation  of  mucus,  or  aphthous  vesicle, 
or  the  curd-like  formation  of  thrush  or  muguet,  either  for  ulceration  or 
pseudo-membranous  deposit.  Aphthae  and  thrush  are  most  frequently 
met  with  in  children,  though  small  aphthous  ulcers  frequently  appear 
toward  the  close  of  wasting,  and  especially  cancerous,  affections.  If  there 
be  a  doubt,  pass  a  moistened  hair  pencil  lightly  over  the  apparent  deposit, 
or  allow  the  patient  to  gargle  the  throat  with  water,  and  then  re-inspect  it. 

Many  causes  may  produce  nausea  and  vomiting,  which  almost  always 
occur  together;  that  is,  vomiting  rarely  takes  place  without  previous 
nausea,  although  the  latter  may  exist  without  the  former.  In  the  man- 
ner of  vomiting  there  are  some  differences  more  or  less  characteristic, 
as  the  distressing  retching  of  sea-sickness  and  of  tartar  emetic  or  other 
irritant  poisoning,  and  the  spasmodic  out-spurting  of  rice-water  fluid 
in  malignant  cholera.  The  matter  vomited  is  often  very  important 
in  diagnosis.  In  mere  indigestion  the  food  taken  is  apt  to  come 
up,  and  the  same  may  happen  in  flatulent  colic.  When  the  liver  is  in- 
volved, as  in  bilious  colic,  bile  also  is  ejected.  Nothing  peculiar  exists  in 
the  ejecta  of  morning  sickness  in  pregnancy.  The  ejecta  contain  mucus 
in  gastritis,  blood  in  ulcer  and  in  cancer  of  the  stomach,  stercoraceous 


MEDICAL  DIAGNOSIS.  163 

material  in  obstruction  of  the  bowels,  black  vomit  in  bad  cases  of  yellow 
fever.  Hysterical  vomiting  sometimes  closely  imitates  the  latter  in 
appearance.  Other  affections  attended  by  vomiting  are  cholera  morbus, 
remittent  fever,  brain  disease,  Bright's  disease  of  the  kidney,  etc. 

Spitting  blood  may  be  either  haematemesis  or  haemoptysis  proper.  If 
the  former,  nausea  generally  precedes  the  ejection  of  the  blood  by  vomit- 
ing, and  it  is  apt  to  be  mingled  with  food  partly  digested.  It  is  coughed 
up,  bright  red  and  frothy  usually,  when  coming  from  the  lungs  or  bron- 
chial tubes.  But  blood  may  proceed  from  the  gums  or  throat,  or  may  run 
back  through  the  posterior  nares  from  the  nose,  and  then  it  gives  alarm 
by  seeming  to  proceed  from  the  chest.  It  is  necessary  to  inquire  very 
particularly  into  all  such  possibilities  in  every  case  of  hemorrhage. 

Between  vomiting  of  blood  from  ulcer  and  from  cancer  of  the  stomach 
we  have  mostly  these  distinctions :  in  ulcer  it  follows  soon  after  taking 
food,  in  cancer  (this  being  generally  at  the  pylorus),  an  hour  or  more 
after  eating ;  ulcer  is  attended  also  by  tenderness  on  pressure  at  a  cer- 
tain spot  over  the  stomach,  without  tumor;  cancer  presents  a  tumor, 
with  much  less  marked  tenderness  on  pressure.  By  aid  of  the  micro- 
scope in  examination  of  the  matter  vomited  this  diagnosis  may  be  com- 
pleted. 

Constipation  is  an  exceedingly  frequent  symptom  under  many  and 
diverse  circumstances.  Pathologically,  we  account  for  it  in  several  ways  : 
1,  torpor  of  the  muscular  coat  of  the  intestinal  canal ;  2,  deficiency  of 
secretion  in  the  glands  of  the  bowels  and  in  the  liver ;  3,  imperfect  inner- 
vation  of  the  abdominal  organs ;  4,  mechanical  obstruction,  as  by  a  foreign 
body,  intussusception,  strangulated  hernia,  cancerous  or  other  tumor, 
stricture  of  the  rectum,  etc.  Dyspeptic  persons  are  ordinarily  consti- 
pated. So  are  almost  all  patients  at  the  beginning  of  attacks  of  measles, 
scarlet  fever,  small-pox,  and  other  acute  febrile  maladies.  Typhoid 
fever  is  scarcely  an  exception  to  this ;  although  the  bowels  in  that 
affection  become  loose  after  a  few  days,  they  seldom  are  so  at  the 
very  beginning  of  the  attack.  Sea-sickness  is  commonly  accom- 
panied by  total  or  nearly  total  inaction  of  the  bowels,  the  secretion 
of  the  intestinal  glands  being  almost  null,  often  for  many  days  together. 
Torpor  of  the  brain  is  sometimes  attended  by  marked  constipation. 
The  latter  may  be  a  contributing  cause  of  the  former,  as  in  certain  severe 
cases  of  scarlet  fever,  in  which  threatening  coma  may  be  relieved  by  active 
purgation.  We  must  not,  however,  occupy  space  here  by  attempting  to 
enumerate  the  many  conditions  under  which  constipation  may  present 
itself  as  a  symptom. 

Almost  as  various  are  the  associations  of  the  opposite  state  of  the 
bowels,  diarrhoea.  Excessive  or  abnormally  frequent  discharges  from 
the  bowels  may  be  either  fecal,  bilious,  mucous,  membranous,  purulent, 
bloody,  fatty,  or  watery,  and  they  may  occur  with  or  without  pain  and 
straining  (teuesmus). 

If,  with  frequent  disposition  to  pass  something,  only  small  quantities 
of  bloody  mucus  escape,  with  pain  and  bearing  down,  we  recognize  dysen- 
tery. When,  instead,  a  large  quantity  of  colorless  fluid,  with  or  with- 
out floating  flakes  (rice-water),  comes  from  the  bowels  at  short  inter- 
vals, with  vomiting  of  the  same  sort  of  material,  we  suspect  epidemic 
cholera,  and  must  inquire  for  corroborative  or  corrective  indications  in 


164     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

reference  to  that  suspicion.  Very  bad  cases  of  cholera  morbus  also  may, 
at  a  late  stage,  present  this  symptom.  So  may  exceptional  cases  of 
pernicious  malarial  fever.  The  diarrhoea  of  typhoid  fever  exhibits 
usually  liquid  stools  of  a  brownish  color  (gutter-water  passages).  Occa- 
sionally, hemorrhage  from  the  bowels  adds  to  the  danger  of  this  fever, 
as  well  as  to  that  of  malarial  remittent  fever.  In  phthisis  pulmonalis, 
at  a  late  stage,  colliquative  diarrhoea,  like  colliquative  perspirations, 
shows  the  breaking  up  of  the  system  by  excessive  waste.  Very  foul, 
oifensive  discharges  from  the  bowels  may  always  be  understood  as 
showing  that  in  the  alimentary  canal,  whether  originating  there  or  in 
the  blood,  morbid  changes  have  been  going  on.  The  indication  is  to 
promote  the  elimination  of  such  material  as  soon  and  as  thoroughly  as 
possible. 

Clayey  stools  show  absence  or  deficiency  of  bile  in  the  intestines,  whether 
from  its  non-secretion  by  the  liver  or  from  obstruction  to  its  entrance 
by  a  gall-stone  in  the  common  gall-duct.  Green  stools  are  not  uncom- 
mon in  sick  children.  The  cause  of  the  color  has  been  much  disputed. 
Probably  it  depends  chiefly  on  a  modification  of  the  bile-pigment,  with 
some  admixture  of  altered  blood.  When  mercurials  have  been  taken 
sulphide  of  mercury  may  give  a  green  color  to  the  discharges. 

Blood,  nearly  or  quite  unmixed,  coming  from  the  bowels,  may  have  its 
origin  in  internal  hemorrhoids,  intestinal  ulceration,  cancer  of  the  rectum, 
intussusception,  rupture  of  an  aneurism,  typhoid  or  yellow  fever,  or  vica- 
rious menstruation. 

Pus  is  discharged  per  anum  in  cases  of  dysenteric  or  other  ulceration 
of  the  bowel ;  also  when  an  abscess  occurring  in  any  part  of  the  abdomen 
(most  frequently  hepatic)  opens  into  the  intestine.  Pseudo-membranous 
discharges,  shreds  or  other  fragments  of  fibrinous  material,  appear  some- 
times in  what  may  be  called  diphtheritic  dysentery.  Tubular  casts 
are  occasionally  seen  (diarrhoea  tubularis),  which,  however,  are  most 
likely  to  consist  of  thickened  and  accumulated  mucus.  Fatty  dis- 
charges from  the  bowels  are  rare.  Authors  report  observation  of  them 
in  cases  of  disease  of  the  liver  or  pancreas,  as  well  as  in  phthisis,  typhoid 
fever,  diabetes  mellitus,  cholera,  and  tubercular  enteritis  of  children. 

Lientery  is  the  term  applied  when  imperfectly  changed  food  appears  in 
the  stools.  It  shows,  of  course,  great  deficiency  in  the  process  of  diges- 
tion. 

Urination  affords  symptoms  often  of  extreme  consequence  in  disease. 
Suppression  of  urine  is  one  of  the  most  alarming  of  signs ;  an  approxi- 
mation to  it  only  is  likely  to  be  met  with  in  cholera,  a  late  stage  of  scai'let 
fever,  typhus  or  typhoid  fever,  in  acute  yellow  atrophy  of  the  liver,  and 
in  advanced  kidney  disease.  Careful  examination  of  the  abdomen,  by 
inspection,  palpation,  and  percussion,  as  well  as  by  inquiry  of  attendants, 
is  needful  in  all  cases  of  fever  or  other  disorders  with  delirium  or  stupor, 
to  ascertain  the  presence  or  absence  of  retention  of  urine.  Dysuria — /.  e. 
difficult  urination,  strangury — may  have  several  causes.  Cantharides, 
absorbed  from  a  blister,  may  produce  it  temporarily.  The  more  contin- 
uous states  wrhich  cause  it  are — stricture  of  the  urethra,  enlargement  of 
the  prostate  gland,  and  calculus  in  the  bladder.  In  stricture,  when  the 
patient  can  pass  water,  it  is  apt  to  be  in  a  twisted  stream.  Dribbling 
often  occurs  when  the  prostate  is  enlarged.  When  a  stone  is  present  the 


MEDICAL  DIAGNOSIS.  165 

stream  may  flow  naturally  for  a  time  and  then  suddenly  cease  from 
obstruction  at  the  outlet  of  the  bladder.  Enuresis,  incontinence  of 
urine,  is  often  very  troublesome  in  children;  its  diagnosis  presents  no 
difficulty. 

Diabetes  properly  means  simply  excessive  flow  of  urine.  It  may  be 
attended  by  no  change  in  the  secretion  except  dilution  of  its  solids 
(diabetes  insipidus),  as  in  certain  nervous  cases  or  after  very  large 
imbibition  of  fluids.  More  serious  is  diabetes  mellitus,  in  which  large 
amounts  of  sugar  are  found  in  the  urine. 

Variations  in  the  quantity  and  in  the  composition  and  solid  ingredients 
of  the  urine,  as  ascertained  by  aid  of  chemical  analysis  and  the  microscope, 
will  be  fully  considered  in  other  portions  in  this  work. 

Menstruation  in  the  female  requires  scrutiny  in  every  case  of  deviation 
from  health.  Its  abnormities  will  be  elsewhere  treated  of.  The  subject 
of  the  signs  of  pregnancy  belongs  of  course  to  treatises  on  Obstetrics. 

Pain  is  one  of  the  most  important  of  the  signs  of  disease.  We  must 
always  examine  its  character,  location,  and  associations.  As  to  character, 
that  of  pleurisy  is  sharp  and  cutting,  increased  by  deep  breathing  or 
coughing.  In  pneumonia  and  in  myalgia  it  is  dull  or  aching.  Rheu- 
matic joints  or  muscles  suffer  a  gnawing,  tearing  pain.  In  neuralgia  it 
is  darting,  shooting,  lancinating ;  and  the  last  of  these  expressions  is  often 
applied  to  the  pains  of  cancer.  Griping  pains  occur  in  colic,  and  bearing- 
down  pains  in  dysentery,  as  well  as  in  the  second  stage  of  labor.  Besides 
these  varieties  we  have  the  pulsating  pain  of  an  acute  external  inflamma- 
tion, as  of  the  hand,  especially  before  suppuration  has  occurred;  the 
burning  and  smarting  of  erysipelas ;  and  the  stinging,  nettling  sensations 
(formication)  of  urticaria. 

Tenderness  on  pressure  is  significant  either  of  local  inflammation, 
whose  other  signs  are  then  to  be  discerned,  or  of  non-inflammatory 
hypersesthesia.  The  origin  of  the  latter  may  require  careful  examination 
of  various  organs  for  its  discovery.  If  pain  is  relieved  by  pressure,  we 
may  be  sure  of  the  absence  of  severe  acute  local  inflammation. 

Not  infrequently  the  seat  of  disease  may  be  at  some  distance  from  that 
of  pain,  as  in  the  familiar  instances  of  pain  at  the  top  of  the  head  in 
uterine  derangement ;  in  the  glans  penis  from  calculus  in  the  bladder ;  in 
the  knee  from  hip-joint  disease ;  under  the  shoulder-blade  in  liver  dis- 
order ;  about  the  heart  or  between  the  shoulders  from  dyspepsia. 

Anaesthesia,  loss  of  sensibility,  has  much  value  as  a  symptom  in 
neurotic  affections,  as  paralysis,  etc.  Its  discussion  will  find  place  in 
connection  with  diseases  of  the  Nervous  System  in  other  portions  of 
this  work. 

As  an  example  of  the  diversified  associations  of  pain,  cephalalgia 
(headache)  may  be  mentioned  as  having  at  least  the  following  possible 
causes :  congestion  of  the  brain,  neuralgia,  rheumatism  of  the  scalp, 
uterine  irritation,  disease  of  the  kidneys,  early  stage  of  remittent, 
typhoid,  or  yellow  fever,  alcoholic  intoxication,  chronic  disease  of  the 
brain. 

Abdominal  pain  may,  in  like  manner,  be  traced,  in  different  cases,  to 
many  morbid  conditions,  such  as  flatulent  colic,  lead  colic,  neuralgia  or 
rheumatism  of  the  bowels,  intestinal  obstruction,  dysentery,  passage  of  a 
gall-stone  or  of  a  nephritic  calculus  through  one  or  the  other  duct  respect- 


166     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

ively ;  cancer,  aneurism  of  the  aorta,  caries  of  the  spine ;  in  the  female, 
dysmenorrhoea,  metralgia  or  ovaralgia — i.  e.  neuralgia  of  the  uterus  or 
ovaries. 

Similar  diversity  in  the  origins  of  pain  might,  but  for  want  of  space, 
be  pointed  out  in  morbid  states  of  the  contents  of  the  chest  and  of  other 
parts  of  the  body. 

Subjective  symptoms  often  affect  the  special  senses. 

Taste  and  touch  have  been  already  referred  to.  Of  sight  we  may  have 
photophobia,  connected  with  exaggerated  sensibility  of  the  retina  or  of 
the  brain ;  muscse  volitantes,  specks,  rings,  or  chains  of  spots  from  float- 
ing semi-opaque  particles  in  the  vitreous  humor;  diplopia,  double  vision  ; 
hemiopia,  seeing  only  half  of  an  object  at  a  time;  amblyopia,  indistinct- 
ness of  vision  of  all  objects. 

Hearing  is  affected,  besides  all  possible  degrees  of  deafness,  with  the 
subjective  sensations  of  ringing,  whistling,  or  roaring  sounds — tinnitus 
aurium.  One  form  of  this  (as  I  conclude  from  observation  in  my  own 
ears)  depends  upon  spasmodic  vibration  of  the  tensor  tympani  or  stape- 
dius  muscle.  Sometimes  the  seat  of  the  sensation  is  in  the  auditory 
nervous  apparatus  proper.  It  has,  not  seldom,  a  marked  connection  with 
brain-exhaustion.  An  attack  of  Meniere's  disease  (labyrinthine  vertigo) 
is  often  preceded  by  it.  No  constant  signification,  however,  can  be 
attached  to  aural  tinnitus.  Large  doses  of  quinine  or  of  salicylic  acid 
will  occasion  it  in  many  patients. 

Very  briefly,  deafness  may  be  here  disposed  of  by  mentioning  that,  in 
greater  or  less  degree,  it  may  be  produced  by  accumulated  wax  in  the 
ear;  obstruction  of  the  Eustachian  tube;  thickness  of  the  membrana 
tympani ;  perforation  of  that  membrane ;  mucus  or  pus  in  the  middle 
ear ;  disease  of  the  ossicles  of  the  ear ;  paralysis  of  the  auditory  nerve ; 
typhus  or  typhoid  fever ;  excessive  doses  of  quinine  or  salicylic  acid. 

Vertigo  is  chiefly  of  two  kinds,  dizziness  or  giddiness  (swimming  in  the 
head),  and  reeling  vertigo,  or  a  disposition  to  fall  or  turn  to  one  side  or 
the  other.  Giddiness  is  produced  by  running  or  whirling  many  times  in 
a  circle,  or,  in  some  persons,  by  swinging  rapidly  or  sailing.  Reeling 
vertigo  is  mostly  observed  in  connection  with  disorder  of  the  brain  or  of 
the  labyrinth  of  the  ear  (Meniere's  disease).  Dizziness,  with  nausea,  is 
common  as  a  symptom  of  cholsemia  (cholestersemia  of  Flint)  in  what  is 
popularly  called  a  bilious  attack. 

Delirium  is  present  in  many  acute  disorders,  and  not  infrequently  at 
a  late  stage  in  pulmonary  phthisis.  Its  special  study  will  be  taken  up  in 
connection  with  the  special  articles  upon  these  affections. 

Coma,  or  stupor,  is  met  with  chiefly  in  the  following  morbid  states  : 
severe  typhus  or  typhoid  fevers ;  malignant  scarlet  fever ;  small-pox ; 
rarely  in  measles ;  pernicious  malarial  fever ;  ursemia  ;  apoplexy  ;  opiate 
narcotism,  or  that  from  chloral  or  alcoholic  intoxication ;  asphyxia  from 
inhaling  carbonic  acid  gas,  ether,  chloroform,  etc. ;  fracture  of  the  skull 
with  compression  of  the  brain. 

For  an  account  of  aphasia  and  other  morbid  psychological  manifesta- 
tions the  reader  is  referred  to  the  articles  on  Aphasia,  Insanity,  Hysteria, 
etc.  in  this  work. 

Physical  and  Instrumental  Diagnosis  will  be  treated  in  connection  with 
those  diseases  in  which  they  have  special  importance. 


PROGNOSIS.  187 


PROGNOSIS. 

The  elements  of  medical  prognosis  are  essentially  involved  in  diag- 
nosis. Our  ability  to  anticipate  the  mode  of  progress,  duration,  termina- 
tion, and  results  of  any  case  of  illness  depends  upon  our  knowledge — 1, 
of  the  nature  of  the  malady,  with  its  tendencies  toward  death,  self-lim- 
itation, or  indefinite  continuance ;  2,  the  soundness  or  imperfection  of 
the  patient's  constitution,  with  or  without  special  predispositions  or  the 
consequences  of  previous  ailments;  3,  the  present  state  of  his  system 
as  to  the  performance  of  the  general  functions,  his  strength,  and  vital 
resistance  or  persistence ;  4,  the  probable  modifying  influences  of  medical 
treatment,  and  also  those  of  situation,  surroundings,  and  nursing — L  e. 
the  care  of  those  attending  to  the  patient  during  the  absence  of  the  phy- 
sician and  having  the  duty  of  carrying  out  his  directions. 

1.  As  to  the  nature  of  the  malady.  While  every  sickness  must  be 
supposed  to  encroach  somewhat  upon  the  vital  energy  of  its  subject,  very 
few  diseases  (leaving  aside  deadly  poisons  and  surgical  injuries)  are,  ab 
iuitio,  certainly  fatal.  Hydrophobia  (rabies  canina)  has  been,  until 
latterly,  regarded  as  incurable,  and  always  mortal  within  a  few  days  or 
a  week  or  two.  A  few  cases  have,  during  the  last  few  years,  been 
reported  as  cured,  but  the  diagnosis  of  these  continues  to  be  somewhat 
doubtful. 

Cancer  exhibits  a  tendency  to  extend  its  destructive  malnutrition  so  as 
to  render  death  inevitable  unless  it  can  be  removed  early  and  completely, 
or  unless  the  morbid  process  can  be  arrested  in  some  manner  not  yet 
known.  Remedies,  such  as  condurango  and  Chian  turpentine,  which 
furnished  hope  of  such  an  effect,  have,  after  prolonged  trial,  been  aban- 
doned as  not  justifying  the  confidence  of  the  profession. 

Tubercular  phthisis  was  once  considered  to  be  almost  necessarily  a 
fatal  disease,  although  with  a  very  indefinite  period  of  duration.  Under 
improved  hygienic  management,  with  mild  palliatives  and  recuperative 
medication,  a  not  inconsiderable  minority  of  cases  now  end  in  recovery. 
This  term  may  be  properly  applied  when,  with  cicatrization  of  a  cavity 
or  cavities  in  the  lungs,  no  more  tubercle  is  deposited  and  lung-substance 
enough  is  left  for  good  respiration,  even  although  the  structurally  changed 
portions  of  pulmonary  tissue  do  not  undergo  entire  repair. 

Tubercular  meningitis  is  a  nearly  always  incurable  affection.  Yet  a 
few  instances  of  lasting  recovery  have  been  reported  where  the  diagnosis 
was  as  certain  as  it  can  be  in  that  disease  in  the  absence  of  post-mortem 
examination.  A  child  attended  by  myself,  in  whom  the  symptoms  had 
been  of  the  most  unfavorable  kind,  became  apparently  quite  well,  and 
continued  so  for  a  month.  Then  it  was  attacked  suddenly  with  convul- 
sions, which  were  almost  unremitting  until  it  died  within  a  day  or  two. 

Gangrene  of  the  lung  is  very  seldom  recovered  from,  but,  unless  the 
diagnosis  from  examination  of  putrescent  sputa  has  been  at  fault,  there 
have  been  cases  in  which,  with  the  limited  destruction  of  the  affected 
lung,  it  was  not  fatal. 

Pseudo-membranous  croup  destroys  life  in  the  majority,  but  not  in 
nearly  all  the  cases  of  its  occurrence.  It  is  most  likely  to  end  in  death 
when  distinctly  a  part  of  an  attack  of  epidemic  or  endemic  diphtheria. 


168     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

Valvular  heart  lesions  were  formerly  regarded  as  incurable,  in  the 
sense  of  restoration  of  the  normal  condition  and  action  of  the  valves 
impaired,  yet  not  incompatible  with  years  of  life.  This  restoration 
certainly  very  seldom  takes  place.  But  the  experience  of  many  close 
observers  leads  to  caution  in  anticipation  of  necessary  and  permanent 
disability  of  the  heart  because  of  murmurs,  or  even  functional  disturb- 
ances, seeming  to  prove  either  aortic  or  mitral  iusufficency  or  stenosis. 

Aneurism  of  the  aorta  is  very  seldom  recovered  from,  but,  besides  a 
variable  duration,  whose  period  can  almost  never  be  anticipated  with 
exactness,  there  appear  to  have  been  some  cases  of  disappearance,  or  at 
least  prolonged  quiescence,  of  the  tumor  and  of  its  morbid  eifects. 

Yellow  atrophy  of  the  liver  is  one  of  the  disorders  most  rarely  ending 
otherwise  than  in  death. 

With  a  course  altogether  indefinite  in  time,  there  appears  to  be  a  tend- 
ency to  exhaust  vital  energy,  without  self-limitation,  in  the  different 
forms  of  organic  degeneration,  such  as  fatty  heart,  Addison's  disease, 
chronic  Bright's  disease,  diabetes  mellitus,  cirrhosis,  and  amyloid  degen- 
eration of  the  liver,  etc.  The  same  may  be  said  also  of  the  different 
forms  of  cerebral  and  spinal  sclerosis,  of  pernicious  anemia,  and  of 
myxoedema. 

Lastly,  it  is  an  exception  to  a  very  general  rule  of  fatality  when  a  case 
of  trichinosis,  with  well-marked  abdominal,  muscular,  and  general  symp- 
toms, ends  otherwise  than  in  death  within  a  few  weeks. 

Self-limitation  is  familiar  in  the  natural  history  of  typhus  and  typhoid 
fever,  relapsing  fever,  yellow  fever,  cholera,  diphtheria,  whooping  cough, 
mumps,  small-pox,  varicella,  scarlet  fever,  and  measles.  In  the  sense  of 
a  definite  duration  of  each  paroxysm  intermittent  and  remittent  fevers 
are  self-limited.  Are  they  so  also  in  tending  toward  recovery,  without 
curative  treatment  within  a  certain  time  ?  This  has  been  asserted,  and 
in  the  case  of  remittent  there  is  evidence  that  spontaneous  cures  do  some- 
times happen.  Some  observers  aver  that  ague  tends  toward  cessation  of 
the  chills  after  six,  eight,  or  ten  weeks.  The  obstinacy  of  the  attacks  in 
many  instances  under  anti-periodic  medication  seems  to  make  it  probable 
that  spontaneous  recovery  from  intermittent  hardly  belongs  to  the  typical 
natural  history  of  the  disease. 

Whether  the  term  self-limited  can  or  cannot  with  propriety  be 
applied  to  pneumonia  and  other  acute  inflammations,  as  pericarditis, 
etc.,  has  been  a  mooted  question.  If  it  be  so,  it  appears  to  the  writer 
1  o  be  true  in  a  different  meaning  of  the  word  self-limitation  from  that 
in  which  it  is  applied  to  variola  or  typhoid  fever.  Yet  some  nosol- 
ogists  deny  this  distinction,  and  regard  pneumonia  as  strictly  a  lung 
fever.  Some  of  the  facts  supporting  this  view  belong  to  the  history 
of  pneumonia  as  complicating  malarial  fever ;  e.  g.  in  the  winter  fever 
of  some  parts  of  our  Southern  States.  It  must  be  admitted,  however, 
that  the  inflammatory  process,  though  morbid,  is  generally  eliminative  or 
corrective  of  a  disturbing  cause  which  produced  it,  and,  unless  that  cause 
is  continued  or  repeated  in  action,  a  limitation  belongs  to  the  succession 
of  stages,  ending  either  in  resolution  or  in  adhesions,  serous  accumulation, 
suppuration,  or  gangrene. 

2.  It  is  not  necessary  to  dwell  here  upon  the  significance  in  prognosis 
of  the  patient's  original  constitution  and  hereditary  or  acquired  predispo- 


FBOGNOSIS.  169 

sitions,  or  ou  that  of  results  left  by  previous  attacks  of  illness.  These  are 
all  obviously  of  importance.  In  a  member  of  a  family  predisposed  to 
consumption  a  bronchial  attack  following  exposure  may  be  much  more 
dangerous  than  in  others.  So  also  a  cause  of  mental  agitation  may  pro- 
duce insanity  in  a  person  who  inherits  a  tendency  thereto  or  who  has 
before  had  an  attack  of  mental  derangement,  while  it  would  be  innocuous 
to  another  who  has  no  such  proclivity.  A  second  or  third  attack  of 
delirium  tremens  is  much  more  dangerous  to  life  than  a  first  attack.  On 
the  other  hand,  if  yellow  fever  occurs  at  all  in  a  patient  who  has  before 
had  it,  the  course  of  the  disease  is  apt  to  be  milder  than  usual.  The  most 
striking  example  of  the  influence  of  previous  disease  is  seen  in  the  com- 
parative mildness  of  varioloid — i.  e.  small-pox  modified  by  the  system 
having  been  placed  under  the  action  of  the  vaccine  virus. 

3.  Most  important  of  all  data  in  prognosis  are,  in  most  cases,  the  indi- 
cations of  the  present  state  of  the  patient's  system  as  to  the  performance 
of  the  organic  functions,  his  sum  of  energy,  and  vital  resistance  and  per- 
sistence.    Especially  must  these  indications  be  regarded  comparatively ; 
that  is,  ascertaining  whether,  in  a  period  of  weeks,  days,  or,  sometimes 
hours  (in  malignant  cholera  even  of  minutes),  the  patient's  general  con- 
dition has  been  and  is  gaining  or  losing  in  the  evidences  of  strength  and 
healthy  function  of  the  great  organs. 

Every  student  of  clinical  medicine  must  become  acquainted,  as  soon  as 
possible,  at  the  bedside,  with  these  tokens  and  evidences,  which  make 
almost  the  alphabet  of  practice  :  What  is  a  good,  a  doubtful,  and  a  bad 
pulse  ?  How  does  a  patient  breathe  when  moribund  from  simple  exhaus- 
tion, and  how  does  such  respiration  differ  from  the  toil  and  struggle  of 
asthma  or  the  stertor  of  narcotism  ?  Why  does  a  glance  suffice  to  make 
known  to  a  surgeon  the  state  of  collapse  after  a  railroad  accident,  or  to  a 
physician  that  of  cholera  or  pernicious  intermittent  ?  What  is  the 
impression  given  to  the  finger  upon  the  skin  by  intense  fever,  and  what 
by  the  relaxation  which  precedes  death  ?  These  and  many  other  such 
questions  are  to  be  answered  fully  to  each  student  only  by  the  use  of  his 
own  senses,  with  such  interpretation  as  is  to  be  obtained  by  the  careful 
comparison  of  cases,  with  the  aid  of  books  and  didactic  instruction. 

To  a  well-trained  eye  and  hand  a  look  and  a  touch  will  often  suffice  to 
make  known  the  commencement  of  convalescence  or  of  the  precipitous 
decline  toward  death.  Yet  a  wise  physician  will  be  very  cautious  in 
acting  upon  even  seemingly  obvious  prognostications.  Changes  may  be 
going  on  in  important  organs  whose  effects  have  hardly  yet  begun  to 
show  themselves,  and  which  may  after  a  while  materially  alter  the  aspect 
of  the  case.  Particularly  near  the  beginning  of  an  attack  of  enthetic 
disease,  such  as  scarlet  fever,  small-pox,  typhus  or  typhoid  fever,  the 
physician  should  beware  of  too  confidently  forecasting  the  progress  of 
the  case  for  better  or  for  worse.  In  nothing,  probably,  is  the  prudence 
of  a  practitioner  more  often  or  more  severely  tested  than  in  his  answers 
to  inquiries  made  concerning  prognosis. 

4.  Anticipation  of  the  modifying  action  of  remedies  is  undoubtedly  a 
proper  factor  in  our  estimate  of  the  probable  result  of  any  case  of  illness. 
Few  diseases,  however,  are  as  yet  so  subject  to  control  by  specific  medica- 
tion as  to  allow  certainty  in  such  expectations.     In  a  first  attack  of  ague 
\ve   may  look  with   much   confidence  toward  the   speedy  cure  of  our 


170     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

patient  under  quinia.  In  one  who  has  had  chills  all  winter  even  this 
confidence  may  need  qualification.  A  sufferer  with  syphilitic  rheumatism 
may  generally  be  promised  relief  under  the  use  of  iodide  of  potassium, 
or  one  afflicted  with  scabies  under  the  application  of  sulphur  ointment. 
We  seldom  have  misgivings  about  our  ability  to  give  relief  in  colic,  con- 
stipation, or  diarrhsea.  Yet  the  first  two  of  these  may  prove  to  be  symp- 
toms of  intestinal  obstruction  resisting  treatment,  and  the  last  may  depend 
upon  chronic  ulceration  of  the  bowel,  giving  it  unexpected  continuance. 
In  all  such  instances  careful  and  (when  practicable)  accurate  diagnosis 
must  precede  prognosis ;  our  estimate  of  the  action  of  remedies  becomes 
then  a  secondary,  although  often  a  valuable,  part  of  the  calculation  of  the 
probabilities  of  the  case. 

Prognosis  in  particular  diseases  involves  the  consideration  not  only  of 
those  signs  of  the  general  vital  condition  to  which  we  have  just  been 
giving  attention,  but  also  of  such  as  are  more  or  less  peculiar  to  each 
disorder.  To  a  certain  extent  •  these  signs  may  be  grouped.  We  may 
refer  to  good  and  bad  signs  in  pulmonary,  cardiac,  intestinal,  renal, 
cerebral,  and  febrile  affections  respectively.  Still,  there  will  be  for  each 
malady,  if  it  really  has  a  distinctive  character,  some  tokens  which  expe- 
rience shows  to  be  specially  indicative  of  favorable  or  unfavorable  progress 
and  results. 

Let  us  notice  some  of  these  as  examples. 

In  pneumonia  the  best  signs  are  the  lowering  of  a  high  temperature, 
reduction  of  the  number  of  respirations  to  20  or  25  in  the  minute,  expec- 
toration of  sputa  less  and  less  tinged  with  red  or  brown,  and  gradual 
reduction  of  the  region  of  dulness  on  percussion.  Worst,  in  the  same 
disease,  are  an  axillary  temperature  over  106°,  respirations  40  or  more 
per  minute,  with  delirium,  and  expectoration  becoming  more  abundant, 
grayish,  and  purulent ;  also  with  continued  dulness  on  percussion  and 
abundant  mucous  rales  on  auscultation. 

In  croup  the  best  sign  is,  after  a  hoarse,  dry,  barking  cough  and  dysp- 
no3a,  a  soft,  liquid  rale,  heard  in  the  larynx  and  trachea  during  respira- 
tion or  coughing.  Worst,  in  croup,  is  a  steadily  or  paroxysmally  increasing 
difficulty  of  breathing,  with  a  dry  hissing  or  whistling  sound  of  respira- 
tion and  cough  succeeding  the  barking  sounds  of  the  earlier  stage. 

In  phthisis  pulmonalis  among  the  best  signs  are  the  patient's  increasing 
in  weight,  coughing  and  expectorating  less,  ceasing  to  have  hectic  and 
night  sweats.  These  may  give  renewed  hope,  even  before  much  change 
is  discernible  in  the  physical  signs.  Of  bad  omen  are  intense  hectic 
fever,  incessant  cough  with  abundant  nummular  sputa,  copious  perspira- 
tions, diarrhoea,  breathing  growing  shorter  and  shorter,  and  extreme 
emaciation  and  debility. 

In  all  organic  affections  of  the  heart  an  extremely  rapid  and  irregular 
pulse,  with  orthopnoea  and  increasing  anasarca,  and  especially  the  Cheyne- 
Stokes  respiration  (described  under  DIAGNOSIS),  must  cause  unfavorable 
expectations. 

In  obstruction  of  the  bowels  the  best  of  all  symptoms  is,  usually,  of 
course,  a  copious  fecal  evacuation.  Yet  a  few  cases  have  occurred  in 
which  a  very  large  evacuation,  delayed  by  obstruction  for  a  week  or  two, 
has  been  almost  immediately  followed  by  collapse  and  death.  The  worst 
signs  in  cases  of  obstruction  are  (besides  long-unyielding  constipation) 


PROGNOSIS.  171 

stercoraceous  vomiting,  a  small,  rapid  pulse,  and  increasing  coldness  and 
clamminess  of  the  surface  of  the  body. 

In  cholera  infantum  the  best  signs  are  cessation  of  vomiting  and  purg- 
ing, the  discharges  growing  more  nearly  natural,  the  face  becoming  less 
shrunken  in  aspect,  sleep  taking  the  place  of  coma  vigil  or  waking  apathy, 
and  water  or  milk,  when  taken,  remaining  on  the  stomach.  Worst,  in 
the  same  disease,  are  incessant  rejection  of  everything  swallowed,  watery 
passages  from  the  bowels  every  half  hour  or  hour,  shrinking  of  the  face 
and  body  to  skin  and  bone,  with  an  apathetic  expression  of  the  open  or 
half-open  eyes,  the  latter  rolling  often  from  side  to  side. 

In  epidemic  cholera  good  signs  are  the  arrest  of  vomiting  and  of  rice- 
water  discharges  from  the  bowels,  rapid  movement  of  the  blood  in  the 
veins  after  removal  of  momentary  pressure,  return  of  natural  color  and 
warmth  to  the  skin,  with  filling  up  of  the  pulse  at  the  wrist.  Bad  signs 
in  cholera  are  shrinking  of  the  cheeks  and  of  the  flesh  upon  the  hands, 
deepening  ashiness  or  blueness  of  the  skin,  coldness  and  clamminess  to 
the  touch,  dyspncea,  loss  of  pulse,  incessant  vomiting  and  purging  of 
rice-water  stools,  constant  cramps  of  the  limbs,  and  suppression  of  urine. 

In  acute  cerebral  meningitis  good  signs  are  lessened  temperature  of  the 
head,  quiet  sleep  without  stertor,  disappearance  of  delirium,  more  natural 
pulse,  and  attention  to  surrounding  objects,  without  disquietude.  Bad 
signs  in  the  same  disease  are  deep  stupor,  strabismus,  convulsions,  paral- 
ysis, involuntary  defecation  and  urination. 

In  typhus  fever  good  signs  are  the  pulse  becoming  slower  and  fuller, 
the  skin  less  hot,  more  soft  and  moist,  the  tongue  moist  and  clean,  the 
face  losing  its  dusky  flush,  and  consciousness  returning  instead  of  muttering 
delirium.1  Bad,  in  the  same  fever,  are  deepening  of  the  flush  of  the 
countenance,  profound  stupor,  rapid  and  feeble  pulse,  lying  on  the  back 
and  sinking  down  toward  the  foot  of  the  bed,  with  suppression  of  urine. 

In  typhoid  fever  many  of  the  good  and  bad  signs  are  the  same  as  in 
typhus,  belonging  to  closely  similar  general  conditions.  But  in  typhoid 
fever  we  observe  also  as  favorable  signs  the  lessening  of  tympanites, 
more  nearly  natural  fecal  stools,  and  the  absence  of  tenderness  in  any 
part  of  the  abdomen.  As  unfavorable,  increase  of  tympanites  and  diar- 
rhoea, sometimes  large  hemorrhages  from  the  bowels ;  worst  of  all,  at  a 
late  stage,  sudden  increase  of  abdominal  distension,  with  dulness  on  per- 
cussion, coldness  of  the  skin,  great  rapidity  and  feebleness  of  the  pulse 
following  perforation  of  the  bowel,  resulting  usually  in  fatal  peritonitis. 

In  scarlet  fever,  measles,  and  small-pox  it  is  a  favorable  sign  for  the 
eruption  to  come  out  well  at  the  usual  time ;  its  sudden  recession 
threatens  malignancy.  In  small-pox  a  confluent  eruption  marks  a 
dangerous  case,  and  so  does  the  occurrence  of  distinct  pustules  in  the 
throat.  Early  in  scarlet  fever  stupor  is  very  threatening,  though  not 
necessarily  mortal.  Late  in  the  same  disease  bloody  urine,  or,  worse 
yet,  suppression  of  urine,  may  well  cause  alarm. 

In  all  children's  diseases  the  early  occurrence  of  convulsions  shows  a 

1  Incidentally,  it  may  be  mentioned  that  the  return  of  the  pulse  to  its  normal  rate 
is  often  considerably  delayed  in  convalescence  from  typhus  and  typhoid  fevers  and 
other  protracted  diseases.  If,  then,  the  temperature  is  not  above  99°  F.,  and  is  stable 
from  morning  to  night,  the  tongue  is  clean  and  moist,  and  appetite  begins  to  appear,  we 
need  not  be  alarmed,  although  the  pulse  continues  as  high  as  90  or  100  per  minute,  in  a 
case  attended  by  positive  debility. 


172     GENERAL  ETIOLOGY,  MEDICAL  DIAGNOSIS,  AND  PROGNOSIS. 

severe  but  not  always  a  dangerous  attack.  The  late  occurrence  of  con- 
vulsions is  commonly  much  more  serious  in  its  significance.1  Convulsions 
are  always  of  vastly  less  importance,  prognostically,  in  children  than  in 
adolescents  or  adults.  Yet  they  are  always  serious  signs.  While  recov- 
ered from  in  the  large  majority  of  cases,  they  may  at  any  time  be  fatal. 

These  enumerations,  selected  as  examples  merely,  might  be  much 
farther  extended  but  that  the  special  prognosis  of  each  disease  will 
be  fully  set  forth  in  the  several  articles  upon  them  in  the  body  of  this 
work.  Those  now  given  may  suffice  for  the  illustration  of  the  method 
and  general  principles  by  which  the  physician  must  be  guided  in  his 
anticipation  of  the  progress  and  result  of  cases  of  disease.  The  caution 
may  be  repeated,  to  observe  great  care  in  forming  a  conclusion  in  regard 
to  prognosis  in  every  instance,  and  still  more  in  expressing  it,  unless  in 
the  presence  of  very  clear  and  positive  evidence. 

1  Yet  I  saw  a  case  of  acute  cerebro-meningitis,  in  a  girl  ten  years  of  age,  in  which  a 
violent  convulsion  occurred  on  about  the  sixth  day  of  the  disease,  and  was  followed  hy 
convalescence. 


HYGIENE. 

BY  JOHN   S.   BILLINGS,  M.  D. 


THE  purpose  of  this  paper  is  to  indicate  some  of  the  ways  in  which 
hygiene,  both  private  and  public,  is  connected  with  the  duties  of  the 
general  practitioner,  and  to  give  some  information  as  to  modern  methods 
of  investigation  and  work  in  preventive  medicine. 

While  the  business  of  the  physician  is  more  especially  the  care  of  the 
sick  with  reference  to  the  cure  of  disease,  or,  where  that  is  beyond  his 
power,  as  is  too  frequently  the  case,  to  relieve  suffering  and  secure  tem- 
porary ease  for  his  patient,  he  is  nevertheless  often  called  upon  to  answer 
questions  as  to  the  causes  of  disease,  and  the  best  means  of  avoiding  or 
destroying  these  causes.  Not  only  does  diagnosis  often  turn  Upon  con- 
siderations of  etiology,  but  a  very  considerable  part  of  the  treatment  of 
actual  disease  must  be  hygienic  in  the  broader  sense  of  the  word.  The 
prescription  or  the  surgical  operation  must  not  only  be  supplemented  by 
advice  as  to  residence,  clothing,  food,  exercise,  etc.,  but  must,  in  many 
cases,  be  merely  supplementary  to  such  advice,  which  indicates  the 
really  essential  method  of  treatment;  and  the  giving  this  advice  then 
becomes  the  most  important  part  of  the  physician's  work,  although  not 
usually  recognized  as  such  by  his  patients.  The  chief  value  of  the 
prescription  is,  in  fact,  often  to  methodize  the  mode  of  life  of  the  patient 
and  to  remind  him  at  frequently  recurring  intervals  of  the  regimen  which 
has  been  ordered  with  it. 

The  physician  has  also  certain  duties  in  relation  to  the  public  at  large, 
as  well  as  to  his  individual  patients,  and  these  duties  become  more 
numerous  and  important  as  the  density  of  population  increases,  so  that 
in  the  large  cities  of  most  civilized  countries  he  finds  himself,  nolens 
volens,  in  almost  daily  contact  with  legally  constituted  authorities  in  the 
shape  of  registrars,  health  officers,  coroners,  etc.,  and  is  not  infrequently 
summoned  before  the  courts  as  a  supposed  expert  in  matters  connected 
with  the  public  health. 

Moreover,  the  physician  who  has  become  eminent  in  his  profession  is, 
in  many  cases  the  adviser,  and,  so  far  as  professional  subjects  are  con- 
cerned, to  a  great  extent  the  guide,  of  those  who  legislate  for,  or  execute 
the  laws  of,  not  only  his  own  city  or  county,  but  his  state  and  the 
nation ;  and  he  must  to  a  corresponding  degree  be  held  responsible  for 
the  position  which  he  takes  and  the  advice  which  he  gives  in  regard  to 
public  health  matters.  This  is  true  whether  his  attitude  on  these  subjects 

173 


174  HYGIENE. 

be  active  or  passive,  for  his  silence  will  be  taken  to  mean  that  there  is  uo 
necessity  for  action  or  change. 

The  limits  of  this  paper  do  not  permit  the  presentation  of  proofs  and 
illustrations  of  these  somewhat  dogmatic  assertions,  but  it  is  believed  that 
they  will  meet  with  general  assent  from  medical  men  without  formal  and 
detailed  argument,  and  that  it  is  unnecessary  here  to  urge  the  interest  or 
importance  of  practical  hygiene  upon  the  medical  profession,  or  to  enlarge 
upon  the  desirability  that  the  practitioner,  as  well  as  the  professional  sani- 
tarian, should  be  familiar  with  the  conclusions  of  modern  science  and 
technology  with  regard  to  it. 

In  the  minds  of  many  intelligent  and  thoughtful  physicians  there  is, 
no  doubt,  a  feeling  of  unformulated  distrust  as  to  the  real  possibilities  or 
probabilities  of  improving  the  health  and  diminishing  the  mortality  of 
the  community  at  large;  and  this  feeling  is  in  part  due  to  the  exaggerated 
claims  and  emotional  exhortations  of  some  advocates  of  hygiene.  A 
careful  and  unprejudiced  survey  of  what  has  been  accomplished  by  sani- 
tary measures  will,  however,  largely  dissipate  this  distrust. 

The  natural  term  of  the  life  of  man  is  fixed  by  the  physiologist  at 
about  one  hundred  years,  which  is  nearly  in  accordance  with  the  law 
indicated  by  Flourens,  that  the  period  of  life  of  an  animal  is  about  five 
times  that  required  to  perfect  the  development  of  its  skeleton  and  unite 
the  epiphyses  with  the  shafts  of  the  long  bones.  The  actual  average 
duration  of  human  life  is  less  than  half  this,  but  there  is  satisfactory  evi- 
dence that  it  has  increased  in  civilized  countries.  The  ancient  estimate 
is  expressed  in  David's  declaration,  that  "  the  days  of  a  man  are  three- 
score years  and  ten,  and  if  by  reason  of  strength  they  be  fourscore  years, 
yet  is  their  strength  labor  and  sorrow."  Kolb,  a  cautious  and  learned 
statistician,  concluded,  from  his  studies,  that  while  the  maximum  age 
reached  by  man  has  not  materially  changed  for  many  centuries,  the  num- 
ber of  persons  who  now  survive  infancy  and  of  those  who  reach  a  ripe 
old  age  has  decidedly  increased ;  and  this  opinion  is  sustained  by  Mr. 
Lewis,  the  secretary  of  the  Chamber  of  Life  Insurance  of  New  York, 
who  points  out  that  while  civilization  largely  interferes  with  the  laws  of 
evolution  by  survivorship,  it  aids  by  economizing  the  waste  which  occurs 
in  its  absence.  "Under  natural  selection,  when  variations  in  capacity 
arise,  thousands  of  them  are  wasted  where  one  is  secured,  fixed,  and 
transmitted.  But  human  society  economizes  much  of  this  waste,  fastens 
upon  and  improves  an  immensely  larger  proportion  of  the  capacities 
lavishly  produced  by  Nature,  and  thus  concentrates  forces  which  wrould 
otherwise  spread  their  operation  over  countless  ages." ' 

We  have,  however,  no  record  of  the  duration  of  life  in  ancient  Greece 
and  Rome,  and  it  is  quite  possible  that  it  was  greater  than  in  Western 
Europe  during  the  Middle  Ages,  which  formed  a  period  of  retrogression 
in  a  sanitary  point  of  view.  The  Jew,  the  Greek,  and  the  Roman,  prior 
to  the  Christian  era,  were  probably  cleaner  in  person  and  in  dwellings 
than  the  people  of  the  time  when  dirt  became  the  odor  of  sanctity. 

In  the  absence  of  reliable  data  for  this  country,  it  is  impossible  to 
speak  with  certainty  of  the  results  of  attempts  made  here  to  prevent  dis- 
ease and  death.  Each  sex,  race,  and  age  has  its  own  rate  of  mortality, 

1  "Influence  of  Civilization  on  the  Duration  of  Life,"  Reports  Am.  Pub.  Health  Assfn, 
X.  Y.,  1877,  vol.  iii.  p.  173. 


CAUSES  OF  DISEASE,  ETC.  175 

and  until  this  rate  is  determined  we  can  only  guess  as  to  whether  good 
work  is  being  done  or  not. 

"We  can  never  hope  to  diminish  the  total  number  of  deaths  which  will 
occur  in  long  periods,  say  two  hundred  years,  but  we  may  rationally  try 
to  prolong  the  average  duration  of  life,  to  diminish  infant  mortality,  and 
to  secure  greater  comfort  and  better  health  for  individuals  and  for  the 
community  at  large. 

The  reader  must  remember  that  only  a  mere  outline  of  the  subject  can 
be  presented  here ;  the  details  would  require  several  volumes,  and  the 
tendency  to  specialization  in  this,  as  in  other  branches,  is  so  great  that  it 
is  hardly  to  be  expected  that  any  one  man  shall  have  either  the  theo- 
retical or  the  practical  knowledge  necessary  for  covering  the  entire  field. 
There  are  certain  things  in  relation  to  hygiene  which  every  physician 
should  know ;  there  are  many  other  things  with  regard  to  which  it  is 
sufficient  if  he  knows  where  to  find  full  and  reliable  information  when 
he  needs  it.  With  this  preface  we  will  pass  at  once  to  our  subject,  which 
may  be  conveniently  divided  as  follows : 

I.  Causes  of  disease,  means  of  discovery,  and  prevention. 
II.  Personal  hygiene  in  its  relations  to  the  practice  of  medicine. 

III.  Public  hygiene  in  its  relations  to  physicians. 


L  Causes  of  Disease,  Means  of  Discovery,  and  Prevention. 

Although  the  origin  of  disease  has  from  the  earliest  times  been  the 
subject  of  study  by  medical  men,  the  physician  has  not  heretofore,  usu- 
ally, been  called  upon  to  investigate  the  causes  of  disease  in  particular 
localities,  until  the  occurrence  of  sickness  in  that  locality  has  called  atten- 
tion to  the  matter.  The  education  of  the  public  as  to  the  importance  of 
sanitary  work  has,  however,  recently  made  great  progress,  and  it  is  now 
not  unusual  to  ask  the  opinion  of  the  family  physician  as  to  the  health- 
fulness  of  a  given  locality  or  house.  The  question  may  be  presented  in 
three  different  ways :  First.  In  a  given  case  of  disease,  what  is  the  prob- 
able cause  ?  Second.  Given  the  presence  of  a  known  or  suspected  cause 
of  disease,  what  are  the  best  means  of  avoiding  or  destroying  it  ?  Third. 
In  the  absence  of  cases  of  disease,  to  determine  whether  causes  of  disease 
are  probably  present,  and  if  so,  what  causes. 

The  word  "  cause  "  is  here  used  in  its  widest  sense,  including  not  only 
what  are  commonly  called  predisposing  and  exciting  causes,  but  also  those 
conditions  which  aggravate  or  continue  the  disease.  These  causes  may  be 
roughly  classed  as  follows  :  Heredity ;  impure  air ;  impure  water ;  climate ; 
habitations ;  occupation ;  food ;  intemperance  of  various  kinds ;  clothing ; 
errors  in  exercise ;  sexual  errors ;  parasites ;  contagia ;  expectant  attention 
and  other  mental  causes,  including  worry,  etc.  In  most  cases  two  or 
more  of  these  classes  of  causes  are  combined  in  action  for  the  production 
of  a  given  case  or  outbreak  of  disease,  and  when  we  refer  any  disease  to 
a  single  factor,  what  is  meant  usually  is,  not  that  this  is  the  sole  and  ex- 
clusive cause,  but  that  it  is  the  most  prominent  one. 

Bearin^  this  in  mind,  let  us  consider  brieflv  some  of  the  causes  above 

• 

mentioned. 

I.  HEREDITY. — That  the  child  inherits  from  its  parents  its  physical 


176  HYGIESE. 

type,  including  color,  stature,  physiognomy,  temperament,  and  certain 
peculiarities  of  structure  or  arrangement  of  internal  organs,  is  well  known. 
This  hereditary  influence  is  stronger  from  the  immediate  than  from  the 
remote  ancestry,  although  the  curious  phenomena  of  atavism  sometimes 
form  exceptions  to  this  rule.  The  hereditary  causes  of  disease  can  be 
guarded  against  when  known.  Theoretically,  by  preventing  generation 
on  the  part  of  persons  who  are  unfit  to  produce  offspring ;  practically,  to 
a  certain  extent,  by  taking  special  precautions  against  these  causes  and 
their  effects  in  the  individual,  particularly  at  those  ages  in  which  these 
influences  seem  to  have  their  greatest  force.  The  most  important  of  these 
hereditary  diseases  are  syphilis,  consumption,  scrofula,  cancer,  gout,  certain 
skin  diseases,  insanity,  and  criminal  tendencies  of  various  kinds. 

The  physician's  advice  is  rarely  asked  with  regard  to  the  propriety, 
from  a  sanitary  point  of  view,  of  a  proposed  marriage,  nor  is  it  often  taken 
when  given,  unless,  indeed,  it  happens  to  correspond  with  the  wishes  of 
the  recipient ;  nevertheless,  he  is  occasionally  in  a  position  to  exert  influ- 
ence in  such  a  matter,  and  when  this  is  the  case  the  following  general 
rules  may  be  borne  in  mind:  1.  No  marriage  should  occur  between  per- 
sons having  the  same  hereditary  tendency  to  disease ;  and  this  is  especially 
important  in  marriages  between  relatives.  2.  A  girl  should  not  marry 
under  the  age  of  twenty.  3.  A  person  affected  with  hereditary  or  well- 
marked  constitutional  syphilis,  or  having  a  strong  consumptive  taint,  or 
tendency  to  mental  unsoundness,  should  not  marry  at  all. 

The  precautions  to  be  taken  in  individual  cases  in  which  there  is  a 
known  hereditary  predisposition  to  certain  diseases  will  probably  be  indi- 
cated in  the  articles  upon  those  special  diseases.  The  most  important  of 
these,  from  the  sanitary  point  of  view,  are  consumption  and  gout,  partly 
because  of  their  frequency,  partly  because  of  the  undoubted  power  which 
a  proper  regimen,  applied  in  time,  has  in  controlling  them.  The  pain  in 
gout  has  often  an  excellent  sanitary  effect ;  it  is  an  inducement  to  temper- 
ance much  stronger  than  any  amount  of  good  advice. 

The  influence  of  heredity  in  producing  abnormities  of  refraction  and 
accommodation  of  the  eye,  and  the  importance  of  detecting  these  early  and 
giving  them  proper  treatment,  have  not  hitherto  received,  from  the  gen- 
eral practitioner,  the  attention  which  they  deserve.  Children  of  parents 
affected  with  astigmatism,  ametropia,  etc.  should  be  carefully  examined 
before  being  placed  at  school,  and  if  necessary  fitted  with  proper  glasses. 

The  heredity  of  idiosyncrasies  as  to  certain  articles  of  food  or  certain 
drugs  must  also  be  borne  in  mind  by  the  physician,  for,  although  implicit 
confidence  is  not  always  to  be  placed  in  the  statement  of  a  patient  that  he 
cannot  take  a  certain  medicine,  yet  a  knowledge  of  the  facts  will  occa- 
sionally save  the  prescriber  from  some  awkward  mistakes. 

The  importance  of  bearing  in  mind  the  family  peculiarities  is  best  appre- 
ciated by  the  old  family  doctor  who  has  had  two  or  three  generations  pass 
under  his  hands :  he  knows,  for  example,  that  in  one  family  he  may  ex- 
pect brain  complications,  in  another  lung  troubles,  and  that  what  would 
be  grave  symptoms  in  one  house  are  of  comparatively  small  import  in 
another.  Unfortunately,  the  greater  part  of  this  kind  of  knowledge  has 
not  yet  been  formulated,  and  each  physician  has  to  acquire  it  for  himself; 
but  he  will  find  the  process  of  acquisition  greatly  facilitated  if  in  all  cases 
in  a  new  family  he  makes  it  a  rule  to  learn  something  of  the  medical  his- 


CAUSES  OF  DISEASE,  ETC.  177 

tory  of  the  parents,  and  he  will  find  intelligent  laymen  quick  to  appreciate 
his  inquiries  in  this  direction. 

The  importance  of  taking  into  account  hereditary  influences  is  well  illus- 
trated by  the  care  which  is  taken  to  obtain  information  with  regard  to 
them  in  well-conducted  life  insurance  companies.  The  medical  examiners 
of  such  companies  have  their  attention  specially  called  to  this  matter,  and 
the  following  extract  from  a  manual  of  instructions  shows  how  it  is  re- 
garded from  a  business  point  of  view :  "  If  consumption  is  found  to  have 
occurred  in  the  family  of  the  applicant,  he  is  to  be  regarded  not  insurabla 
under  the  following  circumstances,  viz. : 

YEARS  OP  AGE. 

If  in  both  parents,  not  insurable  until 40 

If  in  one  parent,  not  insurable  until 30 

(Except  for  ten-year  endowments,  then  20  years.) 

If  in  two  members  (not  parents) 35 

If  in  one  member  (brother  or  sister) 20 

(Except  for  ten-year  endowments,  when  peculiarly  favorable.)" 

If  apoplexy,  paralysis,  or  heart  disease  is  found  to  have  occurred  in 
any  two  members  of  the  applicant's  family,  he  is  to  be  regarded  as  insur- 
able only  upon  the  endowment  plan,  the  term  of  insurance  to  expire  prior 
to  his  reaching  the  age  of  fifty  years.  If  insanity  shall  have  so  occurred 
(in  two  members),  a  provisionary  clause  is  essential,  and  is  attached  to  the 
policy  by  the  company. 

II.  IMPURE  Airf. — The  dangers  of  impure  air,  water,  and  food  depend 
largely  upon  the  fact  that  through  these  media  may  be  introduced  into 
the  body  particles  of  organic  matter,  living  or  dead,  which  tend  to  pro- 
duce disease  in  the  recipient.  The  parasites  are  types  of  this  mode  of 
disease-production,  and  these  blend  with  the  contagia  of  the  specific  dis- 
eases in  such  a  way  that  it  is  not  easy  to  draw  the  distinction  in  all  cases. 
There  are  also  certain  poisonous  gases  and  inorganic  compounds  which 
may  occasionally  be  present  in  air  or  water  to  such  an  extent  as  to  pro 
duce  disease;  but  as  a  rule  the  gaseous  impurities  of  the  air  are  offensive 
to  the  smell  rather  than  dangerous,  as  will  be  seen  when  we  come  to  con- 
sider the  effluvium  nuisances. 

The  subject  of  ventilation,  for  the  purpose  of  procuring  an  adequate 
supply  of  pure  air,  is  one  of  so  much  importance,  and  one  upon  which  the 
physician  is  so  liable  to  be  called  for  practical  advice,  that  it  seems  proper 
to  state  briefly  the  general  principles  which  should  govern  investigations 
into,  or  recommendations  upon,  this  subject. 

The  impurities  of  air  which  are  to  be  disposed  of  by  ventilation  arn 
for  the  most  part  derived  from  the  human  body,  chiefly  from  respiration, 
and  these  only  will  be  considered  here.  In  some  cases  it  is  necessary  to 
make  special  provision  for  the  products  of  combustion  from  gas,  etc.,  but 
as  a  rule  this  is  rather  for  the  purpose  of  regulation  of  temperature  than 
anything  else.  The  impurities  of  air  due  to  the  presence  of  human  beings 
consist  mainly  of  carbonic  acid,  ammonia,  sulphuretted  hydrogen,  and 
sulphide  of  ammonium,  and  of  various  organic  compounds,  mostly  in  the 
form  of  minute  particles  of  organic  matter  of  uncertain  structure,  but 
extremely  prone  to  decomposition.  It  is  usual  to  estimate  the  degree  of 
impurity  by  the  amount  of  carbonic  acid  present,  and  this  leads  many 
persons  to  suppose  that  the  carbonic  acid  is  in  itself  the  chief  and  most 
dangerous  impurity.  This  gas  is,  however,  not  perceptible  to  the  senses, 

VOL   L— 12 


178  HYGIENE. 

nor  is  it  injurious  to  health,  unless  present  in  much  greater  proportion 
than  that  in  which  it  will  be  found  in  the  most  crowded  habitations  or 
assembly-rooms.  Its  importance  in  questions  of  ventilation  depends 
upon  the  fact  that  its  increase  in  a  room  beyond  the  amount  present  in 
the  outer  air  may  usually  be  taken  to  be  in  direct  proportion  to  the  amount 
of  the  really  dangerous  and  offensive  impurities  present,  and  that  the 
amount  of  carbonic  acid  can  be  ascertained  by  chemical  tests  with  com- 
parative ease  and  rapidity;  which  is  not  the  case  with  regard  to  the 
organic  matter.  The  carbonic  acid  is  therefore  taken  as  the  measure  of 
the  impurity,  although  it  is  not  itself  the  impurity  of  which  we  are  most 
anxious  to  be  free. 

To  decide  as  to  whether  a  room  is  well  ventilated  or  not,  some  standard 
of  permissible  impurity  must  be  fixed,  and  this  standard  is  now  usually 
taken  to  be,  in  a  room  occupieel  by  human  beings,  that  condition  of  air 
which  produces  in  a  person  having  a  normal  sense  of  smell,  and  who 
enters  from  the  fresh  air,  a  faint  sensation  of  an  odor  very  slightly  musty 
and  unpleasant.  Upon  testing  the  air  of  such  a  room,  it  will  be  found 
that  the  amount  of  carbonic  acid  impurity  present — that  is,  the  excess  of 
this  acid  over  the  amount  in  the  external  air — will  be  between  2  and  3 
parts  in  10,000. 

As  the  amount  of  carbonic  acid  in  normal  air  varies  from  2  to  5  parts 
in  10,000  in  different  places,  and  in  the  same  place  at  different  times,  it 
is  better  to  look  to  the  carbonic  acid  impurity  as  ab'ove  defined  rather 
than  to  the  total  amount  of  the  acid  found  present,  if  strict  accuracy  is 
desired ;  but  usually  the  statement  of  Dr.  Parkes  is  correct,  that  the 
organic  impurity  of  the  air  is  not  perceptible  to  the  senses  until  the  total 
carbonic  acid  rises  to  the  proportion  of  6  parts  in  10,000  volumes.  When 
the  carbonic  acid  reaches  9  parts  in  10,000  the  air  is  close,  and  when  it 
exceeds  1  part  in  1000  the  air  is  usually  decidedly  unpleasant.  If  we 
take  2  parts  in  10,000  as  the  permissible  maximum  of  carbonic  acid 
impurity,  it  follows  that  the  amount  of  fresh  air  which  must  be  supplied 
and  thoroughly  distributed  for  each  person  per  hour  is  3000  cubic  feet. 
If  3  parts  per  10,000  be  taken  as  the  permissible  maximum  (which  is 
the  standard  of  Pettenkofer),  the  amount  of  air  per  head  per  hour  must 
be  2000  cubic  feet.  While  it  is  impossible,  as  Dr.  Parkes  remarks,  to 
show  by  direct  evidence  that  the  impurity  indicated  by  7,  8,  or  even  10, 
parts  of  carbonic  acid  per  10,000  is  injurious  to  health,  it  is  advisable  to 
accept  his  standard,  because  it  is  a  simple  one,  and  can  be  practically 
applied  without  special  apparatus  or  technical  skill,  and  because  there  is 
evidence  of  the  injury  to  health  which  continued  exposure  to  air  impure, 
by  this  standard,  ultimately  produces. 

Keeping  this  standard  in  view,  the  physician  may  be  called  on  for  an 
opinion  as  to  whether  the  ventilation  of  a  given  building  is  satisfactory 
or  as  to  the  merits  of  a  proposed  plan  for  ventilation.  The  first  is  a 
question  of  fact :  What  are  the  effects  produced  upon  the  inmates  ?  Are 
there  unpleasant  odors  in  the  building  or  not?  What  percentage  of  car- 
bonic impurity  is  present?  What  is  the  number  of  cubic  feet  of  air  per 
head  that  is  introduced  and  removed  per  hour?  And  what  is  the  charac- 
ter of  the  fresh-air  supply  as  to  purity  ?  Does  it  come  from  the  cellar,  or 
from  other  rooms,  or  from  a  foul  area  ?  Air-currents  can  usually  be  best 
investigated  by  the  fumes  of  nascent  muriate  of  ammonia  produced  by 


CAUSES  OF  DISEASE,  ETC.  179 

exposing  a  cylinder  of  common  blotting-paper,  moistened  with  dilute 
hydrochloric  acid,  to  the  vapors  coming  from  a  crumpled  fragment  of  the 
same  paper  moistened  with  common  aqua  ammonia  and  placed  within 
the  cylinder.  The  process  for  carbonic  acid  determination  is  simple,  and 
can  be  learned  in  three  hours  in  a  laboratory  under  a  skilful  teacher. 
It  does  not  seem  worth  while  to  describe  it  here.  The  determination  of 
the  amount  of  air  passing  through  a  given  register,  flue,  or  chimney  in 
a  given  time  is  to  be  made  by  the  use  of  an  anemometer,  an  instrument 
which  registers  the  velocity  of  the  current  of  air  passing  through  it. 

In  judging  of  the  merits  of  a  plan  of  ventilation  the  following  points 
should  be  remembered :  The  defect  in  most  plans  for  ventilation  is  in  the 
air-supply.  Many  people  suppose  that  they  have  made  all  necessary  pro- 
vision for  ventilation  if  they  have  put  in  tubes  or  openings  for  the  escape 
of  foul  air,  forgetting  that  these  outlets  will  have  no  effect  if  correspond- 
ing inlets  are  not  provided.  Examine,  first  of  all,  therefore,  the  ducts, 
flues,  and  openings  proposed  for  the  fresh-air  supply,  with  reference  to 
their  size  and  position  and  the  amount  of  air  to  be  furnished  by  them. 
These  will  almost  invariably  be  found  to  be  too  small.  The  proper  size 
of  flues  and  registers  for  a  given  room  is  ascertained  by  dividing  the 
number  of  cubic  feet  of  air  to  be  supplied  per  second  by  the  velocity  in 
feet  per  second  which  the  air  is  to  have  in  the  flue  or  opening,  bearing  in 
mind  that  it  is  much  better  that  these  flues  and  registers  shall  be  too  large 
than  too  small,  since  it  is  easy  to  reduce  their  capacity,  but,  in  most  cases, 
impossible  to  increase  it.  When  the  fresh-air  register  is  so  situated  that 
the  current  of  air  from  it  is  liable  to  strike  upon  the  person  of  an  occu- 
pant of  the  room,  the  velocity  of  this  current  should  not  exceed  1J  feet 
per  second  if  unpleasant  draughts  are  to  be  avoided ;  and  it  will  usually 
be  found  best  that  the  velocity  of  the  air  in  the  flue  shall  not  exceed  6 
feet  per  second,  except  in  the  case  of  very  large  flues,  where  the  element 
of  friction  becomes  of  comparatively  small  importance.  In  the  great 
majority  of  cases  the  amount  of  air  to  be  supplied  depends  upon  the 
number  of  persons,  and  not  on  the  cubic  space;  but  in  exceptional 
instances,  where  the  amount  of  cubic  space  is  very  large  in  proportion  to 
the  number  of  persons,  and  the  heating  is  effected  by  warm  air,  it  may 
require  more  air  to  keep  the  room  at  a  comfortable  temperature  than  is 
necessary  for  the  supply  of  the  occupants.  The  cubic  space  is  also  rela- 
tively much  more  important  in  rooms  which  are  to  be  occupied  but  a 
short  time  continuously,  and  can  then  be  thoroughly  aired,  than  it  is  in 
rooms  constantly  occupied. 

The  methods  of  calculation  can  be  best  illustrated  by  one  or  two  exam- 
ples. What  should  be  the  number  and  size  of  flues  and  registers  for 
fresh-air  supply  for  a  hospital  ward  to  contain  24  beds,  the  ward  being  a 
rectangular  pavilion  with  windows  on  opposite  sides  ?  In  this  case  the 
room  is  constantly  occupied,  and  the  supply  of  air  should  be  1  cubic  foot 
per  head  per  second,  or,  in  all,  24  cubic  feet  per  second.  The  velocity 
of  current  at  the  registers  should  not  exceed  3  feet  per  second — better 
only  2.  This  will  require  from  8  to  12  square  feet  of  clear  opening  in 
the  registers.  If  we  allow  four  on  each  side  of  the  room,  each  register 
must  have  at  least  1  square  foot  of  clear  opening.  The  velocity  of  the 
air  in  the  flues  supplying  these  registers  should  not  exceed  4  feet  per 
second,  and  therefore  the  area  of  each  flue  should  be  about  9  by  12 


ISO  HYGIENE. 

inches.  Suppose  the  same  question  be  asked  with  regard  to  a  school-- 
room to  contain  48  pupils.  In  this  case  the  room  will  not  be  occupied 
more  than  two  hours  at  a  time.  The  air-supply  desirable  may  be  put 
down  at  35  cubic  feet  per  head  per  minute,  or  28  cubic  feet  per  second 
for  the  whole.  The  velocity  in  the  flues  may  be  put,  as  before,  at  4  feet 
per  second ;  hence  we  need  7  square  feet  area  of  flue,  or  seven  flues,  each 
having  1  square  foot  of  area.  It  is  safe  to  say  that  there  are  not  twenty 
school-houses  in  the  United  States  which  have  fresh-air  flues  of  sufficient 
area ;  the  deficiency  is  made  up,  for  the  most  part,  by  leakage  of  the 
outer  air  through  cracks  around  windows  and  directly  through  the  wall, 
and  also  by  the  passage  of  air  from  the  central  hall  into  the  room,  this 
last  air  coming  from  the  cellar  or  basement. 

The  velocity  of  the  air  at  the  foul-air  registers  and  in  the  foul-air  ducts 
may  be  greater  than  in  the  fresh-air  flues,  since  there  is  no  danger  of  its 
causing  draughts,  and  hence  there  is  no  truth  in  the  common  notion  that 
the  outlets  should  be  larger  than  the  inlets  to  allow  for  the  expansion  of 
heated  air.  It  is  important  that  the  velocity  of  the  current  in  the  outlet 
shaft  or  chimney  should  be  at  least  8  feet  per  second  at  the  point  where 
it  escapes  into  the  outer  air;  and  if  the  outlets  be  too  large  for  the  inlets, 
the  result  may  be  that  some  of  the  foul-air  flues  will  work  backward  and 
become  inlets.  The  plan  of  making  everything  a  little  larger  than  is 
necessary  is  not  a  safe  one  as  regards  chimney-flues  and  outlet  shafts. 

The  merits  of  a  plan  of  ventilation  depend  not  only  on  the  amount  of 
air  introduced,  but  on  its  distribution.  The  test  for  distribution  is  chem- 
ical analysis  of  samples  taken  in  different  parts  of  the  room  and  at  differ- 
ent levels.  A  very  good  idea  of  the  direction  taken  by  the  incoming  air 
can  also  be  obtained  by  the  use  of  fumes  of  nascent  muriate  of  ammonia, 
as  above  described.  In  considering  the  distribution  which  will  probably 
take  place  in  a  given  plan,  care  should  be  taken  not  to  fall  into  the  com- 
mon error  of  supposing  that  because  pure  carbonic  acid  gas  is  heavier  than 
air,  therefore  the  carbonic  acid  derived  from  respiration  sinks  to  the  floor, 
and  that  special  provision  should  be  made  to  remove  it  at  that  point. 
The  law  of  the  diffusion  of  gases  effectually  prevents  this  separation  and 
sinking  of  the  carbonic  acid  from  the  mixture  of  gases  expired,  and  it  will 
be  found  to  be  present  in  about  equal  proportions  in  all  parts  of  an  inhab- 
ited room. 

The  methods  of  introducing  and  distributing  fresh  air  depend  to  a  great 
extent  upon  the  methods  of  heating  employed ;  and  it  is  necessary  to 
remember  that  while  good  ventilation  is  a  very  desirable  thing,  satisfac- 
tory heating  is,  in  cold  weather,  still  more  desirable,  and  must  be  attained 
even  if  the  ventilation  is  interfered  with  for  that  purpose.  The  principal 
difficulty  in  the  way  of  securing  good  ventilation  is  its  cost.  In  a  cold 
climate  satisfactory  heating,  good  ventilation,  and  cheapness  are  not  com- 
patible ;  it  is  comparatively  easy  to  obtain  any  two  of  them,  but  impossi- 
ble to  have  the  three  together.  This  fact  should  be  fully  understood  and 
realized  by  the  physician,  for  its  comprehension  will  save  much  time  in 
considering  the  merits  of  various  patent  ventilators  and  ventilating  appli- 
ances, which,  according  to  their  inventors,  produce  good  ventilation  at  no 
expense  beyond  that  of  the  original  cost  of  the  apparatus ;  which  is  prac- 
tically about  the  same  as  a  claim  to  have  discovered  perpetual  motion. 
Patent  ventilators  are  usually  cowls  to  be  placed  upon  the  top  of  outlet 


CAUSES  OF  DISEASE,  ETC.  181 

flues.  I  know  of  none  which  are  superior  to  the  common  Emerson  Venti  - 
lator,  on  which  there  is  now  no  patent.  In  cold  weather  the  air  must  be 
warmed  to  secure  comfort ;  it  must  be  changed  to  secure  ventilation.  The 
changing  of  the  air  carries  off  heat,  the  loss  of  which  must  be  supplied  by 
fuel,  which  fuel  costs  money.  The  greater  the  ventilation,  the  more  rapid 
the  change  and  the  more  heat  required.  It  is  therefore  quite  possible  to 
judge  somewhat  of  the  merits  of  a  heating  and  ventilating  apparatus — 
for  example,  of  a  school-house — from  the  amount  of  fuel  consumed ;  but 
the  conclusion  will  be  precisely  the  reverse  of  that  drawn  by  the  average 
trustee,  since  it  will  be,  that  within  certain  limits  the  less  fuel  required 
the  less  satisfactory  the  apparatus. 

The  evil  effects  of  insufficient  ventilation,  although  very  certain  and 
very  serious,  are  not  immediate,  or  such  as  to  attract  attention  at  first,  ex- 
cept in  very  aggravated  cases  with  excessive  over-crowding.  The  power 
of  the  organism  to  adjust  itself  to  surrounding  circumstances  is  very  great, 
and  perhaps  as  great  in  regard  to  the  endurance  of  foul  air  as  anything 
else.  Yet  this  power  is  greater  in  seeming  than  in  reality,  for  at  last  such 
air  produces  disease  and  shortens  life.  Its  effects  are  manifested  in  dis- 
eases of  the  respiratory  organs,  acute  and  chronic,  and  it  is  now  generally 
admitted  that  the  undue  prevalence  of  phthisis  in  troops  is  due  to  the  foul 
air  of  the  barrack-rooms. 

Some  persons  are  much  more  susceptible  than  others  to  the  effects  of 
impure  air,  and  will  suffer  from  headache,  languor,  loss  of  appetite,  etc. 
where  others  would  experience  little  inconvenience.  Children  thus  sus- 
ceptible dread  the  school-room  as  ordinarily  constructed  and  ventilated, 
and  their  discomfort  should  be  taken  into  account  and  guarded  against. 

Thus  far,  reference  has  been  made  only  to  those  impurities  of  air  due  to 
respiration  and  lights;  in  other  words,  the  necessary  impurities  found  in 
human  habitations.  The  impurities  due  to  sewer  gases  will  be  referred  to 
hereafter;  they  should  be  prevented  absolutely,  and  not  provided  for  by 
ventilation.  One  of  the  most  difficult  problems  presented  to  the  phy- 
sician is  to  determine  whether  the  effluvia  from  a  given  locality  are  in- 
jurious to  health,  and  if  so,  to  what  extent.  These  effluvia  may  be  due  to 
certain  occupations  or  manufactures,  or  they  may  result  from  the  disposal 
of  excreta,  from  obstructed  drainage  giving  rise  to  swamps  and  the  collec- 
tion of  decaying  organic  matter,  and  in  other  ways.  The  best  definition 
of  the  term  "injurious  to  health"  in  this  connection  is  perhaps  that  sug- 
gested by  Dr.  Ballard — i.  e.  that  exposure  to  the  offensive  effluvia  causes 
bodily  discomfort  or  other  functional  disturbance,  continuing  or  recurring 
as  the  exposure  continues  or  recurs,  and  tending  by  continuance  or  repe- 
tition to  create  an  appreciable  impairment  of  general  health  and  strength, 
to  render  those  exposed  more  liable  than  others  to  attacks  of  disease,  and 
more  apt  to  suffer  severely  when  attacked,  and,  in  the  more  serious  forms, 
to  the  direct  production  of  the  disease  and  the  shortening  of  life. 

The  group  of  symptoms  due  to  offensive  effluvia  is,  as  Dr.  Ballard 
remarks,  a  tolerably  constant  one,  and  consists  of  loss  of  appetite,  nausea, 
headache,  giddiness,  faintness,  and  a  general  sense  of  depression,  with,  in 
some  cases,  vomiting  and  diarrhoea.  But  it  is  usually  impossible  to  prove 
by  statistics  that  these  phenomena  are  due  to  a  given  effluvium  complained 
of,  for  those  who  suffer  from  it  are  usually  exposed  to  other  causes  of  ill- 
health,  such  as  poverty,  overcrowding,  collection  of  filth,  etc. ;  and,  on  the 


182  HYGIENE. 

other  hand,  many  of  those  exposed  to  the  effluvium  seem  to  suffer  very 
little,  if  at  all,  from  their  surroundings.  And  so  true  is  this,  that  in  the 
carefully  prepared  report  upon  effluvium  nuisances  recently  issued  by  Dr. 
Ballard,1  it  will  be  found  that  as  a  rule  no  attempt  is  made  to  prove  that 
the  effluvia  from  any  particular  branch  of  industry  are  injurious  to  health  ; 
the  test  practically  applied  is  that  they  produce  offensive  odors. 

The  legal  view  of  this  subject  is  given  in  the  various  decisions  as  to 
what  should  be  considered  a  nuisance,  the  essence  of  which  is  the  use  of 
one's  own  property  in  such  a  way  as  to  inflict  damage  upon,  and  injure 
the  rights  of,  another.  If  a  man  collects  on  his  own  premises,  for  his  own 
use,  any  material,  such  as  water  or  filth,  he  is  bound  to  retain  it  within 
his  own  premises  or  to  let  none  of  it  escape  in  such  a  way  as  to  damage 
others;  and  this  holds  good  as  regards  gases,  vapors,  and  odors.  The 
decision  of  Mansfield,  in  the  case  of  Rex  vs.  White,  is  often  quoted 
approvingly  by  jurists,  viz.:  "It  is  not  necessary  that  the  smell  be 
unwholesome;  it  is  enough  if  it  renders  the  enjoyment  of  life  uncom- 
fortable." But,  practically,  the  question  as  to  whether  the  discomfort  pro- 
duced is  sufficient  to  produce  ill-health  will  be  the  one  upon  which  the 
physician  is  called  to  give  evidence,  and  the  one  also  upon  which  he  will 
find  it  most  difficult  to  obtain  data  sufficient  to  enable  him  to  form  a  posi- 
tive opinion. 

III.  IMPURE  WATER. — Of  all  the  various  preventable  or  removable 
causes  of  disease  to  which  the  attention  of  the  physician  engaged  in  prac- 
tice in  the  small  towns  and  rural  districts  is  directed,  it  will  usually  be 
found  that  the  water-supply  is  the  most  important,  because  it  is  in  these 
localities  that  it  is  most  liable  to  become  contaminated  in  such  a  way  as 
to  produce  sickness. 

All  water  used  for  drinking  purposes  is  impure  in  the  chemical  sense, 
since  it  contains  some  inorganic  matters  or  salts,  and  in  most  cases  organic 
matter  also.  It  is  difficult  to  define  precisely  what  should  be  considered 
an  impure  water  in  a  sanitary  sense,  and  the  best  we  can  do  is  to  indicate 
probabilities  in  the  absence  of  positive  evidence  of  the  production  of  dis- 
ease by  the  suspected  water.  So  far  as  inorganic  impurities  are  concerned, 
the  most  important,  from  the  sanitary  point  of  view,  are  the  salts  of  lead, 
magnesia,  and  lime,  but  in  this  country  these  are  so  rarely  the  cause  of 
disease  that  they  hardly  require  special  notice.  The  physician  should, 
however,  bear  in  mind  possibilities  of  lead-poisoning  in  some  obscure 
cases  which  he  will  meet. 

The  diseases  due  to  impure  water  are  certain  specific  fevers,  diarrhoeal 
diseases,  and  some  affections  due  to  parasites  which  find  entrance  to  the 
body  through  this  medium.  The  water-supply  is  to  be  suspected  in  case 
of  prevalence  of  diarrhoeal  disease  in  a  community,  and  especially  if  the 
outbreak  be  sudden  and  affect  a  number  of  persons  and  families.  Sudden 
outbreaks  of  cholera,  typhoid  fever,  or  malarial  fever,  confined  to  a  limited 
locality,  should  lead  to  careful  examination  of  the  water-supply.  The  im- 
purity in  water  which  causes  these  diseases  is  supposed  to  be  either  organic 
or  the  product  of  organic  life,  and  at  present  the  prevailing  opinion  is  that 
the  really  dangerous  impurities  consist  of  minute  living  organisms  or 

1  Report  in  respect  of  the  Inquiry  rts  to  Effluvium  Nuisances  arising  in  connection  with  various 
Manufacturing  and  other  branches  of  Industry.  By  Dr.  Ballard,  London.  Her  Majesty's 
Stationery  Office,  1882,  8vo. 


CAUSES  OF  DISEASE,  ETC.  183 

germs.  It  is  usual  to  estimate  the  impurity  of  water  by  the  amount  of 
organic  matter  present,  but  it  is  evident  that  this  alone  can  give  no  pos- 
itive information,  since  by  this  standard  milk  and  soup  would  be  very 
dangerous.  Much  depends  upon  the  character  of  the  organic  matter, 
whether  it  is  derived  from  the  animal  or  vegetable  kingdom — whether  it 
is  in  a  state  of  fermentation  or  putrefaction,  etc.  etc. ;  but  the  presence  of 
specific  germs  in  it  is  the  most  important  part  of  all,  and  at  the  same  time 
the  most  difficult  to  ascertain.  Nitrogenous  organic  matter  in  a  state  of 
decomposition  is  dangerous,  yet  it  does  not  always  produce  disease,  even 
when  ingested  in  comparatively  large  quantity,  as  in  case  of  "high"  game 
or  tainted  meat;  and  it  is  easy  to  find  instances  where  water  strongly  pol- 
luted with  sewage  has  been  used  for  a  considerable  period  without  pro- 
ducing marked  ill  effects.  It  is,  however,  so  extremely  probable  as  to  be 
for  practical  purposes  certain,  that  water  contaminated  with  the  discharges 
from  persons  suffering  from  certain  diseases  will  produce  similar  diseases 
in  those  who  drink  it,  and  there  is  also  enough  evidence  that  water 
containing  filth  of  various  kinds  either  produces  or  promotes  disease  to 
warrant  much  more  attention  to  this  subject  than  has  heretofore  been 
bestowed  upon  it. 

The  chemical  examination  of  a  suspected  water  is  by  no  means  a  simple 
process,  and  in  most  cases  had  better  be  referred  to  an  expert  in  such  mat- 
ters. It  is  highly  desirable,  however,  that  the  physician  should  have 
sufficient  technical  knowledge  to .  be  able  to  make  a  rough  analysis  at 
least,  if  for  no  other  reason  than  that  he  may  be  able  to  appreciate  the 
results  reported  by  the  chemist.  As  a  rule,  when  a  water  is  so  polluted 
with  decomposing  organic  matter  as  to  be  positively  dangerous  it  will 
have  an  unpleasant  odor,  which  is  best  developed  by  half  filling  a  quart 
bottle  with  the  water  to  be  examined  and  shaking  it  thoroughly.  The 
so-called  simple  and  ready  methods  which  are  from  time  to  time  advo- 
cated in  the  newspapers,  such  as  the  addition  of  sugar  to  the  suspected 
water  and  allowing  fermentation  to  take  place,  the  use  of  tannin  as  a 
precipitant,  or  the  decolorization  of  a  solution  of  potassium  permanganate, 
are  really  of  very  little  value  and  should  not  be  relied  upon.  In  the 
hands  of  an  expert  the  best  simple  method  of  determining  the  quality 
of  a  water  is  by  evaporation  of  a  known  quantity  and  the  ignition  of  the 
solid  residue.  From  the  amount  of  the  total  residue,  the  quantity  left 
after  ignition,  the  amount  of  blackening  produced,  and  the  odor,  a  very 
fair  opinion  can  be  formed  as  to  the  amount  of  organic  matter  present, 
and  whether  it  is  of  animal  or  vegetable  origin. 

It  is  not  within  the  province  of  this  paper  to  describe  the  methods 
used  by  chemists  in  water  analysis,  of  which  the  principal  are  known  as 
the  Franklin  and  Armstrong,  the  Wanklyn,  and  the  permanganate  meth- 
ods. A  careful  examination  of  these  methods  has  recently  been  made 
under  the  direction  of  the  National  Board  of  Health,  and  a  preliminary 
note  of  the  results,  prepared  by  Professor  Mallet,  has  been  published  in 
the  Bulletin.  From  this  it  appears  that  the  chief  value  of  chemical  anal- 
ysis is,  first,  the  verification  of  gross  pollution,  which  will  usually  be  de- 
tected by  the  appearance  and  smell  of  the  water;  and,  second,  in  periodical 
examination  of  a  water-supply  to  detect  changes  from  the  normal  or  usual 
character  of  the  water,  which  may  be  taken  to  have  a  certain  local  standard 
of  purity.  Special  importance  is  attached  to  the  careful  determination  of 


184  HYGIENE. 

nitrates  and  nitrites  in  water  to  be  used  for  drinking,  these  being  the 
results  of  oxidation  of  organic  matters,  and  therefore  giving  evidence  of 
previous  contamination. 

Prof.  Mallet  concludes  that  "  there  are  no  sound  grounds  on  which  to 
establish  such  general  standards  of  purity  as  have  been  proposed,  looking 
to  exact  amounts  of  organic  carbon  or  nitrogen,  albuminoid  ammonia, 
oxygen  of  permanganate  consumed,  etc.,  as  permissible  or  not.  Distinc- 
tions drawn  by  the  application  of  such  standards  are  arbitrary  and  may 
be  misleading."  While  this  is  perfectly  true,  considered  from  the  stand- 
point of  scientific  precision,  it  does  not  sufficiently  take  into  account  the 
value  of  probabilities  in  these  matters,  considered  as  motives  to  action. 
It  is  perfectly  true  that  there  can  be  no  fixed  standard — that  a  water 
which  the  chemist  wrould  report  as  relatively  pure  might  be  much  more 
apt  to  produce  disease  than  one  which  he  would  pronounce  impure — but 
it  is  nevertheless  true  that  from  the  results  of  chemical  analysis,  taken  in 
connection  with  evidence  as  to  the  source  and  history  of  the  water,  an 
opinion  can  be  formed  as  to  the  danger  from  its  use  which  is  sufficiently 
reliable  to  be  acted  upon  in  the  absence  of  positive  evidence,  such  as  the 
production  of  disease. 

In  many  cases  the  matter  must  be  doubtful,  and  Prof.  Mallet  truly 
says  that  it  will  not  do  in  all  such  cases  to  forbid  the  use  of  the  water,  for  it 
often  happens  that  this  should  not  be  done  unless  it  is  absolutely  necessary ; 
but  there  are  many  other  cases  in  which  there  is  very  little  doubt,  and 
where  action  should  be  governed  by  the  probabilities. 

The  microscopical  examination  of  suspected  waters  sometimes  gives 
decided  indication  as  to  the  nature  of  the  impurities ;  and  it  may  be  that 
hereafter,  in  connection  with  physiological  tests,  it  will  become  of  even 
more  importance  than  the  chemical.  To  determine  the  presence  of  organ- 
isms in  a  sample  of  water  the  best  method  known  at  present  is  to  kill  and 
coagulate  them  by  means  of  osmic  acid  or  chloride  of  platinum,  and  allow 
them  to  subside.  This  method  is  of  course  inapplicable  if  it  be  desired  to 
use  them  for  either  culture-  or  inoculation-tests. 

Chemists  have  no  uniform  system  of  reporting  the  results  of  their  anal- 
yses, some  using  grains  per  gallon,  U.  S.  or  Imperial  as  may  be,  and  others 
parts  per  hundred  thousand  or  per  million  of  the  water.  It  is  therefore 
difficult  to  appreciate  the  value  of  the  figures  as  given  by  them.  The  fol- 
lowing, in  parts  per  100,000,  will  enable  the  practitioner  to  form  a  general 
estimate  of  the  character  of  analytical  reports ;  but  the  opinion  in  indi- 
vidual cases  is  so  modified  by  the  coincident  amounts  of  chlorine,  ammonia, 
nitrous  and  nitric  acids,  that  the  experienced  sanitarian  only  is  qualified 
to  put  on  the  results  an  estimate  which  shall  be  in  accordance  with  our 
present  knowledge  of  such  matter : 

Upland  Surf  ace -Waters. 

Allowable.  Doubtful.  Impure. 

Total  organic  elements to  .4  .4      to  .6  Over  .6 

Oxygen  required to  .3  .3      to  .4  "     .4 

Albuminoid  ammonia to  .015  .015  to  .025  "     .025 

All  Other  Waters. 

Total  organic  elements to  .2  .2      to  .4  Over  .4 

Oxygen  required to  .15  .15    to  .2  "     .2 

Albuminoid  ammonia to  .010  .010  to  .015  "     .015 


CAUSES  OF  DISEASE,  ETC.  185 

In  connection  with  impure  water  should  be  mentioned  impure  ice.  Ice 
is  purer  than  the  water  from  which  it  forms,  but  if  cut  on  a  foul  pond  it 
will  itself  be  foul,  and  the  vitality  of  some  microscopic  organisms  is  not 
destroyed  by  their  being  frozen,  as  is  shown  by  the  fact  that  samples  from 
the  centre  of  blocks  of  ice  will  inoculate  sterilized  infusions  with  the 
germs  of  putrefaction,  precisely  as  the  water  of  which  the  ice  is  composed 
would  have  done  before  it  was  frozen.  Disease  has  been  traced  to  impure 
ice,  and  it  may  be  that  it  is  more  frequently  due  to  this  cause  than  has 
heretofore  been  supposed ;  at  all  events,  it  is  well  to  bear  the  possibility 
in  mind. 

The  subject  of  impure  water  will  be  further  considered  in  speaking  of 
habitations. 

IV.  CLIMATE. — The  literature  of  the  effects  of  different  climates  upon 
the  human  body  is  very  extensive,  following  the  general  rule  that  the  less 
positive  or  precise  knowledge  there  is  upon  a  given  subject  the  more  will 
be  written  about  it.  Of  all  animals,  man  seems  to  adapt  himself  most 
readily  to  the  extremes  of  climate;  and,  although  it  is  commonly  supposed 
that  a  tropical  climate  is  injurious  to  those  coming  from  cooler  regions, 
yet  it  has  been  found  that  where  he  takes  the  same  precautions  to  ensure 
cleanliness,  pure  water  and  air,  and  proper  food,  the  European  does 
not  have  a  higher  rate  of  mortality  in  Algeria  or  in  the  East  or  West 
Indies  than  he  does  at  home,  if  the  effects  of  cholera  and  yellow  fever 
be  excepted. 

Dr.  Parkes  defines  the  effect  of  climate  upon  the  human  body  to  be 
"  the  sum  of  the  influences  which  are  connected  with  the  solar  agencies, 
the  soil,  the  air,  or  the  water  of  a  place ;"  in  other  words,  he  makes  it 
nearly  equivalent  to  the  locality  or  the  environment.  By  "  climate  "  we 
understand,  commonly,  the  sum  of  meteorological  influences,  the  most 
important  of  which,  as  regards  health,  are  temperature,  humidity,  and 
wind.  The  effects  of  temperature  in  producing  disease  are  often  con- 
founded with  the  effects  of  change  of  temperature,  which  last  is  perhaps 
the  more  important  of  the  two,  and  should  be  specially  borne  in  mind  in 
advising  climato-therapy  for  chronic  or  wasting  diseases. 

The  influence  of  climate  in  causing  disease,  although  well  known  for 
over  two  thousand  years,  has  not  led  to  much  effort  to  avoid  or  prevent 
effects  which  are  accepted  as  inevitable  by  the  great  majority.  It  is  true 
that  in  the  effort  to  secure  physical  comfort  by  houses,  clothing,  artificial 
heat,  and  the  like,  much  hygienic  work  has  been  done,  and  the  steadily 
increasing  tendency  on  the  part  of  all  who  can  afford  it  to  seek  rest  and 
comfort  at  the  seaside  or  in  the  mountains  during  hot  weather  is  no  doubt 
due,  in  part,  to  the  fact  that  experience  has  shown  that  the  money  expended 
in  thus  securing  health  and  strength  is  a  good  investment.  It  is  unfortu- 
nate that  "  health  resorts,"  so  called,  do  not  always  prove  to  be  such  :  they 
become  fashionable,  overcrowded ;  the  arrangements  for  the  disposal  of 
excreta  are  cheap  makeshifts,  leading  to  soil-  and  water-pollution,  until 
finally  an  epidemic  of  diarrhoea  or  typhoid  fever  occurs,  with  the  usual 
results. 

The  consideration  of  climate  as  a  therapeutic  agent  belongs  with  the 
articles  relating  to  the  several  diseases  to  which  it  is  applicable.  The  great 
desideratum  wherewith  to  place  this  subject  upon  a  scientific  and  practical 
basis  is  a  system  of  reliable  returns  of  the  deaths,  and  if  possible  of  cer- 


186  HYGIENE. 

tain  diseases,  throughout  the  country,  and  especially  at  those  points  most 
in  vogue  as  health  resorts. 

V.  HABITATIONS. — That  a  man's  health  depends  very  much  on  the  cha- 
racter, condition,  and  location  of  his  dwelling-place  is  now  so  generally  admit- 
ted that  in  many  cases  where  a  physician  is  called  in  he  will  be  asked  whether 
he  thinks  the  disease  has  been  caused  by  any  peculiarity  about  the  house  or 
the  bedroom  of  the  patient.  And  a  careful  examination  will  usually  dis- 
cover in  one  of  them  several  evils  to  be  remedied,  although  their  con- 
nection with  the  case  in  hand  may  be  very  doubtful.  There  are  very 
few  homes  properly  constructed  from  a  sanitary  point  of  view;  and, 
although  we  may  not  agree  with  Dr.  Wilson,  that  "  the  modern  prison  is 
in  all  sanitary  essentials  the  best  existing  type  of  what  a  healthy  dwelling 
ought  to  be/'  it  is  nevertheless  certain  that  the  health  of  the  inmates  is 
much  more  carefully  consulted  in  planning  a  penitentiary  than  it  usually  is 
in  planning  a  college,  a  hotel,  or  a  dwelling-house.  Matters  are  gradually 
improving  in  this  respect :  the  worst  of  the  tenement- house  rookeries  and 
fever-nests  in  most  of  our  large  cities  have  been  improved  or  abolished, 
and  our  wealthier  citizens  are  beginning  to  pay  some  attention  to  their 
house-drainage  as  well  as  to  the  pattern  of  their  mantelpieces.  But  the 
great  majority  of  men  are  still  careless  and  negligent  as  to  the  sanitary 
condition  of  their  homes,  and  probably  two  physicians  out  of  three  live 
in  houses  in  which  numerous  defects  would  be  pointed  out  by  a  sanitary 
engineer — defects  of  which  they  are  themselves  more  or  less  aware.  The 
majority  of  people  in  our  large  cities  under  existing  conditions  cannot 
aiford  to  have  healthy  houses,  and  the  great  causes  of  the  excessive  mor- 
tality, and  brevity  of  life,  in  all  such  cities,  are  poverty  and  overcrowding, 
the  latter  resulting  from  the  former.  The  problem  as  to  the  best  mode 
of  improving  the  sanitary  condition  of  the  tenement-house  population 
does  not,  however,  come  before  the  practising  physician  for  special  con- 
sideration, and  need  not  be  considered  here.  Nor  is  the  physician  liable 
to  be  consulted  with  regard  to  the  sufficiency,  from  a  sanitary  point  of 
view,  of  the  plan  of  a  house  yet  to  be  built,  although  he  will  occasionally 
be  asked  as  to  the  healthfulness  of  a  proposed  site.  The  questions  Avhich 
he  will  be  asked  are  such  as  the  following :  "  Is  the  cause  of  this  particular 
case  of  disease  in  the  house,  or  connected  with  it?  and  if  so,  what  is  it?" 
— "Do  you  think  this  is  a  healthy  house?" — "Is  the  location  a  healthy 
one  ?" — "  Is  it  necessary  that  I  should  give  up  this  house  to  preserve  the 
lives  and  health  of  my  children  ?"  While  it  is,  of  course,  often  impos- 
sible to  answer  with  precision  such  questions  as  these,  an  answer  of  some 
kind  must  be  given ;  and  this  should  not  be  a  mere  random  guess,  but 
based  on  a  deliberate  estimate  of  the  probabilities  in  the  case.  The 
healthfulness  of  a  house  is  to  be  judged  of,  in  part,  from  its  history,  if  it 
be  possible  to  obtain  any ;  in  part,  from  such  facts  as  can  be  discovered 
by  a  careful  examination  of  the  premises  and  vicinity.  The  sanitary 
history  of  a  house  is  the  history  of  the  diseases  and  deaths  which  have 
occurred  in  it,  together  with  a  set  of  plans  showing  the  precise  location 
and  character  of  the  house-drainage  and  of  its  fresh-air  supply.  Such  a 
record  is  in  most  cases,  unfortunately,  not  attainable,  although  to  a  per- 
son proposing  to  buy  or  rent  a  house  it  would  often  be  quite  as  important 
as  a  record  of  title.  In  a  well-organized  health-office  it  should  be  pos- 
sible to  ascertain  the  number  and  causes  of  the  deaths  which  have 


CAUSES  OF  DISEASE,  ETC.  187 

occurred  in  any  given  house  or  square  in  the  city,  and  also  the  character 
and  location  of  its  drainage  and  sewer  connections.  Such  records  are 
especially  valuable  in  an  investigation  of  an  outbreak  of  disease  in  a 
community. 

The  sanitary  inspection  of  a  house  includes  the  site  and  the  building 
itself.  The  character  of  the  site  is  mainly  determined  by  its  dryness,  by 
the  presence  or  absence  of  organic  matter  in  the  soil,  and  by  its  porosity 
taken  in  connection  with  the  character  of  the  vicinity.  One-third  of  the 
volume  of  some  soils  consists  of  air,  and  all  dry  soils  and  rocks  contain  a 
much  larger  quantity  of  air  than  is  commonly  supposed.  The  influence 
of  soil  upon  health  is  exerted  mainly  through  the  media  of  water  and 
air,  but  it  also  aifects  temperature  and  vegetation,  being  an  important 
factor  in  climate.  Residence  on  a  damp  soil  has  a  tendency  to  produce 
diseases  of  the  lungs,  and  especially  phthisis ;  but  how  it  does  this  is 
unknown,  though  it  would  be  easy  to  construct  a  plausible  theory  in 
connection  with  the  supposed  causation  of  phthisis  by  a  bacillus.  The 
practical  point  for  the  physician  is,  that  the  prevalence  of  phthisis  in  a 
locality,  even  if  it  be  so  limited  as  to  comprise  but  a  single  house,  should 
cause  suspicion  and  investigation  as  to  the  character  of  the  soil-drainage. 
Soil-moisture  is  also  an  important  factor  in  the  development  of  periodical 
fevers,  and  the  effect  of  thorough  drainage  in  diminishing  malaria  is  now 
generally  understood. 

It  sometimes  becomes  an  important  question  as  to  the  influence  which  a 
collection  of  water,  such  as  a  mill-pond  or  a  reservoir,  has  upon  the  health 
of  a  community,  and  the  physician  may  be  called  on  for  an  opinion  in 
such  cases  where  large  property  interests  are  involved.  The  essential 
points  to  be  borne  in  mind  are — first,  that  stagnant  water  and  damp  soil 
do  not  in  themselves  produce  malaria ;  there  is  something  else  necessary, 
which  is  commonly  designated  by  the  word  "  germ."  Second,  that  they 
are  in  most  cases  essential  conditions  for  the  production  of  the  disease,  so 
that  if  removed  the  disease  will  disappear.  Third,  that  the  development 
of  malaria  may  follow  either  the  rise  or  fall  of  the  ground  water.  Fourth, 
that  the  condition  of  the  border  of  the  collection  of  water  as  to  presence 
of  organic  matter  and  moisture  is  of  more  importance  than  the  pool  itself. 
And,  finally,  that  each  case  is  a  problem  by  itself,  to  be  determined  by 
the  history  of  the  sickness  of  the  vicinity,  and  that  only  probabilities  can 
be  stated  in  any  case,  although  these  probabilities  may  be  so  great  as  to 
amount,  practically,  to  certainty.  Of  the  four  factors  which  appear  to  be 
essential  to  the  production  of  the  malarial  poison — viz.  moisture,  high 
temperature,  organic  matter  of  vegetable  origin,  and  certain  micro-organ- 
isms— the  first  is  the  one  which  in  any  given  locality  is  most  under  human 
control ;  it  is  the  link  in  the  chain  of  causation  which  is  most  easily 
broken. 

The  influence  of  the  rise  and  fall  of  the  soil  water  in  typhoid  fever, 
upon  which  so  much  stress  is  laid  by  Pettenkofer  and  others,  no  doubt 
exists,  acting  in  some  cases  through  pollution  of  the  drinking  water 
by  the  subsoil  water  leaking  through  a  polluted  soil ;  in  other  cases, 
perhaps,  by  air  from  the  soil  bearing  the  unknown  germ.  The  filter- 
ing power  of  soil  as  regards  air  is,  however,  very  great,  a  few  inches 
of  sand  being  sufficient  to  remove  the  ordinary  germs  of  putrefaction 
from  air  drawn  through  it,  and  this  for  a  long  period ;  while,  on  the 


188  HYGIENE. 

contrary,  many  feet  of  the  same  sand  will  not  remove  the  germs  from 
water  passed  through  it.  Usually,  as  Dr.  Parkes  remarks,  in  an  exam- 
ination of  soil  the  immediate  local  conditions  are  of  more  importance 
than  the  general  geological  formation,  yet  this  last,  as  influencing  con- 
formation and  the  movement  of  water  and  air  over  and  through  a  coun- 
try, is  also  important.  The  practical  questions  on  this  point  are,  what 
higher  ground  than  the  site  in  question  exists  in  the  vicinity?  what 
are  the  character  and  direction  of  the  strata  between  such  elevation  and 
the  site?  and,  what  sources  of  soil-pollution  exist  on  the  higher  level? 
As  to  the  site  itself,  is  it  on  made  ground  ?  what  is  the  height  of  the 
foundation  above  the  subsoil  water  ?  and,  what  precautions  have  been 
taken  to  secure  drainage  and  to  cut  off  communication  between  the  inte- 
rior of  the  house  and  the  ground  air?  Probably  a  trial  excavation  or 
boring  may  be  necessary  to  determine  some  of  these  points. 

The  level  of  the  subsoil  water  should  be  at  least  five  feet  below  the 
foundations,  although  it  is  often  impossible  to  obtain  this.  At  all  times 
when  the  temperature  of  the  house  is  higher  than  that  of  the  external 
air — i.  e.  during  a  large  part  of  the  year  and  nearly  every  night — there 
is  a  strong  and  constant  aspirating  force  at  work  to  draw  into  the  house, 
through  the  cellar  floor  and  walls,  all  gases  and  vapors  contained  in  the 
adjoining  soil.  If  this  soil  contains  a  large  proportion  of  organic  matter, 
as  is  often  the  case  in  filled-in  ground  in  cities,  or  if  there  be  a  leaky 
cesspool  or  sewer  or  gas-pipe  under  or  near  the  house,  the  ground  air 
passing  into  the  house  may  be  of  such  a  character  as  to  be  positively 
dangerous  to  its  occupants.  For  this  reason  it  is  very  undesirable  to 
have  a  sewer  or  soil-pipe  crossing  beneath  the  site  of  a  house,  and  when 
such  location  is  a  necessity,  as  it  often  is  in  cities,  the  soil-pipe  should  be 
laid  in  a  cement-lined  trench  covered  with  a  movable  flap,  so  that  it  can 
always  be  easily  inspected  and  any  leaks  detected  and  remedied.  Damp- 
ness in  the  cellar  or  basement  of  a  house  is  always  a  sign  of  danger.  The 
exhalation  of  gases  and  vapors  from  the  ground  into  the  house  can  be  to 
a  great  extent  cut  off  by  a  layer  of  impervious  material,  such  as  concrete 
covered  with  asphalt,  but  this  layer  must  cover  the  sides  of  the  cellar  as 
well  as  the  floor  to  be  thoroughly  efficient.  If  a  house  have  no  cellar, 
the  space  between  the  floor  and  the  ground  should  be  thoroughly  venti- 
lated ;  and  for  this  purpose,  as  well  as  to  secure  cleanliness,  the  floor 
should  be  sufficiently  elevated  to  permit  of  easy  access  beneath  it. 

Next  to  its  dryness,  the  nature  and  condition  of  the  arrangements  for 
removing  excreta  and  soiled  water  from  a  house  are  of  the  greatest 
importance  in  determining  its  healthfulncss ;  and  in  cities  it  is  with 
regard  to  the  sufficiency  of  these,  including  the  whole  system  of  house- 
plumbing  and  pipe-fitting,  that  the  inquiries  of  one  wishing  to  determine 
as  to  the  presence  or  absence  of  causes  of  disease  will  most  frequently  be 
directed.  The  soil-pipes,  etc.  of  a  house  are  commonly  referred  to  as 
constituting  the  system  of  house-drainage,  but  it  is  desirable  to  use 
another  term,  for  we  need  the  word  "drainage"  to  describe  the  removal 
of  surface  and  subsoil  water,  and  it  should  be  distinguished  from  "  sew- 
erage," which  has  a  different  purpose  and  requirements. 

In  a  properly-arranged  system  of  house  sewerage  all  the  pipe?,  traps, 
etc.  are  easily  accessible  for  purposes  of  inspection,  and  an  examination 
of  them  is  a  comparatively  simple  matter.  This  examination  is  to  be 


CAUSES  OF  DISEASE,  ETC.  189 

made  with  reference  to  the  following  points :  1.  Are  all  the  pipes,  joints, 
and  connections  air-tight  ?  2.  Is  the  soil-pipe  well  ventilated,  or  has  it 
dead  ends  ?  3.  Is  the  communication  between  the  soil-pipe  and  the 
street  sewer  uninterrupted  ?  4.  Are  the  pipes  properly  trapped,  and  is 
there  liability  to  the  removal  of  water  from  any  of  the  traps,  either  by 
siphonage  or  evaporation,  to  such  an  extent  as  to  break  the  seal  ?  5.  Is 
the  water-supply  of  each  closet  entirely  cut  oif  from  the  main  supply  to 
the  house  by  means  of  a  tank  or  cistern? 

In  houses  as  heretofore  constructed  it  is  often  very  difficult  to  obtain 
satisfactory  information  upon  these  points,  because  a  large  part  of  the 
soil-pipe  and  its  connections  is  buried  beneath  the  house  or  concealed  in 
the  walls  or  floors ;  in  which  case  the  services  of  a  skilled  mechanic  will 
usually  be  necessary  to  obtain  access  to  the  various  parts  of  the  system. 
In  a  paper  of  this  kind  it  is  of  course  impossible  to  go  into  details  as  to 
methods  of  inspection,  or  as  to  what  is  and  what  is  not  satisfactory ;  but 
the  following  are  the  general  principles  upon  which  a  judgment  as  to  the 
merits  of  a  system  should  be  formed,  and  these  should  be  so  clearly  under- 
stood by  every  physician  that  he  can  be  neither  persuaded  nor  frightened 
into  thinking  them  incorrect  by  the  eloquence  of  the  man  with  a  patent 
remedy  to  dispose  of.  The  principal  dangers  to  health  from  house  sewer- 
age are  due,  first,  to  the  passage  of  air  from  the  general  system  of  sewers 
or  from  a  cesspool  into  the  house  through  the  soil-pipe  and  its  connections ; 
second,  to  the  generation  of  offensive  and  dangerous  gases  and  organisms 
in  the  soil-pipe  itself,  and  the  passage  of  these  into  the  house ;  third,  to 
leakage  of  soil-pipe  causing  contamination  of  the  water-supply  either  by 
improper  connections  of  water-pipes  with  water-closets  or  slop-hoppers,  or 
by  contamination  of  wells,  cisterns,  or  tanks  with  sewage  or  sewer  gases. 

There  is,  of  course,  no  such  thing  as  a  sewer  gas  having  a  definite  and 
distinctive  composition,  and  the  nature  of  the  mixture  of  gases  in  sewers 
is  constantly  varying  according  to  season,  temperature,  etc.  The  tendency 
which  sewer  air  has  to  cause  disease  depends  in  part  upon  certain  gases,  in 
part  on  minute  particles  of  solid  or  semi-solid  matter  which  are  suspended 
in  the  air.  In  rare  instances  the  sewers  also  contain  illuminating  gas, 
derived  from  leakage  of  gas-pipes  in  the  vicinity.  These  gases  produce 
debility,  headache,  loss  of  appetite,  etc.  As  found  in  sewers  and  soil- 
pipes,  they  are  so  diluted  that  they  are  not  absorbed  by  the  water  of  a 
trap  and  given  off  on  the  other  side  to  a  sufficient  extent  to  produce  an 
evil  effect.  The  air  in  a  soil-pipe  which  is  not  ventilated  is  much  more 
impure  than  that  of  the  ordinary  sewer,  since  the  process  of  decomposi- 
tion is  constantly  going  on  in  the  slimy  coat  which  lines  the  interior  of 
the  pipes ;  and  it  is  for  this  reason  that  it  is  so  important  to  secure  thorough 
ventilation  of  all  the  soil-pipes  in  a  building.  When  this  ventilation  is 
secured,  the  proportion  of  dangerous  gas  in  the  pipes  becomes  very  small, 
and  the  amount  absorbed  by  the  water  in  traps  is  almost  inappreciable. 
The  chief  danger  to  life  from  sewer  and  soil-pipe  air  arises  from  the  pres- 
ence of  minute  particles  of  organic  matter,  dead  and  living,  the  so-called 
germs.  Danger  to  life  from  these  germs  cannot  be  entirely  removed  by 
dilution,  as  can  be  done  with  gases.  It  has  been  found  by  the  experi- 
ments of  Dr.  Carmichael  and  Dr.  Wernick  that  an  ordinary  water-trap 
entirely  prevents  the  passage  of  these  germs,  and  that  organic  putrascible 
fluid  will  remain  unchanged  when  exposed  only  to  the  air  immediately 


190  HYGIENE. 

above  such  a  trap.     A  pin-hole  or  minute  sand-crack  in  the  soil-pipe,  or 
a  very  slight  defect  in  a  joint,  is  far  more  dangerous  than  a  trap. 

The  forms  of  disease  produced  by  sewer  air  and  its  contents  are  more 
especially  diphtheria,  typhoid  fever,  and  ill-defined  disorders  of  the  throat 
and  digestive  organs.  It  is  possible  that  the  germs  of  other  specific  dis- 
eases, such  as  scarlet  fever,  may  be  at  times  transmitted  through  sewer  air, 
but  such  transmission  must  be  very  rare.  While  it  is  true  that  the  germs 
of  the  specific  diseases  are  very  rarely  present  in  sewer  air,  the  house 
system  of  sewerage  must  be  arranged  as  if  they  were  ahvays  present,  in 
order  to  obtain  security.  It  must  also  be  remembered  that  a  system 
originally  well  planned  and  properly  constructed  will  not  always  remain 
so ;  the  pipes  will  corrode,  the  joints  will  become  loosened,  the  valves  will 
become  clogged,  and  whenever  alterations  or  repairs  are  made  there  is 
always  danger  of  injury.  Bearing  these  points  in  mind,  the  method  of 
investigating  a  system  can  be  readily  understood. 

The  first  step  is  to  ascertain  whether  there  is  a  trap  outside  the  house 
disconnecting  the  sewer  from  the  house  system  and  permitting  inspection. 
If  there  is  not,  the  first  thing  to  be  done  is  to  make  an  excavation  and 
open  the  drain  at  the  proper  point  for  placing  such  a  trap.  The  next  step 
is  to  set  the  water  flowing  in  the  various  closets  and  watch  the  flow  at  the 
external  trap,  or  opening,  which  has  been  made  to  ascertain  whether  there 
is  any  obstruction  in  the  pipe  within  the  house.  If  the  sewer  is  properly 
arranged  for  inspection,  as  has  been  above  suggested,  to  determine  whether 
there  is  any  leakage  from  the  sewer  under  the  house  will  be  an  easy 
matter ;  if,  however,  it  is  buried  beneath  the  cellar  floor,  as  is  usually  the 
case,  an  excavation  should  be  made  along  the  floor  in  the  line  of  the  pipe, 
with  a  view  to  having  it  properly  arranged,  as  well  as  for  the  purpose  of 
examining  the  soil.  It  may  also  be  tested  by  opening  the  upright  soil- 
pipes  at  the  farther  end  of  the  house-drain  at  the  height  of  three  or  four 
feet  above  the  floor  and  pouring  water  into  it,  having  temporarily  stopped 
up  the  drain  at  the  external  trap  or  opening.  If  the  water  remain  at  a  con- 
stant level  in  the  upright  piece,  the  sewer  is  water-tight;  if  not,  the  leak- 
age may  be  ascertained  by  the  rate  at  which  it  sinks.  Having  settled 
this,  the  next  point  is  to  determine  whether  all  the  soil-pipes  are  air-tight 
and  properly  trapped.  The  test  usually  applied  for  this  purpose  is  the 
pouring  of  a  small  quantity  of  strong  oil  of  peppermint,  followed  by  a 
dash  of  hot  water,  into  the  top  of  the  soil-pipe,  which  should  always  pass 
through  the  roof  and  be  freely  opened  to  the  outer  air.  If  the  odor  of 
the  oil  is  perceptible  in  the  house,  it  indicates  a  leak,  which  must  be 
further  sought  for.  Ether  may  be  used  for  the  same  purpose.  The  smoke 
test  is,  however,  the  best,  but  it  requires  a  special  apparatus  which  as  yet 
is  little  used  in  this  country.  It  is  applied  by  a  small  machine  with  a  fan, 
by  which  the  smoke  from  burning  cotton-waste  saturated  with  oil,  or  of 
coarse  brown  paper  impregnated  with  sulphur,  can  be  blown  into  the 
pipes ;  this  locates  leaks  with  great  precision. 

It  is  not,  of  course,  expected  that  a  physician  will  personally  make 
the  examination  necessary  to  determine  whether  the  plumbing  of  a  house 
is  in  good  order,  but  he  should  be  able  to  make  it,  if  necessary,  if  for  no 
other  purpose  than  to  know  whether  the  inspector  employed  for  the  pur- 
pose understands  his  business. 

The  dangers  to  health  from  a  properly-constructed  system  of  house 


CAUSES  OF  DISEASE,  ETC.  191 

sewerage,  such  as  is  now  generally  agreed  upon  by  sanitary  engineers,  are 
so  very  small  as  to  practically  amount  to  nothing,  being,  in  fact,  less  than 
those  of  a  well-kept  yard  privy  of  a  country  house,  setting  aside  alto- 
gether the  question  of  water  pollution.  The  real  difficulties  in  the  way 
are  the  expense  of  such  a  system,  which  is  considerable,  and  the  finding 
of  skilled  and  honest  workmen  to  construct  it  and  keep  it  in  repair.  Not 
every  one  who  chooses  to  style  himself  a  sanitary  engineer  or  a  sanitary 
plumber  is  to  be  regarded  as  such,  by  any  means,  but  the  physician 
should  make  it  his  business  to  know  who  are  really  reliable  in  this 
respect,  for  he  will  constantly  be  called  in  for  advice  on  this  point  by 
those  who  have  learned  that  good  plumbing  is  the  only  true  economy, 
but  who  do  not  feel  themselves  competent  to  distinguish  between  good 
and  bad  work.  The  main  points  of  a  satisfactory  system  are  the  fol- 
lowing.1 

1.  All  soil-  and  waste-pipes  should  be  extended  up  to  and  through  the 
roof,  and  be  freely  open  at  the  top.    The  extension  of  the  soil-pipe  should 
be  full  size — i.  e.  from  four  to  six  inches  in  diameter. 

2.  There  should  be  a  fresh-air  inlet  in  the  house  sewer  just  outside  the 
house,  and  between  this  inlet  and  the  main  sewer  should  be  a  trap  so 
arranged  as  to  permit  of  inspection.     This  prevents  the  ventilation  of 
sewers  through  the  soil-pipes.     If  a  perfect  system  of  sewers,  uniformity 
of  house-connections,  and  uniform  height  of  houses  could  be  guaranteed, 
this  inlet  and  trap  would  not  be  so  necessary,  although  even  then  it  wrould 
be  useful. 

3.  Every  water-closet,  wash-bowl,  bath-tub,  sink,  etc.  should  have  a 
trap  placed  as  close  to  it  as  possible.     This  trap  is  desirable,  whether  the 
discharge  be  into  the  sewer  system  or  not.     For  example,  a  kitchen  sink, 
the  pipe  from  which  passes  to  the  outer  air  and  discharges  there,  should 
be  trapped,  for  this  pipe  is  foul,  and  if  it  be  untrapped  will  act  as  an  air- 
inlet. 

4.  The  nearer  to  the  soil-pipe  that  the  fixtures  can  be  arranged  the 
better.     It  is  especially  desirable  to  avoid  the  necessity  for  long  horizontal 
waste-pipes  from  stationary  waste-bowls  and  from  bath-tubs. 

5.  Bell  traps,  D  traps,  bottle  traps,  and  mechanical  traps  are  objection- 
able.    The  S  trap  is,  upon  the  whole,  the  best,  but  it  should  be  provided 
with  a  vent-pipe  to  prevent  siphonage. 

6.  The  best  kind  of  water-closet  for  general  use  is  probably  some  form 
of  what  are  known  as  the  wrash-out  closets.     They  are  made  in  one  piece 
of  earthenware,  have  no  machinery  inside  them,  have  a  quantity  of  water 
in  the  basin  into  which  the  excreta  drop,  and  do  not  require  a  separate 
trap  beneath  them.     Each  closet  must,  however,  be  carefully  tested  by 
itself:  a  very  small  warp  or  twist  produced  in  the  baking  may  so  inter- 
fere with  the  siphonage  as  to  make  it  practically  worthless,  and  the  basin 
cannot  be  altered  or  repaired.     For  use  in  public  places  some  of  the 
hopper  closets  are  very  satisfactory,  the  best  which  I  have  examined  being 
the  Rhoads  Hopper  and  the  Hellyer  Hoppers.     Where  there  are  no  chil- 

1For  further  details  consult  the  following:  American  Sanitary  Engineering,  by  E.  S. 
Philbrick,  N.  Y.,  1881 ;  House- Drainage  and  Water-Service,  by  James  C.  Baylee,  N.  Y., 
1878 ;  "  House-Drainage  and  Sanitary  Plumbing,"  by  W.  P.  Gerhard,  in  Fourth  Annual 
Jleport  State  Board  of  Health  Rhode  Island,  1882 ;  The  Sanitary  Engineer,  a  weekly  jour- 
nal published  at  140  William  St.,  New  York  City. 


192  HYGIENE. 

dren,  and  it  is  certain  that  the  fixtures  will  be  used  with  reasonable  care, 
valve  closets  may  be  used.  No  form  of  pan  closet  can  be  considered  as 
satisfactory,  nor  have  I  found  any  form  of  plunger  closet  that  I  would 
specially  recommend. 

7.  Water-closets  should  always  be  flushed  from  a  special  tank  provided 
for  the  purpose,  and  never  direct  from  the  main  system  of  water-pipes. 
The  flush  must  be  large  and  rapid,  and  this  requires  a  large  supply-pipe, 
and  for  many  forms  of  closets  a  flushing  rim.     Whatever  be  the  form 
of  closet,  it  should  not  be  encased  in  a  wooden  box  or  closet,  as  is  usually 
done,  but  it  should  stand  freely  exposed  to  light  and  air.     Sanitarians 
commonly  advise  that  water-closets  should  be  located  in  outer  walls  and 
have  an  open  window  for  ventilation.     Such  a  position  is  usually  impos- 
sible, and  is  not  specially  desirable  in  our  climate.     The  open  window 
acts  as  an  inlet  quite  as  often  as  it  does  as  an  outlet,  and  the  air  of  the 
closet  is  thus  swept  into  the  house.     The  room  should  be  ventilated  in 
such  a  way  that  the  tendency  of  the  air  at  the  door  shall  always  be  from 
the  house  into  it.     This  is  to  be  effected  by  a  shaft  passing  through  the 
room  up  and  through  the  roof;  and  it  is  well  to  have  this  shaft  take  its 
air-supply  from  just  behind  the  closet  or  from  beneath  the  seat.     It  is  besl 
made  of  galvanized  iron,  and  at  a  convenient  point  should  be  expanded 
into  a  lantern  and  have  a  gas-jet  placed  in  it.     The  air-supply  for  the 
closet  is  to  be  taken  at  the  bottom  of  the  door  or  through  a  transom 
or  louvres.     Ventilating  pipes  from  a  water-closet  should  never  be  run 
into  a  brick  flue.     While  it  is  not  so  important  as  many  writers  seem  to 
think  that  a  water-closet  should  be  placed  on  an  outer  wall,  it  is  very 
important  that  it  should  be  as  light  as  possible,  and  the  placing  it  in  a 
dark  corner  in  the  basement  or  under  the  stairs  is  very  objectionable. 

8.  No  overflow-pipe  from  any  cistern  or  tank,  except  the  one  used  for 
flushing  water-closets,  should  be  connected  with  the  soil-pipe  or  sewer. 
Trapping  such  an  overflow-pipe  does  not  prevent  the  danger.     The  same 
rule  applies  to  waste-pipes  from  refrigerators  and  to  the  waste-pipes  from 
the  safes  which  are  commonly  placed  beneath  fixtures. 

9.  Grease-traps  placed  inside  a  house — for  instance,  beneath  the  kitchen 
sink — are  of  very  doubtful  expediency,  and  if  they  cannot  be  placed  out- 
side, they  had  better  not  be  used  at  all. 

In  an  unsewered  city  one  of  the  first  things  to  be  considered  in  a  sani- 
tary inspection  is  the  manner  in  which  the  sewage  of  the  premises  is  dis- 
posed of.  The  question  is,  however,  by  no  means  superfluous  in  many 
sewered  cities,  for  cesspools  and  vaults  are  to  be  found  in  most  of  them, 
and  not  only  in  yards,  but  beneath  houses,  and  houses  of  the  better  class. 
A  privy-vault  or  cesspool  beneath  a  dwelling  or  near  its  cellar  walls  is 
always  to  be  considered  as  very  dangerous,  for  it  is  practically  impossible 
to  prevent  the  passage  of  gases  from  it  into  the  interior  of  the  house.  A 
cesspit  is  a  dangerous  thing  anywhere,  even  in  the  country ;  but  in  a  city 
it  is  so  dangerous  that  its  existence  should  not  be  permitted. 

If  the  water-supply  of  a  house  is  derived  from  a  well,  and  there  is 
reason  to  suspect  that  this  may  have  been  contaminated  from  a  neighbor- 
ing privy-vault,  the  first  test  to  be  applied  to  the  water  is  that  for  the 
detection  of  chlorides.  If  none  are  present,  the  water  is  not  polluted. 
If  they  are  present,  the  quantity  is  to  be  noted,  and  a  peck  or  two  of 
common  salt  is  then  to  be  thrown  into  the  suspected  vault.  If  repeated 


CAUSES  OF  DISEASE,  ETC.  193 

examinations  of  the  water  show  a  marked  increase  in  the  amount  of 
chlorides  present,  it  may  be  inferred  that  the  contents  of  the  privy  pass 
to  the  well.  The  fact  that  the  water  of  infected  wells  and  springs  is 
usually  much  liked  and  sought  for  is  to  a  considerable  extent  due  to  the 
presence  of  these  chlorides.  Wauklyn  recommends  the  addition  of  50 
grains  of  common  salt  per  gallon  to  drinking  water  to  render  it  palatable. 
Popularity  of  a  certain  well  is  therefore  a  reason  for  suspecting  its  purity. 

This  subject  may  be  dismissed  with  one  caution.  Taking  the  dwell- 
ing-houses of  a  city  or  town  as  they  come,  it  will  be  found  on  exami- 
nation that  over  half  of  them  would  be  described  by  a  competent  inspector 
as  being  in  a  condition  which  might  produce  disease.  It  is  therefore  more 
than  an  even  chance  that  in  any  case  of  disease  some  sanitary  defect  will 
be  found  about  the  premises  quite  irrespective  of  any  direct  causal  con- 
nection with  the  case.  Let  the  physician  therefore  be  cautious  in  decid- 
ing as  to  such  causal  connection,  and  not  conclude  that  because  a  case  of 
diphtheria  or  typhoid  fever  and  a  leaky  soil-pipe  occur  in  the  same  house, 
therefore  one  is  the  cause  of  the  other.  Such  cases  occur  in  houses  whose 
sewerage  is  perfect  and  in  houses  which  have  no  sewerage,  and  it  is  folly 
to  attribute  them  exclusively  or  mainly  to  sewer  gases. 

The  same  caution  applies  to  investigations  into  the  causes  of  a  sudden 
outbreak  of  disease  in  a  community  where  a  number  of  cases  occur  almost 
simultaneously  or  in  rapid  succession.  Such  an  outbreak  may  be  due  to 
direct  contagion,  although  sometimes  very  difficult  to  trace ;  as,  for  exam- 
ple, an  explosion  of  small-pox  in  a  community  largely  unprotected  by 
vaccination,  and  where,  owing  to  circumstances  connected  with  the  first 
few  cases,  a  large  number  of  persons  have  been  exposed  to  the  cause  about 
the  same  time.  The  same  applies  to  an  apparently  sudden  development 
of  yellow  fever  throughout  a  city. 

Another  cause  of  such  outbreaks  is  a  polluted  water-supply,  as  in  some 
epidemics  of  diarrhoeal  disease  or  of  typhoid  fever.  If  the  outbreaks  of 
these  diseases  are  pretty  sharply  localized,  and  depend  upon  the  fouling 
of  a  well  or  wells,  it  will  usually  not  be  very  difficult  to  trace  this  cause. 
If,  however,  the  town  has  water-supply  by  means  of  pipes  from  a  single 
source,  while  the  outbreak  of  disease  is  limited  to  a  part  of  the  town  or 
to  a  single  large  building,  it  will  probably  be  almost  impossible  to  estab- 
lish any  connection  between  the  disease  and  the  drinking  water.  The 
possibility  of  the  contamination  of  a  part  only  of  a  system  of  general 
water-supply  by  means  of  the  drawing  of  foul  air  into  the  temporarily 
empty  pipes  connected  directly  with  a  water-closet  flush  should  never  be 
forgotten,  for  such  a  case  has  actually  occurred,  and  the  account  of  its 
discovery  is  one  of  the  best  pieces  of  sanitary  detective  work  with  which 
I  am  acquainted.  If  the  outbreak  of  typhoid  fever  cannot  be  traced 
directly  to  the  water-supply,  the  next  point  to  be  investigated  is  the 
milk,  and  after  that  other  possible  modes  of  the  conveyance  of  the  con- 
tagium. 

In  cases  of  obscure  disease  characterized  by  fever  of  no  definite  type, 
disorder  of  the  digestive  organs,  headache,  malaise,  etc.,  and  which  seem 
to  be  connected  with  residence  in  a  particular  house  or  in  one  room  in  a 
house,  the  possibilities  of  arsenical  poisoning  from  wall-paper  or  hangings 
should  be  remembered,  for  much  useless  medication  and  some  real  danger 
will  be  avoided  if  this  cause  be  promptly  recognized.  The  effects  pro- 

VOL.  I.— 13 


194  HYGIENE. 

duced  by  arsenical  dust  are  very  various,  and  simulate  sometimes  some 
of  the  specific  fevers,  indigestions,  or  neuroses  in  a  way  that  is  very 
puzzling  if  the  true  nature  of  the  case  is  not  suspected.  The  popular 
notion  is  that  arsenic  is  found  only  in  greens  (more  especially  in  bright 
greens  in  wall-papers),  whereas  in  fact  it  is  found  not  only  in  dull  greens, 
but  in  some  browns,  grays,  and  dull  reds.  The  test  for  its  presence  in 
quantity  sufficient  to  be  a  cause  of  disease  is  an  easy  one,  and  is  fully 
given  in  any  manual  of  chemistry  or  toxicology. 

VI.  OCCUPATION. — While  the  effects  of  occupation  upon  health  are 
no  doubt  great,  they  are  in  many  cases  so  blended  with  tho«>,  of  condi- 
tion in  life,  including  habitation,  food,  and  intemperance,  that  it  is  very 
difficult  to  distinguish  them.  In  attempting  to  investigate  these  effects  by 
means  of  statistics,  it  is  necessary  to  beware  of  a  fallacy  which  not  uufre- 
quently  vitiates  the  conclusions  drawn  from  otherwise  carefully  prepared 
tables  intended  to  show  for  different  occupations  either  the  relative  mor- 
tality or  the  average  age  at  death.  This  fallacy  lies  in  the  fact  that  the 
number  of  persons  engaged  in  each  business  is  unknown ;  that,  in  this 
country  at  least,  men  often  change  their  occupations;  and  that  certain 
trades  or  professions  are  chiefly  carried  on  by  persons  of  certain  ages. 
This  last  is  perhaps  best  illustrated  by  the  remark  of  Dr.  Farr,  that  the 
fact  that  the  average  age  at  death  of  second  lieutenants  is  much  less  than 
that  of  major-generals  proves  nothing  with  regard  to  the  comparative 
healthfulness  of  the  two  grades.  Statistics  showing  merely  the  number 
of  a  particular  class  or  grade  dying  in  a  given  time  are  absolutely  worth- 
less, unless  the  number  of  the  same  class  or  trade  living  at  the  same  time 
is  also  given. 

It  is  also  necessary  to  bear  in  mind  the  power  of  habit  and  the  effects 
of  natural  selection,  especially  Avhen  the  effects  of  an  unhealthy  occupa- 
tion are  immediate  and  marked  upon  those  unfitted  for  them.  For  exam- 
ple, young  men,  when  first  employed  as  scavengers  or  in  sewage-pumping 
works,  usually  suffer  from  disorders  of  the  digestive  organs.  A  certain 
number  find  it  necessary  for  their  health  and  comfort  to  soon  leave  the 
business ;  some  acquire  protection  by  passing  through  an  attack  of  fever ; 
and  by  this  process  of  selection  a  class  of  men  are  obtained  who  seem  to 
thrive  in  the  midst  of  filth  and  remain  unaffected  by  effluvia  which  will 
promptly  cause  illness  in  those  unaccustomed  to  them.  When  men  find 
that,  to  use  a  common  phrase,  they  "  cannot  stand  "  a  particular  kind  of 
work,  they  are  apt  to  give  it  up  and  try  something  else,  especially  if  the 
effects  are  prompt  and  well  marked. 

Much  attention  has  been  given  of  late  years  in  England,  France,  and 
Germany  to  the  means  of  protecting  both  the  workmen  and  the  neigh- 
borhood from  the  ill  effects  of  dangerous  and  offensive  trades,  and  the 
reports  of  the  medical  officer  of  the  Privy  Council  and  of  the  Local 
Government  Board  are  a  mine  of  information  on  this  subject.  It  may  be 
truthfully  asserted  that  in  those  trades  in  which  the  special  danger  is 
caused  by  dust  of  various  kinds,  or  by  gases,  or  by  metallic  poisons — and 
these  three  include  the  greater  number  of  the  dangerous  occupations — it  is 
almost  always  possible  to  so  arrange  the  work  as  to  make  it  compara- 
tively healthful  and  harmless.  Overcrowded  and  unventilated  work- 
rooms are  responsible  for  much  disease,  and  when  to  these  is  added  the 
risk  of  metallic  poisoning,  as  is  the  case  with,  printers,  artificial-flower 


CAUSES  OF  DISEASE,  ETC.  195 

makers,  etc.,  bad  results  are  almost  sure  to  follow.  It  is  curious  that  so 
comparatively  little  ill  effect  seems  to  be  produced  by  exposure  to  great 
heat,  as  in  stokers,  foundry-men,  glass-blowers,  etc. ;  but  further  informa- 
tion is  needed  on  this  point  as  to  the  real  facts  in  the  case.  In  some 
occupations  the  chief  evils  arise  from  want  of  out-door  exercise,  a  subject 
which  will  be  considered  presently.  The  want  of  useful  or  interesting 
occupation  sometimes  becomes  indirectly  the  .cause  of  disease  among  the 
wealthier  classes,  and  the  giving  a  man  or  woman  something  to  do  is  in 
such  cases  the  best  prescription  which  can  be  made.  This  danger  is 
especially  apt  to  occur  in  the  case  of  an  active,  energetic  man  who  retires 
from  business,  intending  to  spend  the  rest  of  his  life  in  pleasure  and  in 
the  enjoyment  of  the  fruits  of  his  industry :  the  preventive  or  remedy  is 
obvious. 

VII.  FOOD. — The  comfort,  energy,  usefulness,  and  moral  character 
of  a  man  depend  largely  upon  his  digestion,  and  this  in  turn  depends 
largely  on  what  it  has  to  act  upon — viz.  food.  There  are,  it  is  true, 
many  men  who  boast  that  they  can  digest  anything,  and  who  are  really 
comparatively  indifferent  as  to  the  kind,  or  mode  of  preparation,  of  the 
food  set  before  them,  so  that  the  quantity  be  sufficient;  but  were  it  not 
that  habit  and  heredity — which  is  the  family  habit — combine  with  natural 
selection  to  adapt  men  to  their  food,  it  is  probable  that  the  frying-pan,  the 
pic,  and  soda-bread  would  depopulate  large  portions  of  this  country.  As 
it  is,  there  can  be  no  doubt  that  fried  food  swimming  in  grease,  leathery, 
sodden  pie-crust,  and  heavy  bread  tend  to  make  life  short  and  the  reverse 
of  merry ;  and  when  the  effect  of  these  is  combined,  as  it  often  is,  with 
those  of  malaria,  damp  soil,  and  a  free  use  of  whiskey,  the  result  is  plenty 
of  work  for  the  doctor  and  very  little  to  pay  him  with.  This  state  of 
things  is  being  gradually  improved,  but  in  all  classes  of  society  and  in 
almost  all  parts  of  the  country  the  rule  is,  that  while  the  raw  materials  of 
food  are  abundant  and  of  excellent  quality,  the  cooking  is  bad.  This  is 
due,  in  part,  to  an  idea  that  it  is  to  a  certain  extent  discreditable  to  a 
person  that  he  should  give  much  attention  to  his  food,  at  least  so  far  as 
its  appearance  and  taste  are  concerned,  and  that  a  man  who  can  plan  a 
good  dinner  must  be  more  or  less  of  a  sensualist  and  a  glutton. 

Another  popular  error  is,  that  a  large  amount  of  disease  is  due  to  over- 
eating, and  that  abstemiousness  in  diet  is  either  certain  to  secure  health, 
or  is,  at  all  events,  indispensable  for  this  purpose.  Upon  this  point  the 
reader  should  consult  a  capital  paper  by  Dr.  Austin  Flint  on  "Food  in 
its  relations  to  personal  and  public  health,"  which  will  be  found  in  vol. 
iii.  Reports  American  Public  Health  Association,  N.  Y.,  1877.  After  re- 
marking that  many  of  the  popular  errors  about  food  and  diet  are  relics  of 
old  and  abandoned  medical  theories,  one  of  which  is  embodied  in  the  not 
uncommon  advice  that  one  should  always  stop  eating  before  the  appetite 
is  fully  satisfied,  and  that  food  should  only  be  taken  at  regular  fixed 
periods,  no  matter  how  hungry  one  may  be,  he  says :  "  Physiology,  expe- 
rience, and  common  sense  are  alike  opposed  to  these  popular  notions 
relating  to  food.  Conditions  for  perfect  health  are,  first,  a  sufficient 
appetite ;  second,  the  gratification  of  normal  appetite  before  the  want  of 
food  reaches  the  abnormal  degree  expressed  by  hunger ;  third,  the  satis- 
faction of  appetite  by  an  adequate  quantity  of  food.  These  conditions 
of  health  are  fulfilled  by  compliance  with  instructive  provisions  for  all- 


196  HYGIENE. 

mentation.  But,  it  will  be  asked,  is  appetite  infallible  as  a  guide  in  diet- 
etics ?  Following  it  as  a  guide,  is  food  never  taken  beyond  the  require- 
ments of  health?  I  answer,  It  is  a  reliable  guide  under  normal 
circumstances.  The  inevitable  circumstances  of  life  are  often  not  alto- 
gether normal,  although  producing  no  distinct  morbid  affection.  Expe- 
rience teaches,  for  example,  that  in  a  state  of  fatigue  or  exhaustion  (which 
is  not  a  normal  state)  inconvenience  may  arise  from  the  full  gratification 
of  appetite ;  that  if  unusual  exertions,  mental  or  physical,  are  to  follow, 
a  hearty  meal  may  occasion  disturbance ;  and  other  examples  might  be 
added.  Irrespective  of  abnormal  or  disturbing  influences,  if  appetite  be 
not  infallible,  it  is,  at  all  events,  more  reliable  than  a  rule  based  on  theo- 
retical ideas,  popular  notions,  or  on  purely  physiological  data.  More- 
over, it  was  evidently  not  intended  that  the  quantity  of  food  should  be 
accurately  adjusted  to  the  needs  of  the  economy.  To  do  this  is  impossi- 
ble, and  therefore  it  is  necessary  to  elect  between  the  risk  of  taking  either 
more  or  less  food  than  is  actually  required.  Which  is  to  be  preferred  ? 
Undoubtedly,  it  is  vastly  better  to  incur  the  risk  of  taking  too  much 
than  that  of  taking  too  little.  Nature  provides  for  a  redundancy,  but 
there  is  no  provision  against  a  persistent  deficiency.  Ex  nihilo  nihil  fit. 
An  ample  supply  of  alimentary  principles  is  indispensable  to  nutrition ; 
and  inasmuch  as  the  supply  cannot  be  made  to  contain  precisely  the 
needed  amount  of  the  different  alimentary  principles,  we  may  say  that  a 
superabundance  of  food  is  a  requirement  for  health. 

"  As  in  appetite  we  have  a  guide  in  respect  of  the  times  of  taking  food 
and  the  quantity  to  be  taken,  so  taste  is  a  guide  in  respect  of  the  kinds 
of  food  required.  The  discrimination  of  food  with  reference  to  the  wants 
of  the  system  is  the  evident  purpose  of  the  sense  of  taste,  and  the  enjoy- 
ment connected  with  this  sense  was  designed  to  afford  a  security,  in  addi- 
tion to  appetite,  for  adequate  alimentation. 

"  Among  professional  men  and  those  who  live  sedentary  lives  the  mis- 
take is  not  uncommon  of  paying  too  much  attention  to  the  sensations 
after  a  meal,  and  deciding  therefrom  whether  certain  articles  of  food  are 
unhealthy  or  not.  If  the  man  who  does  this  is  not  already  dyspeptic, 
he  will  pretty  surely  become  so.  The  remedies  in  this  case  are  exercise 
and  attracting  the  attention  to  something  else." 

A  physician  ought  to  understand  something  of  cooking,  and  a  short 
course  of  practical  instruction  in  what  might  be  dignified  as  the  culinary 
laboratory  would  be  of  more  real  value  to  him  than  some  of  the  branches 
which  are  now  considered  indispensable  in  the  medical  curriculum.  He 
should  know  why  oysters  are  the  best  thing  with  which  to  begin  a 
dinner,  and  why  a  cocktail  is  one  of  the  worst ;  how  to  make  a  salad,  or 
a  cup  of  good  coffee,  or  a  perfect  consomme1;  and  a  number  of  other 
things  pertaining  to  gastronomy  of  which  most  people  are  woefully 
ignorant. 

It  is  not  within  the  scope  of  this  paper  to  give  details  with  regard  to 
the  diet  of  either  the  sick  or  the  well,  but  it  seems  proper  to  remark  with 
regard  to  the  feeding  of  infants,  more  especially  in  our  large  cities  in  the 
summer  months,  that  all  the  various  patent  preparations  for  infants'  food 
are  more  or  less  pernicious,  and  should  be  discountenanced  by  all  medical 
men.  The  proper  food  of  an  infant  is  milk — human  milk  if  it  can  be 
had,  cow's  milk  if  it  cannot.  If  it  be  remembered  that  an  infant  suffers 


CAUSES  OF  DISEASE,  ETC.  197 

from  thirst  as  well  as  hunger,  and  care  be  taken  to  give  it  enough  pure 
cool  water  to  quench  this  thirst,  it  will  be  found  that  in  most  cases  it  will 
thrive  on  pure  cow's  milk. 

With  regard  to  adulterations  of  food,  the  only  form  of  such  adulteration 
found  in  this  country,  which  has  any  special  interest  from  the  sanitary  point 
of  view,  pertains  to  milk.  This  adulteration  is  in  most  cases  the  dilution  of 
the  milk  by  water,  and  this  is  very  common  in  large  cities.  The  danger 
from  the  use  of  such  milk  is  by  no  means  confined  to  infants,  and  it  is 
probable  that  a  larger  proportion  of  the  typhoid  fever,  diphtheria,  scarlet 
fever,  cholera  infantum,  and  diarrhoeal  diseases  in  our  cities  is  due  either 
directly  or  indirectly  to  the  milk-supply  than  is  now  even  suspected. 
The  possibility  of  this  mode  of  origin  should  always  be'  borne  in  mind 
in  investigating  the  causation  of  such  aifections. 

A  very  large  amount  of  food  is  now  furnished  preserved  in  tin  cans, 
and  it  is  almost  invariably  of  excellent  quality.  There  is  a  possibility 
of  the  contamination  of  such  food  by  the  salts  of  lead  or  tin,  but  such 
contamination  to  an  extent  which  is  injurious  to  health  must  be  so 
extremely  rare  as  to  be  hardly  worth  considering.  The  danger  from  the 
entrance  of  parasites,  such  as  trichinae,  etc.,  in  the  food  is  also  extremely 
small — in  fact,  is  nothing  where  the  food  is  properly  cooked. 

Milk  has  so  often  been  the  cause  of  disease,  and  is  so  universally  used, 
that  it  seems  worth  while  to  refer  to  it  again.  The  special  aptitude  of 
milk  for  absorption  of  odors  has  long  been  known,  and  of  late  years  it 
has  been  clearly  proven  in  a  number  of  instances  that  milk  has  been  the 
means  of  conveying  the  cause  of  typhoid  fever  and  of  scarlatina.  Diph- 
theria, yellow  fever,  and  intermittent  fever  have  also  been  supposed  to 
be  conveyed  by  milk.  The  variety  of  nutritive  principles  contained  in 
milk,  which  makes  it  so  valuable  as  a  food,  also  gives  it  the  power  of 
sustaining  many  different  sorts  of  minute  organisms,  and  it  perhaps 
comes  as  near  being  a  universal  culture-fluid  as  anything  yet  devised  for 
that  purpose.  The  possibilities  of  the  contamination  of  milk  are  so 
numerous,  and  especially  in  the  case  of  that  furnished  from  small  estab- 
lishments, that,  in  the  case  of  outbreaks  of  typhoid  or  diarrhoeal  diseases 
in  a  town,  investigations  into  causation  should  always  include  the  milk- 
as  well  as  the  water-supply.  Milk  from  diseased  animals  is  no  doubt 
often  used  without  producing  bad  results,  but  its  effects  in  conveying  to 
man  the  disease  known  as  milk-sickues's  are  well  established,  and  it  has 
also  been  known  to  produce  symptoms  of  the  contagious  aphthae,  or  foot- 
and-mouth  disease,  in  man,  when  derived  from  an  animal  affected  with 
that  disease.  The  only  danger  in  the  use  of  the  milk  of  animals  fed 
upon  sewage-grown  grass  appears  to  be  in  the  possible  contamination  of 
the  milk,  after  it  is  drawn,  by  particles  of  dust  in  the  stable,  derived  from 
the  food  or  litter  of  the  animal  or  from  uncleanliness  of  the  exterior  of 
the  udder,  etc. 

VIII.  INTEMPERANCE. — Every  one  knows  that  alcoholic  drinks  are 
the  cause  of  a  vast  amount  of  disease,  crime,  and  misery  in  all  civilized 
countries.  No  one  knows  how  this  is  to  be  prevented,  for  no  one  knows 
how  to  make  the  great  mass  of  the  people  wise  and  contented.  The 
effects  produced  by  excessive  use  of  alcohol  are  well  known  to  all  physi- 
cians, and  the  remedy  is  self-evident.  I  see  no  use  in  adding  to  the  heap 
of  useless  rubbish  which  exists  in  the  shape  of  the  great  mass  of  existing 


198  HYGIENE. 

popular  literature  on  this  subject,  and  therefore  leave  the  subject  to  the 
reader,  who  is  quite  sure  to  know  all  that  is  really  important  on  this 
subject. 

IX.  CLOTHING. — The    hygiene   of  clothing  is  also  a  subject  which 
may  be  treated  summarily  in  this  paper.     People  wear  what  they  can 
afford,  made  according  to  the  prevailing  style.  Diseases  due  to  insufficient, 
excessive,  or  badly-fitting  clotliing  occur  most  frequently  in  women  and 
children,  and  the  use  of  such  clothing  is  for  the  most  part  due  to  poverty 
or  fashion,  either  of  which  is   beyond  the  power  of  the  physician  to 
successfully  cope  with.     Here  and  there,  in  individual  and  exceptional 
cases,  he  may  be  able  to  do  a  little  good  by  advising  against  tight  lacing, 
high-heeled  shoes,  insufficient  covering  for  the  chest  or  legs,  etc.,  and  he 
will  find  that  a  knowledge  of  the  peculiarities  of  the  various  styles  of 
modern  under-clothing  will  sometimes  be  very  useful.     Men  are,  as  a 
rule,  comfortably  and  sensibly  dressed  to  suit  their  business  and  sur- 
roundings, and  require  no  advice  on  this  subject. 

X.  EXERCISE. — The  ease  and  completeness  with  which  the  functions 
of  an  organ  or  of  an  organism  are  performed  depend  to  a  great  extent 
upon  the  frequency  and  regularity  with  which  such  functions  are  exer- 
cised.    Hence  comes  the  importance  of  bodily  exercise  for  the  preser- 
vation of  health,  and  every  physician  meets  cases  of  disease  due  largely 
to  want  of  work. 

The  term  "  exercise,"  or  "  bodily  exercise,"  is  commonly  used  as  if  it 
referred  only  to  the  muscles,  and  the  amount  of  exercise  which  a  man 
should  take  in  a  day  is  stated  as  equal  to  a  certain  number  of  foot- 
pounds. The  mere  giving  work  to  muscles  is  not,  however,  exercise  in 
the  sanitary  sense.  A  better  definition  is  that  of  Du  Bois  Reymond — viz. 
that  "  exercise  is  the  frequent  repetition  of  a  more  or  less  complicated 
action  of  the  body  with  the  co-operation  of  the  mind,  or  of  an  action  of 
the  mind  alone,  for  the  purpose  of  being  able  to  perform  such  actions 
better."  From  this  point  of  view  it  will  be  seen  that  exercise  relates  quite 
as  much  to  the  nervous  system  as  to  the  muscles.  When,  for  example,  a 
student  takes  a  walk  over  ground  with  which  he  is  familiar,  and  is  at  the 
same  time  so  deeply  engaged  in  thought  as  to  be  practically  unconscious 
of  what  he  is  doing,  only  being  recalled  to  himself,  it  may  be,  by  arriving 
at  his  own  door,  the  exercise  which  he  has  had  is  but  partial  and  insuf- 
ficient. Going  to  the  extreme,  we  can,  as  Du  Bois  Reymond  remarks, 
conceive  of  a  man  with  muscles  individually  exercised  until  they  were 
like  those  of  the  Farnese  Hercules,  and  yet  who  would  be  unable  to  walk, 
much  less  execute  more  complicated  movements  ;  for  the  proper  co-oper- 
ation of  the  muscles,  which  is  effected  through  the  nervous  system,  is 
quite  as  necessary  as  the  force  of  their  contraction. 

The  amount  of  exercise  which  is  necessary  for  health  varies  with  the 
individual  and  with  age,  season,  etc.,  so  that  it  is  difficult  to  state  any 
general  rule  upon  this  subject ;  but  if  stated  in  terms  of  muscular  force 
only,  the  estimate  of  Dr.  Parkes  seems  a  fair  approximation — viz.  that 
every  healthy  man  ought  to  take  daily  an  amount  of  exercise  equivalent 
to  150  tons  lifted  1  foot,  or  a  walk  of  about  nine  miles.  The  majority 
of  trades  and  bodily  occupations  demand  at  least  this  amount  of  work, 
but  in  some  of  them  the  greater  part  of  the  exertion  is  made  only  by 
curtain  groups  of  muscles,  and  they  are  carried  on  in  crowded  and  ill- 


CAUSES  OF  DISEASE,  ETC.  199 

ventilated  shops.  Such  workmen,  as  well  as  all  who  are  engaged  in  sed- 
entary pursuits,  require  exercise  in  the  open  air — exercise  which  will 
bring  into  play  the  unused  muscles  and  will  break  the  train  of  thought 
of  the  professional  man. 

One  of  the  most  important  questions  with  regard  to  physical  exercise 
is  the  extent  to,  and  manner  in,  which  it  should  be  provided  for  in  a 
proper  system  of  education.  One  of  the  latest  and  most  instructive 
articles  on  this  subject  is  that  by  Du  Bois  Reymoud  in  the  "  Physiology 
of  Exercise/'  a  translation  of  which  is  given  in  the  Popular  Science 
Monthly  for  July  and  August,  1882.  He  divides  the  physical  training 
which  is  more  and  more  becoming  a  part  of  modern  systematic  education 
into  three  classes  :  The  first,  the  turning,  or  gymnastics  of  the  Germans ; 
the  second,  the  Swedish  system,  in  which  the  exercises  are  limited  to  very 
simple  though  varied  movements ;  and  the  English  system,  or  rather  want 
of  system,  consisting  largely  of  athletic  games  and  contests  of  various 
kinds.  His  objection  to  the  Swedish  system  is  that,  while  it  strengthens 
the  muscles,  it  does  not  increase  the  power  over  composite  movements ; 
in  other  words,  it  does  not  exercise  the  nervous  system.  Naturally,  he 
prefers  the  German  system  to  any  other,  although  admitting  that  the 
English  meets  better  the  demands  arising  from  our  structure.  "  Were 
the  end  masterhood  in  running,  jumping,  climbing,  in  dancing,  fencing, 
riding,  in  swimming,  rowing,  or  skating,  then  nothing  could  be  more 
advisable  than  to  practise  equally  the  necessary  concatenations  in  the 
actions  of  the  ganglion  cells,  without  pausing  at  the  not  practically 
applicable  preliminary  and  intermediate  steps  of  the  German  turning." 

From  a  sanitary  point  of  view,  the  gymnasium,  as  usually  located  and 
managed,  is  by  no  means  equivalent  to  out-of-door  sports  and  contests, 
although  it  is  often  the  best  substitute  for  them.  The  form  of  exercise  most 
used  by  men  whose  occupation  does  not  involve  bodily  labor  is  walking, 
and  next  to  this  riding.  Whatever  mode  be  selected,  it  is  very  desirable 
that  it  should  be  taken  for  some  other  object  than  that  of  the  mere 
making  muscular  exertion,  or  otherwise  it  will  soon  come  to  be  looked 
upon  as  an  unpleasant  task,  the  time  spent  upon  which  is  given  grudg- 
ingly ;  and  it  will  be  partially  or  wholly  abandoned  as  soon  as  the 
immediate  discomfort  which  induced  its  use  has  ceased. 

It  is  not  an  uncommon  error  among  men  engaged  in  mental  work  to 
suppose  that  they  can,  and  ought  to,  take  the  same  amount  of  exercise 
which  gives  good  results  in  those  whose  occupations  involve  physical 
rather  than  mental  effort,  or  to  think  that  the  more  exercise  they  take 
the  more  study  or  writing  they  are  equal  to.  This  is  a  grave  mistake. 
Expenditure  of  brain-tissue  is  not  to  be  repaired  by  muscular  exertion, 
but  by  sleep  and  food,  and  exercise  in  the  fresh  air  sufficient  to  produce 
appetite  and  sufficient  weariness  to  ensure  restful  sleep  is  all  that  is  neces- 
sary. For  a  time  it  is  true  that  the  student  or  writer  who  has  a  well- 
developed  body  can  continue  to  burn  the  candle  at  both  ends,  and  win 
literary  honors  while  also  standing  high  as  an  athlete;  but  this  surely 
leads  to  physiological  bankruptcy  in  the  end. 

It  is  to  be  remembered  that  good  muscular  development  is  not  neces- 
sarily synonymous  with  health,  and  that  strength  is  not  a  guarantee 
against  disease.  And,  while  it  is  true  that  in  this,  as  in  most  other  mat- 
ters of  individual  hygiene,  each  man  must  to  a  great  extent  be  a  law  to 


200  HYGIENE. 

himself,  and  learn  by  experience  what  kind  of  exercise  and  how  much  of 
it  he  requires,  yet  the  physician  can  often  supply  the  motive  which  was 
wanting,  or  check  undue  effort.  Exercise  for  the  sake  of  health  and 
comfort  is  not  an  end,  but  a  means ;  yet  if  this  means  can  be  made  to 
secure  to  the  patient  an  end  agreeable  and  pleasant  in  itself,  so  much  the 
better. 

XI.  CONTAGION  AND  DISINFECTION. — By  "contagion"  we  mean 
the  communication  of  disease  from  one  person  to  another,  either  by 
direct  contact  or  through  some  medium,  such  as  air,  water,  etc.  It 
therefore  includes  "  infection,"  which  is  now  generally  used  as  a  synonym 
for  it.  The  so-called  infective  diseases  of  modern  German  writers  (In- 
fections-Krankheiten)  include,  besides  what  are  commonly  termed  in 
English,  contagious  diseases,  the  so-called  miasmatic  diseases. 

The  characteristic  of  a  contagious  disease  is  its  specificity ;  that  is,  the 
disease  transmitted  is  always  the  same  in  its  essential  characteristics.  It 
does  not,  however,  follow  that  all  cases  of  the  disease  are  equally  liable  or 
have  the  same  power  to  transmit  it ;  in  other  words,  the  degree  of  viru- 
lence of  the  contagiousness  is  not  an  essential  characteristic.  That  the 
same  disease  sometimes  spreads  rapidly  and  is  very  fatal,  and  at  other 
times  seems  hardly  to  have  any  contagious  properties  and  is  very  mild, 
has  long  been  noticed,  and  has  been  attributed  to  an  unknown  something 
called  the  medical  constitution  of  the  place — the  constitution  medicale  of 
French  writers.  The  true  cause  is  probably  very  complex,  but  in  some 
cases,  at  all  events,  it  seems  to  be  due  to  difference  in  the  contagion  itself. 
If  we  suppose  this  contagion  to  be  a  minute  organism,  it  is  easy  to  form 
a  theory  as  to  the  cause  of  these  differences,  but  there  is  much  careful 
experimental  work  to  be  done  before  we  shall  have  positive  knowledge 
on  this  point.  The  results  obtained  by  Pasteur  in  attenuating  the  virus 
of  chicken  cholera  and  splenic  fever  indicate  one  line  which  these  experi- 
ments will  take,  and  the  researches  of  Koch  point  out  another. 

The  diseases  which  spread  by  contagion  until  they  form  epidemics  are 
those  which  have  from  the  earliest  times  attracted  the  most  general  atten- 
tion, and  which  have  given  rise  to  organized  efforts  for  prevention — i.  e. 
to  public  hygiene. 

They  are  also  the  diseases  which  have  given  rise  to  the  most  bitter 
controversies  among  medical  men  as  to  the  means  of  their  propagation 
and  the  best  methods  of  prevention.  Plague,  cholera,  yellow  fever,  and 
typhus  are  those  with  regard,  to  which  this  difference  of  opinion  has 
chiefly  occurred — one  party  considering  their  chief  cause  to  be  contagion, 
or  specific  germs  derived  directly  or  indirectly  from  the  bodies  of  the 
sick ;  the  second  party  declaring  that  they  are  due  to  filth  plus  an 
unknown  something,  which  is  variously  termed  epidemic  constitution, 
pandemic  wave,  Providence,  or  x.  The  great  majority  of  opinions  at 
present  is  in  favor  of  the  view  that  they  are  all  contagious,  but  not  all, 
or  always,  contagious  from  person  to  person — that  they  spread  from 
infected  localities,  which  localities  receive  their  infection  from  cases  of 
the  disease.  The  best  means  of  dealing  with  them  under  ordinary 
circumstances  are  now  tolerably  well  understood,  and  where  these  means 
can  be  commanded — as,  for  instance,  among  troops  in  time  of  peace — 
epidemics  of  these  diseases  can  be  stopped  with  great  precision  and 
promptness  by  isolation  and  disinfection. 


CAUSES  OF  DISEASE,  ETC.  201 

By  "  isolation  "  is  meant  not  only  the  separation  of  the  sick  from  the 
well,  but  the  isolation  of  the  infected  locality  or  water-supply  until  it  has 
been  rendered  harmless. 

By  "disinfection"  is  meant  the  destruction  of  the  specific  causes  of  dis- 
ease, and  more  especially  of  the  infectious  or  spreading  diseases.  A  disin- 
fectant is  not  necessarily  an  antiseptic  or  a  deodorant,  nor  are  these  last  ne- 
cessarily disinfectants.  The  best  practical  antiseptic  for  sanitary  purposes  is 
cleanliness ;  the  best  disinfectants  are  heat,  bichloride  of  mercury,  sulphate  of 
iron,  chloride  of  zinc,  sulphurous  acid,  chlorine,  sunlight,  and  pure  air,  and, 
for  yellow  fever,  cold.  "With  our  present  very  imperfect  knowledge  of  the 
nature  of  specific  causes  of  disease  which  we  wish  to  destroy,  we  have  no 
means  of  determining  the  presence  of  these  causes  in  or  on  an  article  of 
clothing  or  of  furniture,  or  in  a  room  or  other  locality,  except  by  the 
production  of  their  specific  effects  on  man  or  by  inductive  reasoning ;  in 
other  words,  we  can  only  say  that  it  is  more  or  less  probable  that  such 
causes  are  present.  This  makes  it  necessary,  or  at  least  expedient,  to 
employ  disinfectants  in  many  cases  where  the  presence  of  such  causes  is 
doubtful.  The  practical  difficulties  are,  first,  to  bring  the  disinfecting 
agent  into  such  relation  with  the  causes  of  disease  that  it  can  act  upon 
them,  and  act  upon  all  of  them  ;  second,  to  avoid  unnecessary  destruction 
or  injury  of  things  which  should  be  preserved.  The  majority  of  the 
causes  of  disease  upon  which  we  wish  to  act  by  disinfectants  are  probably 
minute  particles  of  solid  or  semi-solid  matter  which  are  living,  and  may 
be  conveniently  designated  by  the  word  "germs."  In  the  presence  of 
moisture  the  destruction  of  the  vitality  of  these  germs  can  be  effected 
with  comparative  ease  and  rapidity,  but  when  they  have  become  dried, 
or,  as  in  the  case  of  the  bacilli,  are  in  the  form  of  spores,  it  is  a  more 
difficult  matter. 

To  illustrate  the  methods  to  be  pursued  and  the  precautions  to  be 
taken,  let  us  suppose  the  physician  to  be  called  on  for  directions  as  to 
the  management  of  a  case  of  scarlatina,  the  object  being  to  prevent  its 
spread.  The  first  thing  to  be  done  is  to  get  the  patient  in  a  room  by 
himself,  and  to  leave  nothing  in  this  room  which  is  not  necessary. 
Remove  the  carpet,  curtains,  and  all  stuffed  or  upholstered  furniture. 
Let  the  nursing  be  done,  as  far  as  possible,  by  one  person  only,  and  do 
not  allow  others,  and  especially  children,  to  enter  the  room,  no  matter  if 
they  have  had  the  disease.  The  danger  of  contagion  depends  upon  par- 
ticles coming  from  the  skin  and  mucous  membranes.  All  excreta,  and  more 
especially  the  sputa  or  discharges  from  the  mouth  or  nose,  are  to  be  treated 
as  dangerous.  The  excreta  should  be  received  in  vessels  containing  a  solu- 
tion of  sulphate  of  iron,  one  and  a  half  pounds  to  the  gallon.  All  cloth- 
ing, towels,  bed-linen,  handkerchiefs,  napkins,  etc.  should  be  placed  in  a 
solution  composed  of  four  ounces  of  sulphate  of  zinc  and  two  ounces  of 
common  salt  to  the  gallon  of  water  as  soon  as  they  are  not  needed  for 
further  use.  Especial  care  should  be  taken  that  none  of  these  articles 
are  removed  from  the  room  while  dry,  and  while  they  are  in  the  room, 
and  before  they  have  been  moistened,  they  should  not  be  shaken  or 
disturbed  more  than  is  absolutely  necessary.  If  for  any  reason  the  zinc 
solution  above  referred  to  is  not  at  hand — which  should  very  rarely  be 
the  case — the  clothing,  etc.  should  be  placed  in  a  bucket,  tub,  or  boiler 
containing  enough  scalding  water  to  entirely  cover  them,  and  be  removed 


202  HYGIENE. 

from  the  room  in  this  vessel.     All  such  articles  should  be  boiled  at  least 
one  hour. 

No  sweeping  or  dusting  in  the  ordinary  way  is  to  be  done  in  the  room ; 
dust  and  dirt  are  to  be  removed  by  damp  cloths,  which  are  to  be  treated 
like  the  bedding  and  clothing.  The  great  object  is  to  prevent  as  far  as 
possible  the  production  of  dust  in  the  atmosphere  of  the  room.  The 
entire  body  of  the  patient,  including  head,  face,  and  limbs,  should  be 
kept  thoroughly  anointed  with  camphorated  oil,  vaseline,  or  some  similar 
substance,  and  especial  care  should  be  taken  in  this  respect  during  the 
period  of  convalescence  so  long  as  any  roughness  or  desquamation  of  the 
skin  continues.  No  toys  or  books  which  it  is  desired  to  preserve  should 
be  allowed  to  remain  in  the  room,  and  under  no  circumstances  should 
books  or  toys  be  borrowed  to  amuse  the  child  if  they  are  to  be  returned. 
The  best  way  to  disinfect  such  articles  is  to  burn  them  in  the  room. 

When  the  patient  is  fully  convalescent  and  all  desquamation  has  ceased, 
cleanse  him  thoroughly  with  a  warm  bath  and  soap  for  four  successive 
days.  If  at  the  end  of  that  time  no  roughness  of  the  skin  remains,  he 
may  be  dressed  in  clean  clothes  and  taken  from  the  room,  for  he  is  no 
longer  a  source  of  danger.  The  room  itself  and  the  furuitnre  are  then 
to  be  thoroughly  cleansed  and  disinfected.  The  ceiling  and  walls,  if  of 
ordinary  hard  finish,  are  to  be  scraped  and  whitewashed.  All  woodwork 
should  be  rubbed  with  damp  cloths  and  the  floor  well  scrubbed.  Care 
should  be  taken  to  remove  all  dust  from  the  ledges  over  windows  and 
doors.  All  the  cloths  used  in  this  cleansing  process  are  to  be  burned. 

If  these  directions  have  been  carefully  carried  out,  there  is  no  need  for 
further  disinfection.  But  if  upholstered  furniture  has  been  allowed  to 
remain  in  the  room,  or  other  articles  which  cannot  be  burned  or  scrubbed 
or  soaked  in  the  zinc  solution,  it  may  be  desirable  to  attempt  to  disinfect 
the  whole  room  and  its  contents  by  means  of  chlorine  or  sulphurous  acid 
gases.  Of  these,  sulphurous  acid  gas  is  the  cheapest,  and  upon  the 
whole  the  best,  but  it  must  be  used  in  large  quantity,  and  for  a  longer 
time  than  is  customary,  if  it  is  to  be  relied  upon.  For  this  purpose  all 
openings  into  the  room  should  be  closed,  and  pillows,  mattrasses,  uphol- 
stered furniture,  and  articles  which  cannot  be  treated  with  the  zinc  solu- 
tion should  be  opened,  so  that  they  may  be  exposed  throughout  to  the 
fumes.  The  sulphur  should  be  burned  in  an  iron  pan  or  pot,  placed  in  a 
tub  containing  water  or  upon  a  large  surface  of  sand.  About  18  ounces 
of  roll  sulphur  should  be  used  to  each  1000  cubic  feet  of  space,  and  after 
twenty-four  hours  12  ounces  more  should  be  burned  and  the  room  be 
then  closed  for  twenty-four  hours  longer,  after  which  it  may  be  opened 
and  aired.  In  case  of  death  the  body  should  at  once  be  wrapped  in  a 
sheet  thoroughly  soaked  with  the  chloride  of  zinc  solution,  and  either 
be  placed  in  an  air-tight  coffin  at  once  or  be  buried  without  delay.  The 
funeral  should  be  strictly  private,  and  the  sheet  referred  to  should  not 
be  disturbed  or  the  body  exposed  to  view. 

The  cases  most  liable  to  spread  the  disease  are  those  in  which  the  attack 
is  very  light  and  the  child  is  not  confined  to  its  bed.  It  is  desirable  that 
children  in  a  house  in  which  there  are  cases  of  scarlet  fever  should  not  be 
allowed  to  attend  school  or  mingle  with  other  children  who  have  not  had 
the  disease. 

With  regard  to  disinfectants,  it  may  be  well  to  note  that  none  of  the 


CAUSES  OF  DISEASE,  ETC.  203 

| 

various  patent  disinfectants  are  superior  to  bichloride  of  mercury,  chloride 
of  zinc,  sulphate  of  iron,  chlorine,  and  sulphurous  acid;  very  few  are  equal 
to  them,  and  none  cost  so  little.  As  a  gaseous  disinfectant  for  rooms,  etc. 
chlorine  is  superior  to  sulphurous  acid,  but  it  has  the  disadvantage  of 
injuring  metals,  is  not  so  easily  applied,  and  is  more  costly.  It  will 
destroy  the  vitality  of  the  spores  of  the  bacilli  more  rapidly  and  certain- 
ly than  sulphurous  acid,  .which  last,  to  make  sure  work,  must  be  exhibited 
for  a  much  longer  period  than  is  customary.  I  should  not  feel  confident 
as  to  the  thorough  disinfection  by  sulphurous  acid  of  the  hold  of  an 
infected  ship  unless  the  fumes  had  been  applied  for  sixty  hours.  Carbolic 
acid  as  ordinarily  used  is  an  antiseptic  rather  than  a  disinfectant.  Its  vapor 
in  a  sick  room  is  absolutely  useless.  When  applied  in  strong  solution  it 
is  effective,  for  a  time  at  least,  but  as  thus  used  it  is  expensive,  its  odor  is 
unpleasant  to  many,  and  masks  the  odors  from  putrefying  substances  and 
excreta,  etc.,  thus  preventing  the  warning  which  these  odors  would  give. 

Its  use  is  in  manv  cases  very  much  like  removing  the  rattle  from  the 

* 
rattlesnake. 

The  suggestions  made  above  for  limiting  the  spread  of  scarlatina  from 
a  case  to  be  treated  in  the  residence  of  the  patient  apply — with  certain 
modifications  for  each  form  of  disease,  which  will  readily  suggest 
themselves  to  the  physician — to  all  the  affections  due  to  portable  con- 
tagia. 

Among  the  poorer  classes,  however,  it  will  often  be  found  impossible 
to  obtain  the  separate  room  and  service  and  the  constant  intelligent  care 
which  are  necessary  to  ensure  the  desired  result ;  and  in  such  a  case  the 
patient  should  be  removed  to  a  hospital,  for  his  own  sake  as  well  as  for 
that  of  the  community.  The  utility  of  small  hospitals  for  infectious  dis- 
eases is  by  no  means  generally  understood,  and  very  few  of  our  small 
cities  and  towns  are  provided  with  anything  of  the  sort.  If  the  subject 
is  urged  on  the  authorities  of  a  place,  the  reply  will  be  that  it  is  an  unneces- 
sary expense,  that  the  people  would  not  go  to  it,  and  that  such  an  institu- 
tion is  in  itself  a  source  of  danger.  The  facts  are,  that  such  a  hospital 
costs  very  little,  and  is  the  cheapest  insurance  against  epidemics  which  a 
town  can  have ;  if  it  is  kept  clean  and  comfortable,  the  people  will  use  it 
freely,  and  if  properly  managed  it  does  not  offer  the  slightest  danger  to 
the  vicinity.  This  question  will  be  further  discussed  in  the  last  section  of 
this  paper. 

The  principles  of  isolation  as  applied  to  a  single  case  as  indicated  above 
may  also  be  applied  to  infected  localities  in  case  of  epidemics.  When  taken 
in  time,  all  diseases  which  depend  upon  participate  contagia  for  their  origin 
can  be  stamped  out  by  isolation  and  disinfection.  Unfortunately,  to  effect 
this  promptly  and  successfully  requires  money,  labor,  and  the  co-operation 
of  the  well  in  the  viciuitv  ;  which  last  it  is  usually  impossible  to  obtain  vol- 
untarily or  to  compel  sufficiently  to  secure  the  desired  results.  A  question 
which  sometimes  arises  in  case  of  epidemics,  and  with  regard  to  the  necessity 
for  which  physicians  will  be  consulted,  relates  to  the  closure  of  the  public 
schools.  It  is  certain  that  the  assemblage  of  children  in  schools  exerts  a 
powerful  influence  on  the  spread  of  such  diseases  as  scarlet  fever,  diphtheria, 
and  whooping  cough.  On  the  other  hand,  the  closure  of  the  schools  infringes 
upon  the  rights  of  a  large  number  of  the  community,  and  if  long  con- 
tinued, as  it  sometimes  must  be  to  be  really  efficacious,  inflicts  upon  them 


204  HYGIENE. 

a  permanent  loss.  It  is,  moreover,  a  confession  on  the  part  of  the  author- 
ities of  inability  to  induce  or  compel  what  must  always  be  a  comparatively 
small  part  of  the  community  to  take  the  proper  precautions.  It  is  never 
justifiable  to  close  schools  on  account  of  small-pox,  and  where  there  is  a 
competent  health  authority  supported  by  the  influence  of  the  medical  pro- 
fession, it  must  be  a  very  exceptional  set  of  circumstances  which  justifies 
their  closure  for  diphtheria  or  scarlatina. 

It  is  not  deemed  expedient  here  to  discuss  the  vexed  question  of  quar- 
antine. It  is  more  important  against  yellow  fever  than  any  other  disease, 
because  every  day  of  delay  of  the  entrance  of  the  disease  which  it  secures 
lessens  largely  the  subsequent  mortality,  since  the  duration  of  the  disease 
is  limited  by  frost.  This  is  not  the  case  with  cholera,  and  the  mere  keep- 
ing this  disease  out  of  a  place  for  a  feAv  weeks  does  not  diminish  its  rav- 
ages when  it  has  once  gained  an  entrance.  To  rely  altogether  on  quaran- 
tine, either  maritime  or  inland,  to  keep  yellow  fever,  cholera,  or  any  other 
disease  out  of  this  country  is  a  far  greater  mistake  than  to  neglect  it  alto- 
gether. The  practical  way  to  isolate  and  quarantine  is  to  get  as  close  to 
the  affected  spot  as  possible.  Precautions  at  Havana  for  yellow  fever,  or 
at  Hamburg  for  cholera,  are  far  more  useful  to  the  United  States  than  the 
same  amount  of  work  at  our  own  ports  can  possibly  be ;  really  good  work 
in  this  direction  must  be  not  only  national,  but  international. 

XII.  MENTAL  CAUSES  OF  DISEASE. — A  man  may  give  too  much 
attention  to  his  health  and  the  means  for  its  preservation,  and  the  doing 
so  is  both  a  sign  and  a  cause  of  disease — probably  ofteuer  the  former  than 
the  latter,  except  in  cases  of  psychological  epidemics.  The  power  of 
expectant  attention,  especially  if  accompanied  by  belief  or  fear,  to  produce 
derangement  of  function  in  the  nervous  system,  and  through  this  to  affect 
the  circulatory  aud  digestive  systems,  is  well  known  to  medical  men.  The 
effects  of  an  undue  amount  of  brain-work,  and  especially  of  the  anxiety 
aud  worry  which  often  accompany  this  when  it  is  specially  directed  to 
the  acquiring  of  wealth,  fame,  or  power,  are  also  familiar  to  physicians  in 
our  large  cities.  The  analogies  between  mental  and  physical  exertion  are 
close  in  some  respects,  aud  especially  as  to  the  effects  of  over-exertion  in  a 
limited  time  under  the  influence  of  excitement. 

The  danger  from  simple  mental  work,  such  as  study,  when  there  is  no 
excitement  from  a  contest,  is  small,  and  depends  mainly  on  lack  of  physical 
exercise  and  consequent  disorder  of  the  digestive  organs.  The  risk  of 
producing  what  Fothergill  calls  "  physiological  bankruptcy  "  is  greatest 
in  the  youth  studying  for  a  prize,  the  speculator,  the  man  who  feels 
responsibility  which  he  knows  he  probably  cannot  meet.  The  danger  of 
injury  from  overwork  under  excitement  is  a  very  real  one  in  many  of  our 
schools,  and,  while  the  evil  results  are  most  apparent  in.  girls  of  the  mid- 
dle and  upper  classes,  the  boys  and  the  young  men  also  suffer.  The  sys- 
tem of  pass  examinations,  in  which  the  standing  of  the  pupil  is  to  be 
determined,  not  from  the  average  results  of  his  daily  recitations,  but  from 
a  single  examination  at  the  end  of  the  year,  produces  the  greatest  risks  to 
health ;  and  this  is  especially  the  case  where  the  ambition  and  pride  of  the 
children  are  stimulated  by  competition  for  prizes,  medals,  etc.  Such  systems 
of  grading  by  a  single  final  examination  should  not  be  used  in  ordinary 
schools,  and  for  some  pupils  there  will  always  be  a  risk  to  health  connected 
with  them  even  when  they  are  of  age.  No  doubt  the  stimulus  of  competi- 


PERSONAL  HYGIENE,  ETC.  205 

tion  is  useful  with  the  majority  of  children  as  well  as  of  adults,  but  with 
some  of  them  it  is  pretty  sure  to  go  too  far. 

The  symptoms  produced  by  undue  mental  strain  are  familiar  to  all 
physicians,  and  there  is  usually  little  difficulty  in  tracing  the  effect  to  the 
cause  when  attention  has  been  directed  to  the  matter ;  in  fact,  the  patient 
himself  usually  knows  very  well  the  cause  of  his  troubles.  The  remedy 
is,  of  course,  rest — but  that  does  not  mean  idleness.  In  speaking  of  occu- 
pation, allusion  has  been  made  to  the* fact  that  the  physician  must  at  times 
advise  his  patient  as  to  the  adoption  of  some  pursuit,  and  in  cases  of  this 
kind  such  advice  is  also  useful. 

The  effects  of  mental  strain  are  often  mingled  with,  and  aggravated  by, 
those  of  stimulants  which  have  been  used  to  spur  the  flagging  energies. 
Alcohol,  tobacco,  opium,  or  coffee  used  in  this  way  finally  increase  the 
very  discomforts  which  at  first  they  relieved. 


n.  Personal  Hygiene  in  its  Relations  to  the  Practice  of 

Medicine. 

In  the  preceding  section  have  been  indicated  briefly  some  of  the  principal 
causes  of  disease  and  the  methods  for  their  investigation  or  removal.  We 
have  now  to  consider  some  of  the  practical  applications  which  may  be 
made  of  the  laws  of  etiology  and  prevention  of  disease  in  the  treatment  of 
the  sick.  While  the  removal  of  the  cause  of  illness  by  no  means  always 
effects  a  cure,  yet  the  importance  of  a  knowledge  of  this  cause  as  an  aid  to 
diagnosis,  prognosis,  and  therapeutics  is  so  evident  as  to  require  no  proof. 

To  discuss  with  anything  like  completeness  the  practical  applications 
of  what  would  be  commonly  considered  as  hygienic  rules  in  the  treatment 
of  disease  would  be  to  write  a  treatise  on  nursing,  and  would  also  include 
a  large  part  of  the  practice  of  medicine,  for  regimen  is  the  more  important 
half  of  practical  therapeutics.  The  hygienic  requirements  peculiar  to  each 
disease  will  be  pointed  out  by  the  writers  upon  special  subjects,  and  I 
shall  only  venture  upon  one  or  two  general  remarks  in  addition  to  the 
hints  already  given  in  speaking  of  the  several  causes. 

In  the  acute  stages  of  disease  the  sensations — or,  if  the  term  be  pre- 
ferred, the  instincts — of  the  patient  are  usually  the  best  guide  to  his 
regimen  so  far  as  they  go.  In  most  cases  he  desires  quiet,  shade,  but 
not  absolute  darkness,  and  little  or  no  food,  although  there  is  often  a 
craving  for  drinks,  especially  of  a  cooling  character.  In  the  specific 
fevers  which  have  a  tolerably  definite  period  and  course  it  is  important 
to  keep  up  the  nourishment  even  during  the  period  of  anorexia,  in  order 
to  provide  against  the  debility  which  is  to  follow.  This  nourishment  is 
best  given  in  the  form  of  drink,  and  very  frequently  fresh  milk  is 
the  type  of  what  is  required.  The  old  notion  that  whatever  a  sick  man 
desired  must  be  hurtful,  and  therefore  that  the  fever  patient  must  be  kept 
hot  and  refused  cool  water,  has  now  almost  entirely  passed  away. 

In  convalescence  from  acute  disease  and  in  many  chronic  cases,  the  sen- 
sations of  the  patient  are  not  to  be  trusted  as  a  guide  in  the  choice  of  food. 
In  such  diseases  as  yellow  fever  and  typhoid  fever  to  allow  the  convales- 
cent to  follow  the  dictates  of  his  appetite  is  to  run  great  risk  of  a  fatal 
result.  In  other  cases  the  patient  really  has  no  wish  in  the  matter,  but  it 


200  HYGIENE. 

will  often  be  found  that  one  who  can  think  of  nothing  which  he 
desires  to  eat,  and  who  will  even  refuse  a  dish  which  he  lias  requested 
and  been  thinking  about,  will  eat  with  enjoyment  some  unexpected  dainty 
Avhen  presented  at  the  right  moment  and  properly  served  as  a  skilled 
nurse  knows  how  to  do.  The  manner  of  serving  the  food,  independent 
of  its  cooking,  is  not  a  matter  of  such  small  importance  that  the  physician 
can  afford  to  overlook  it,  and  he  will  succeed  best  as  a  practitioner  who 
best  appreciates  the  influence  which  *  cracked  goblet,  a  chipped  saucer,  a 
soiled  napkin,  or,  on  the  other  hand,  a  hot  plate  or  a  touch  of  color  in  the 
shape  of  a  leaf  or  flower,  may  have  upon  the  capricious  appetite  of  the 
sick.  In  ordering  diet  for  convalescence  it  is  not  an  uncommon  error  to 
select  only  those  articles  which  are  agreeable  to  the  physician  himself, 
forgetting  the  old  proverb,  that  what  is  one  man's  meat  may  be  another 
man's  poison,  and  also  that  it  is  above  all  things  desirable  to  avoid  mo- 
notony. One  doctor  always  orders  chicken,  another  eggs,  a  third  a  'mut- 
ton-chop, etc.  The  practice  in  this  respect  lias  probably  been  unduly 
influenced  by  the  reports  of  Beaumont  of  the  results  of  his  observa- 
tions on  Alexis  St.  Martin,  and  we  still  find  that  the  relative  digestibility 
of  various  articles  of  food  is  estimated  according  to  the  scale  laid  down 
in  these  reports,  with  no  allowance  for  individual  peculiarities,  previous 
habits,  mode  of  cooking,  etc.  The  secret  of  success  in  the  diet  of  con- 
valescence lies  mainly  in  the  simplicity  of  the  individual  dishes,  in 
varying  the  different  meals,  in  the  manner  of  serving,  and  in  carefully 
observing  the  effects  on  the  sick  person,  and  being  guided  by  the  results. 

To  promote  appetite  and  digestion,  and  to  secure  refreshing  sleep,  one 
of  the  most  important  things  is  fresh  air,  but  in  many  houses  a  sick  per- 
son will  obtain  but  a  very  limited  allowance  of  this  if  the  physician  does 
not  give  special  attention  to  the  matter.  Except  in  cases  of  contagious 
disease,  the  rules  for  managing  which  have  been  given  in  a  previous  sec- 
tion (p. ),  as  soon  as  a  patient  is  sufficiently  recovered  to  be  moved  for 

a  short  time  into  another  room  his  bedroom  should  be  thoroughly  aired 
and  cleansed,  and  this  should  be  done  morning  and  evening  thereafter. 

In  treating  cases  of  contagious  disease  the  question  often  arises  as  to 
means  of  individual  prophylaxis  to  be  used  by  those  who  must  be  exposed 
to  the  effects  of  the  infected  locality  or  of  the  presence  of  the  sick.  The 
attempts  which  have  been  made  to  secure  this  individual  protection  in  the 
midst  of  an  epidemic  have  been  numerous  and  varied,  ranging  from  the 
use  of  the  "  vinegar  of  the  four  thieves"  of  the  Middle  Ages  to  the  employ- 
ment of  the  sulphites  and  chlorates  to  make  the  blood  unsuited  to  the 
growth  and  multiplication  of  the  supposed  germs,  or  of  cotton-wool  respi- 
rators to  strain  the  infected  air,  or  of  supposed  specifics  for  particular  dis- 
eases, as  belladonna  for  scarlet  fever  and  vaccination  against  small-pox. 
As  yet,  there  is  little  or  no  satisfactory  evidence  as  to  the  value  of  indi- 
vidual precautions  against  those  diseases  whose  contagion  is  conveyed 
through  the  air,  small-pox  alone  excepted,  but  in  case  of  diphtheria  in  one 
member  of  a  family  of  children  it  might  be  well  to  try  the  use  of  chlorate 
of  potash  internally,  combined  with  the  local  application  of  the  tincture 
of  the  chloride  of  iron,  as  suggested  by  E.  M.  Hunt.  The  question 
is  one  to  be  investigated  by  careful  observation  and  experiment;  and, 
though  it  is  improbable  that  any  definite  results  will  be  obtained  except 
in  those  diseases  Avhich  are  communicable  to  animals,  and  therefore  sus- 


PUBLIC  HYGIENE,  ETC.  207 

ceptible  of  direct  experiment,  still,  it  is  possible  that  some  advance  may 
be  made.  In  rare  and  exceptional  cases — as,  for  instance,  in  exploring  a 
crowded,  filthy,  and  intensely  infected  typhus-fever  nest,  as  a  tenement- 
house,  or  an  infected  yellow-fever  ship — it  may  be  worth  while  for  the 
physician  or  inspector  who  is  unprotected  by  a  previous  attack  of  these 
diseases  to  make  use  of  a  cotton-wool  respirator,  which  is  readily  extem- 
porized, and  belongs  to  that  exceedingly  valuable  and  popular  class  of 
remedies  which,  "  if  they  do  no  good,  can  do  no  harm."  In  epidemics  of 
typhus,  cholera,  or  yellow  fever  one  of  the  most  valuable  prophylactics  is 
to  have  a  mind  so  occupied  with  other  matters  that  it  pays  little  or  no 
attention  to  the  danger,  while  in  case  of  small-pox  fear  of  the  disease  is 
indirectly  the  best  prophylactic,  since  it  leads  to  careful  vaccination. 

This  branch  of  the  subject  is  closed  with  the  remark  that  it  would  be 
well  if  physicians,  and  especially  the  younger  ones,  gave  more  attention 
to  the  preservation  of  their  own  health  than  many  of  them  do.  The  pos- 
session of  a  medical  diploma  does  not  prevent  the  evil  effects  of  irregular 
and  hurried  meals,  insufficient  sleep,  exposure  to  inclement  weather,  and 
lack  of  systematic  and  sufficient  exercise ;  and  too  much  tobacco,  some- 
times too  much  alcohol,  and  in  exceptional  cases  too  much  study  and  lit- 
erary work,  so  often  combine  with  anxiety  about  individual  patients  or 
with  pecuniary  worries  to  damage  the  digestion  and  nervous  system  of  the 
young  practitioner  that  the  wonder  is  that  so  many  survive  the  ordeal. 
And,  in  fact,  the  mortality  among  physicians  under  the  age  of  thirty  is 
higher  than  that  of  any  other  profession  during  the  same  period  of  life. 


IE.  Public  Hygiene  in  its  Relations  to  Physicians. 

An  important  difference  between  man  and  animals  is  found  in  the 
extent  to  which  he  will  sacrifice  a  present  pleasure  or  convenience  to 
secure  a  future  good  or  to  avoid  a  future  evil.  The  savage  will  do  this 
to  only  a  very  limited  extent — little  more,  in  fact,  than  the  beaver  or  the 
squirrel — and  the  lesson  is  learned  but  slowly  and  by  sad  experience. 
This  is  especially  the  case  as  regards  matters  affecting  health.  When  a  man 
begins  to  take  special  precautions  as  to  his  diet  or  exercise,  having  in  view 
rather  his  future  health  than  his  present  comfort  and  tastes,  he  has  in  most 
cases  already  begun  to  suffer  from  the  effects  of  his  imprudence,  and  does 
not  commence  a  hygienic  course  of  life  as  a  perfectly  sound  and  healthy 
person.  The  same  is  true  for  a  community.  It  will  not  usually  submit 
to  the  burden  of  taxation  necessary  to  secure  drains  and  sewers  or  a  proper 
registration  of  vital  statistics,  nor  to  the  cost  and  inconvenience  of  the 
machinery  necessary  to  limit  the  spread  of  contagious  diseases,  until  the 
neglect  of  these  things  has  resulted  in  such  an  amount  of  disease  and 
death  as  to  forcibly  call  attention  to  the  matter.  The  result  is,  that  the 
burden  is  far  heavier  than  it  would  have  been  had  the  work  been  under- 
taken in  proper  season,  and  individuals  may  find  it  to  their  interest  to 
leave  the  place  and  settle  elsewhere  rather  than  remain  and  meet  their 
proportion  of  the  expense. 

When  a  state  or  municipality  has  so  far  advanced  in  civilization  as  to 
consider  it  desirable  to  take  measures  to  protect  the  public  health  by  pre- 
venting individuals  from  polluting  the  air  or  water  liable  to  be  used  by 


208  HYGIENE. 

their  neighbors,  etc.,  the  services  of  the  medical  profession  are  always 
called  upon.  The  foundation  of  public  hygiene 'is  information  as  to  the 
occurrence  of  certain  forms  of  disease,  the  cause  of  which  can  be  referred 
with  more  or  less  precision  to  a  certain  limited  locality.  This  information 
may  be  very  imperfect,  consisting  of  little  more  than  rumor  and  opinions 
as  to  the  existence  of  an  undue  amount  of  sickness  or  mortality  in  a  certain 
place,  or  it  may  consist  of  precise  reports  setting  forth  the  number  of  deaths 
from  each  cause,  the  proportion  of  each  of  these  to  the  population  by  age, 
sex,  occupation,  etc.,  and  of  the  whole  to  births — constituting  what  is 
commonly  called  the  "  vital  statistics  of  a  place  " — and  also  of  reports  of 
the  occurrence  of  certain  preventable  diseases ;  and  between  these  two  the 
information  may  be  of  various  degrees  of  completeness,  but,  whatever  there 
be,  it  is  for  the  most  part  obtained  either  directly  or  indirectly  from  medical 
men.  The  reliability  and  completeness  of  the  information  thus  obtained 
by  the  state  determines  to  a  great  extent  the  direction  and  character  of  the 
work  done  in  destroying  or  preventing  the  causes  of  disease,  and  it  is  also 
an  important  means  of  increasing  our  knowledge  with  regard  to  the  nature 
of  these  causes. 

The  character  of  this  information  depends  largely  upon  the  character 
of  the  physicians  who  furnish  it.  In  a  large  part  of  the  country  med- 
icine is  legally  in  the  position  of  any  common  occupation ;  that  is,  the 
term  "  physician "  is  defined  as  applied  to  "  any  one  who  publicly  an- 
nounces himself  to  be  a  practitioner  of  this  art,  and  undertakes  to  treat 
the  sick  either  for  or  without  reward."  Under  such  circumstances  there 
can  be  no  guarantee  that  all  who  call  themselves  physicians  are  properly 
qualified  or  competent  to  furnish  reliable  information  for  registration  pur- 
poses, and,  as  a  matter  of  fact,  a  large  number  are  not  so  qualified.  It  is 
for  this  reason  that  there  is  such  a  close  connection  between  public  health 
authorities,  registration  of  vital  statistics,  and  the  registration  of  those 
pjjysicians  whose  certificates  as  to  causes  of  deaths,  etc.  will  be  accepted 
by  the  state ;  and  hence  the  nature  of  the  public  health  organization  of  a 
state  and  the  personnel  of  its  officials  are  matters  of  great  importance  to 
physicians.  On  the  other  hand,  the  efficiency  of  a  public  health  service 
depends  very  largely  upon  the  relations  which  it  holds  with,  and  the  light 
in  which  it  is  regarded  by,  the  medical  profession.  A  health  officer  who 
is  distrusted  and  disliked  by  the  physicians  of  his  district  cannot  effect 
much  unless  he  can  overcome  this  feeling,  and  his  tenure  of  office  must 
always  be  very  insecure. 

The  official  relations  of  the  practitioner  with  the  health  authorities  are 
usually  Confined  to  the  subjects  of  registration  of  vital  statistics  and  of 
checking  the  spread  of  contagious  diseases.  The  most  marked  exception 
to  this  rule  is  furnished  by  the  States  of  Alabama  and  North  and  South 
Carolina,  in  which  the  State  Medical  Society  is  the  State  Board  of  Health, 
having  been  given  legislative  powers  and  the^  right  of  selecting  the  health 
officers.  The  most  complete  organization  of  this  kind  is  that  of  the  State 
of  Alabama,  where  by  the  act  of  1875  the  Medical  Association  of  the 
State  was  constituted  the  State  Board  of  Health,  and  the  county  medical 
societies  in  affiliation  with  the  State  Society  were  made  county  boards  of 
health,  to  be  under  the  general  direction  of  the  State  Board.  These 
county  boards  at  first  had  advisory  powers  only,  and  were  to  be  conducted 
without  expense  to  the  State  or  the  county,  except  that  the  competent  legal 


PUBLIC  HYGIENE,  ETC.  209 

authorities  of  any  county  might  invest  the  county  board  with  such  powers 
and  duties  for  the  promotion  of  the  public  health  as  might  be  mutually 
agreed  on ;  but  in  such  case  the  right  to  elect  or  appoint  those  employed 
in  sanitary  administration  is  reserved  to  the  board  of  health,  while  all 
questions  relating  to  salaries,  appropriations,  and  expenditures  shall  be 
reserved  to  the  legal  authorities.  It  was  further  provided  "  that  no  board 
of  health,  or  advisory  or  executive  medical  body  of  any  name  or  kind  for 
the  exercise  of  public  health  functions,  shall  be  established  by  authority 
of  law  in  any  county-town  or  city  of  this  State  except  such  as  are  con- 
templated by  the  provisions  of  this  act,  the  object  of  this  prohibition 
being  to  secure  a  uniform  system  of  sanitary  supervision  throughout  the 
State."  By  an  act  of  1881  the  county  board  is  directed  to  elect  a  health 
officer,  who  is  to  keep  a  register  of  the  births,  deaths,  and  cases  of  pesti- 
lential or  infectious  diseases  occurring  in  the  county,  and  furnish  to  phy- 
sicians, free  of  charge,  reliable  vaccine — to  obtain  information  as  to  the 
sanitary  condition  of  his  county,  etc.  etc.  It  will  be  seen  that  this  plan 
of  organization  is  an  attempt  to  overcome  the  practical  difficulties  in  the 
way  of  obtaining  from  physicians  the  information  necessary  for  the  reg- 
istration of  vital  statistics  and  the  work  of  preventing  the  spread  of 
infectious  diseases. 

While  the  great  majority  of  physicians  are  willing  to  furnish  the  infor- 
mation as  to  the  cause  of  death,  etc.  which  is  necessary  for  a  useful  regis- 
tration, there  are  always  some  who  either  neglect  or  refuse  to  do  so ;  and 
if  the  law  be  made  compulsory,  it  provokes  hostility  unless  compensation 
is  furnished,  while  as  regards  the  requiring  physicians  to  furnish  informa- 
tion as  to  the  existence  of  contagious  diseases,  this  always  rouses  opposition 
on  the  part  of  a  certain  number  of  medical  men,  even  if  payment  for  such 
notification  is  provided.  And  while  this  opposition  is  no  doubt  in  many 
cases  due  to  improper  motives,  such  as  personal  hostility  to  the  existing 
authorities,  party  politics,  or  a  desire  for  notoriety,  its  strength  neverthe- 
less rests  upon  the  fact  that  it  is  unjust  for  the  state  to  compel  the  services 
of  any  man  or  class  of  men  without  furnishing  compensation.  The  advo- 
cates of  health  and  registration  laws  are  thus  placed  between  Scylla  and 
Charybdis :  if  they  propose  compensation,  which  involves  appropriations 
from  the  public  treasury,  the  law  cannot  be  passed ;  if  there  is  no  com- 
pensation allowed,  complete  results  cannot  be  obtained. 

The  Alabama  law  makes  compulsory  the  furnishing  by  physicians  of 
information  relating  to  births,  deaths,  and  infectious  diseases,  and  gives 
compensation — not  in  money,  but  by  allowing  the  medical  profession  to 
have  the  sole  management  of  the  matter  and  to  choose  the  health  officers 
to  whom  they  are  to  report;  in  other  words,  they «tre allowed  to  tax  them- 
selves. The  result  in  Alabama  is  yet  doubtful.  If  competent  and  faith- 
ful health  officers  and  registrars  can  be  obtained  without  paying  them  a 
fair  compensation,  it  will  be  contrary  to  experience ;  and  if  these  officers 
receive  a  salary,  it  will  be  strange  if  the  positions  do  not  become  the  reward 
of  partisan  political  work. 

It  should  be  noted  that  the  requiring  a  physician  to  report  the  births 
occurring  in  his  practice  stands  on  a  very  different  basis  from  the  requir- 
ing him  to  report  the  cause  of  death,  since  there  is  no.  special  necessity  for 
the  former.  It  requires  no  expert  knowledge  to  report  a  birth,  and  the 
duty  should  obviously  devolve  on  the  householder. 
VOL.  I.— U 


210  HYGIENE. 

In  those  States  in  which  by  law  only  properly  qualified  medical  men, 
as  determined  by  examination,  have  the  right  to  practice,  to  hold  medical 
office,  or  to  furnish  medical  certificates,  the  State  certainly  is  entitled  to 
require  of  all  physicians  thus  registered  and  authoritatively  recommended 
to  the  people  as  competent,  that  they  shall  furnish,  free  of  charge,  certificates 
of  the  cause  of  death  in  those  cases  where  they  are  cognizant  of  such  cause. 

States  and  municipalities  often  demand  much  more  than  this ;  as,  for 
instance,  that  the  medical  man  shall  fill  out  the  whole  certificate,  includ- 
ing age,  nativity,  nativity  of  parents,  etc.,  and  that  he  shall  furnish  the 
information  to  the  registrar.  In  some  cases  it  is  provided  that  any  phy- 
sician having  attended  a  person  during  his  last  illness  shall  furnish  the 
certificate :  this  would  apply  to  cases  where  the  physician  may  not  have 
seen  the  case  for  weeks  before  death. 

While  it  is  most  convenient  to  have  the  certificate  of  cause  of  death 
upon  the  same  form  which  contains  the  data  necessary  to  identify  the  indi- 
vidual, the  certificate  should  be  distinct  from  the  latter,  and  the  duty  of 
making  the  return  to  the  registrar  should  devolve  on  the  householder  or 
undertaker,  and  not  on  the  physician.  On  the  other  hand,  it  is  easy  for 
the  physician  to  be  hypercritical  in  these  matters :  his  certificate  is  to  be 
considered  rather  as  a  statement  of  opinion  than  as  a  statement  of  facts 
within  his  personal  knowledge,  precisely  as  he  would  certify  as  to  his  own 
age  and  birthplace. 

The  compulsory  notification  of  infectious  diseases  to  the  health  authori- 
ties is  a  matter  presenting  much  greater  difficulties  than  that  of  certificates 
as  to  causes  of  death.  The  state  has  no  right  to  require  such  notifica- 
tion from  the  physician  without  giving  some  quid  pro  quo,  and  it  is  not 
expedient  to  make  it  compulsory,  even  with  payment,  except  from  physi- 
cians employed  by  the  state  or  municipality,  to  furnish  gratuitous  medical 
attendance  to  the  poor.  The  state  has  the  right  to  require  such  informa- 
tion from  the  parent  or  householder,  and  it  has  also  the  right  to  require 
the  physician  to  notify  the  parent  or  householder  as  soon  as  he  recognizes 
the  existence  of  such  infectious  disease.  It  is  extremely  desirable  that  the 
health  authorities  of  a  city  should  receive  promptly,  and  direct  from  phy- 
sicians, notification  of  the  occurrence  of  such  diseases,  and  there  will  usually 
be  no  difficulty  in  obtaining  this  if  the  health  officer  has  tact  and  discre- 
tion and  the  city  is  prepared  to  do  its  duty.  This  duty  is  not  confined  to 
registering  the  information  or  placarding  the  house,  nor  will  it  be  properly 
performed  by  merely  removing  the  sick  person  to  a  hospital  and  disinfect- 
ing the  premises.  If  the  case  occur  in  a  family  which  can  secure  its  proper 
isolation,  and  the  attending  physician  certifies  that  it  is  so  isolated  and 
makes  himself  responsible  for  its  management  (for  which  responsibility 
he  should  be  paid  by  the  patient  or  his  friends),  the  health  officer  should 
not  interfere  nor  do  more  than  furnish  a  competent  person  to  secure  disin- 
fection if  required.  The  employment  of  a  trained  nurse  known  by  the 
health  authorities  to  be  competent  and  reliable  would  do  away  with  most 
of  the  difficulties  connected  with  such  cases  in  the  upper  and  middle  classes 
of  society ;  and  such  nurses  should  be  registered  just  as  physicians  and 
mid  wives  are. 

Where  the  case  cannot  be  thus  isolated  and  properly  cared  for,  it  should 
be  removed  to  a  proper  hospital.  This  presupposes  that  the  city  has  such 
a  hospital,  and  if  it  has  not,  and  is  not  prepared  for  such  cases,  notification 


PUBLIC  HYGIENE,  ETC.  211 

is  useless.  When  the  city  places  a  house  in  quarantine  so  as  to  interfere 
with  business,  it  should  be  for  the  shortest  possible  time  consistent  with 
securing  thorough  disinfection  of  the  premises,  and  the  city  should  bear 
not  only  the  cost  of  such  disinfection,  but  the  cost  of  caring  for  the  per- 
sons in  the  house  in  an  isolated  place  until  no  further  danger  is  to  be 
apprehended  for  them.  When  the  city  undertakes  to  pay  all  expenses  for 
isolation  and  disinfection  of  such  cases,  it  has  the  right  to  require  that  all 
such  cases  shall  be  so  treated,  leaving  it  to  private  parties  to  meet  the  cost 
in  case  they  prefer  not  to  use  the  buildings  and  apparatus  provided  by  the 
city  for  that  purpose.  And  when  the  city  does  its  duty  in  this  respect,  it 
will  be  found  that  physicians  and  the  people  will  do  theirs,  with  rare 
exceptions. 

When  a  city  becomes  very  unhealthy  the  usual  policy  is  to  conceal  the 
fact  as  much  as  possible,  and  to  attribute  the  mortality  to  some  other  than 
the  real  cause.  The  influence  of  the  mercantile  part  of  the  community 
is  in  such  a  case  strongly  exerted  on  the  daily  press  and  on  the  health 
authorities  to  produce  such  representations  of  the  condition  of  things  as 
will  tend  to  allay  apprehensions  on  the  part  of  their  customers.  The 
healthfulness  of  a  place  is  usually  estimated  from  its  mortality  reports, 
but  the  reliability  of  these  is  by  no  means  always  what  it  should  be. 
Yellow  fever  is  called  typho-malarial  or  pernicious  fever,  typhoid  is 
reported  as  diarrhoea  or  malarial  fever,  etc.  etc.,  and  great  stress  is  laid 
upon  what  is  called  the  sanitary  condition  of  the  place,  which  is  declared 
to  be  excellent. 

Unfortunately,  this  phrase,  "sanitary  condition,"  means  different  things 
at  different  times.  When  the  mortality  is  low,  sanitary  condition  means 
the  healthful  11  ess  of  a  place;  when  it  is  high,  it  means  the  clean- 
liness of  a  place.  To  a  certain  extent  physicians  are  responsible  for  the 
truth  of  the  statistical  returns,  not  so  much  in  relation  to  the  number  as 
to  the  causes  of  deaths ;  but  none  save  those  who  have  practised  in  a  city 
liable  to  epidemics  can  realize  the  enormous  pressure  which  is  brought  to 
bear  on  medical  men  to  induce  them  to  aid  in  or  wink  at  concealing  the 
true  state  of  the  case.  Of  course,  this  ostrich-like  policy  is  in  the  long 
run  an  exceedingly  unwise  one,  but  neither  the  average  householder  nor 
community  can  be  expected  at  present  to  pursue  any  other,  except  under 
pressure. 

There  are  many  questions  as  to  the  best  form  of  public  health  organ- 
ization, and  the  powers  and  duties  which  should  be  conferred  upon  it, 
which  can  only  be  properly  answered  by  taking  into  consideration  the 
circumstances  in  each  case.  In  a  large  city  the  health  officers  must  have 
great  powers  if  they  are  to  be  really  efficient.  They  have  to  contend  with 
ignorance,  custom,  and  self-interest,  and  their  action  must  in  many  cases 
be  prompt  and  unrestricted  if  it  is  to  be  efficacious.  They  must  some- 
times be  in  conflict  with  wealthy  and  powerful  corporations,  whose  interests 
are  opposed  to  the  reforms  which  they  urge,  and  Although  their  business  is 
to  protect  the  most  important  interest  of  the  community  at  large — i.  e.  its 
health — against  the  interests  of  individuals,  yet  these  last  are  much  more 
immediately  concerned,  and  are,  naturally,  so  active  that  they  are  often, 
although  few  in  number,  able  to  defeat  any  attempt  to  interfere  with  their 
occupations. 

It  not  unfrequently  happens  that  a  health  board  may  have  all  the  power 


212  HYGIENE. 

necessary,  so  far  as  the  laws  are  concerned,  and  yet  may  be  able  to  accom- 
plish little  for  want  of  funds  to  pay  the  inspectors  and  other  officials  whose 
services  are  necessary.  For  a  city,  a  health  officer  usually  does  better  work 
than  a  board  of  health  :  his  responsibility  is  more  direct,  and  he  has  stronger 
motives  to  do  good  work,  than  a  board.  Of  course,  a  poor  health  officer 
is  less  efficient  than  a  good  board  of  health,  but  the  general  rule  is  as 
above  stateck  The  problems  of  hygiene  require  special  knowledge,  and 
the  man  who  is  to  deal  with  them  requires  special  training.  The  folly  of 
treating  diseases  by  their  names  with  popular  or  patent  remedies  is  not 
greater  than  that  of  the  attempt  to  make  a  healthy  house  or  city  by  men 
who  are  not  architects  or  engineers  or  physicians,  or  who  have  only  the 
information  possessed  by  the  average  architect  or  engineer  or  physician. 
And,  of  all  professional  or  educated  men,  the  physician  especially  should 
recognize  his  own  ignorance.  When  he  is  asked  what  one  should  take  for 
dyspepsia  or  pneumonia  his  answer  is,  "  Take  the  advice  of  a  physician ;" 
and  so  when  he  is  asked  how  the  plumbing  of  a  house  should  be  arranged, 
how  a  hospital  should  be  ventilated,  how  a  city  should  be  sewered,  how  a 
marsh  should  be  dealt  with  or  a  water-supply  provided,  he  should  reply, 
"  Get  expert  advice  and  supervision,  and  be  prepared  to  pay  the  amount 
necessary  to  secure  it."  It  is  the  special  duty  of  the  physician  to  exert 
his  influence  to  secure  properly  constituted  sanitary  authorities  for  his  own 
locality,  his  State,  and  for  the  nation,  and  to  support  these  against  the  hos- 
tility which  they  must  inevitably  arouse  if  they  are  efficient.  And  he  should 
do  this,  not  blindly  and  as  a  partisan,  but  intelligently  and  with  due  con- 
sideration of  all  the  important  interests  involved. 

The  body  of  educated  physicians  in  a  community  forms  the  tribunal  by 
which  the  work  of  sanitary  officials  is  to  be  judged,  and  they  cannot  judge 
wisely  unless  they  appreciate  the  difficulties  with  which  health  officials 
have  to  contend.  If  a  city  has  an  incompetent  or  dishonest  board  of 
health,  the  medical  profession  of  that  city  are  to  a  certain  extent  respon- 
sible for  it ;  if  a  competent,  energetic,  and  faithful  sanitary  officer  is  crip- 
pled and  harassed  or  forced  out  of  office  because  he  is  on  the  wrong  side 
of  politics,  or  because  in  the  legitimate  and  proper  exercise  of  his  functions 
he  has  come  in  conflict  with  the  interests  of  powerful  and  wealthy  individ- 
uals or  corporations,  it  is  the  duty  of  medical  men  to  support  him,  and  to 
do  this  actively  and  promptly.  And  I  take  great  pleasure  in  being  able 
to  say,  as  the  result  of  somewhat  extended  observation,  that,  as  a  rule,  the 
physicians  of  this  country  do  cheerfully  and  promptly  co-operate  with  the 
sanitary  authorities  where  such  exist,  and  are  the  first  to  try  to  have  them 
properly  organized  and  given  the  necessary  means  and  powers  to  do  effect- 
ive work. 


DRAINAGE  AND  SEWERAGE  IN  THEIR 
HYGIENIC  RELATIONS. 

BY   GEO.    E.    WARING,   JR. 


FOR  reasons,  sometimes  sound  and  sometimes  fanciful,  the  drainage 
question  often  presents  itself  to  the  medical  practitioner  as  an  annoying 
if  not  as  a  serious  one.  It  is  not  necessary  for  the  physician  to  make 
himself  an  adept  in  the  art  of  sanitary  drainage,  but  he  can  properly 
meet  neither  the  demands  of  nervous  patients  nor  the  exigencies  of  some- 
times serious  situations  without  having  an  intelligent  general  idea  con- 
cerning it.  Not  only  to  prescribe  improvement,  but  frequently  to  allay 
ill-grounded  apprehension,  he  should  be  able  to  address  himself,  intelli- 
gently and  promptly,  at  least  to  the  few  simple  problems  presented  in 
connection  with  ordinary  houses.  I  use  the  expression  "ill-grounded 
apprehension,"  not  because  the  drainage  in  and  about  houses  is  generally 
tolerably  good,  for  it  is  not,  but  because  the  race  seems  to  have  so 
inured  itself  to  certain  grave  defects  in  plumbing-work  that  one  may 
reasonably  hesitate,  and  look  elsewhere  for  the  occasion  of  diseases  before 
accusing  the  imperfect  sanitary  appliances  of  an  average  house. 

Anything  like  a  treatise  on  the  technical  details  of  house -drainage 
would  be  quite  out  of  place  here.  There  are  note-books  easily  accessible 
to  such  physicians  as  care  to  make  a  thorough  study  of  the  subject.  It 
does  seem  worth  while,  however,  to  pass  in  careful  review,  in  a  work  of 
this  character,  the  various  conditions  of  interior  and  exterior  drainage 
upon  which  a  physician  is  frequently  called  to  pass  judgment. 

The  perfect  drainage  of  a  house,  like  the  perfect  drainage  of  a  town, 
implies  the  immediate  and  complete  removal,  to  a  point  well  beyond  its 
limits,  of  all  waste  matters  which  are  a  proper  subject  of  water-carriage ; 
such  a  thorough  ventilation  of  the  channel  which  these  matters  have 
traversed  as  to  reduce  to  a  minimum  the  production  of  deleterious  gases 
arising  from  the  decomposition  of  the  film  with  which  they  may  have 
soiled  the  walls  of  their  conduit ;  and  adequate  provision  for  the  absolute 
and  permanent  exclusion  from  the  atmosphere  within  the  house  of  the  air 
of  the  pipe  or  sewer.  This  is  a  brief  and  simple  statement  of  the  fun- 
damental and  absolute  requirements  of  all  good  drainage.  It  is  founded 
on  the  one  grand  object  which  governs  all  improvement  of  this  charac- 
ter :  the  prevention  of  decomposition  of  refuse  matters  anywhere  in  house 
or  town. 

Practically,  it  is  safe  to  say  that  these  conditions  are  never  complete, 
and  that  instances  of  perfect  work  are  so  exceptional  as  to  need  no  con- 

213 


214  DRAINAGE  AND  SEWERAGE 

sideration  here.  We  have  to  assume,  substantially  in  every  case  that  is 
presented,  that  we  are  dealing  with  defective  work,  ordinaril}  with  work 
that  is  very  seriously  defective.  Most  houses  have  been  built  by  con- 
tractors, and  the  plumbing  is  perhaps  the  item  of  the  whole  structure  that 
it  is  considered  easiest  and  safest  to  scamp  or  to  neglect.  Even  where  the 
motive  of  economy  has  had  no  controlling  influence,  the  drainage  has 
almost  invariably  been  planned  by  a  plumber  who  has  learned  his  trade 
and  conceived  his  ideas  in  the  performance  of  work  which  was  done  at  a 
time  when  no  one  realized  the  serious  consequences  of  its  being  improperly 
done.  The  absence  of  interior  ventilation,  leaky  joints,  ill-arranged  con- 
nections between  the  various  plumbing  appliances  and  the  main  outlet 
from  the  house,  pipes  and  traps  so  large  that  an  ordinary  current  is 
powerless  to  keep  them  clean,  defects  of  form,  defects  of  material,  and 
defects  of  construction,  are  met  with  on  every  hand.  This  general  state- 
ment is  of  itself  sufficient  to  show  how  hopeless  it  is  for  the  average  phy- 
sician to  prescribe  the  manner  in  which  the  drainage  of  a  house  should 
be  constructed  or  remodelled. 

If  we  view  the  question  solely  with  reference  to  its  bearing  on  the 
causation  of  disease,  we  enter  a  field  where  neither  the  sanitarian  nor  the 
physician  is  ever  sure  of  his  footing.  The  precise  relation  between  bad 
drainage  and  ill-health  no  man  knows.  Certain  diseases  are  undoubtedly 
traceable  to  conditions  of  air  or  of  drinking-water  due  to  the  improper 
disposal  of  organic  wastes,  but  the  extent  and  exact  bearing  of  these 
influences  are  still  greatly  a  matter  of  conjecture.  It  is,  however,  un- 
doubtedly safe  to  assume — and  the  assumption  is  supported  by  ample 
general  observation,  if  not  by  precisely  ascertained  facts — that  whether  we 
are  considering  serious  diseases  or  the  slighter  ailments,  every  argument 
leads  to  the  enforcement  of  the  most  strenous  requirements  of  cleanliness. 
Through  all  the  ages  no  one  has  disputed,  and  no  one  has  improved  upon, 
the  simple  sanitary  formula,  "Pure  air,  pure  water,  and  a  pure  soil." 
We  may  safely  wait  until  the  enthusiastic  investigators  now  engaged  with 
the  subject  shall  have  adduced  the  testimony  of  positive  facts,  if  we  will 
in  the  mean  time  adhere  strictly  to  the  requirements  of  Hippocrates'  pre- 
scription. The  physician  will  surely  not  go  wrong  if  he  treats  all  obvious 
defects  of  drainage  as  positive  evils,  and  insists  upon  their  complete  ref- 
ormation. 

Not  to  confine  ourselves  to  houses  which  are  provided  with  the  ordinary 
modern  plumbing-works,  but  to  include  all  collateral  branches  of  the 
subject,  we  have  to  consider  the  following  conditions  : 

I.  THE  REMOVAL  OF  HUMAN  EXCREMENT: 

(a)  By  water-carriage  in  houses  provided  with  modern  plumbing ; 
(6)  By  some  form  of  dry  conservancy ; 

(c)  By  the  fiendish  privy-vault  which  prevails  so  generally,  save 
in  the  larger  cities. 

II.  THE  REMOVAL  OF  LIQUID  HOUSEHOLD  WASTES: 

(a)  By  delivery  to  public  sewers ; 

(b)  By  irrigation  disposal ; 

(c)  By  delivery  into  cesspools. 

Incidentally  to  the  above  there  must  be  considered  the  influences  of  the 
ultimate  disposal  of  all  household  waste,  whether  by  the  public  sewer  or 
the  private  house-drain. 


REMOVAL  OF  HUMAN  EXCREMENT.  215 

I.  THE  REMOVAL  OF  HUMAN  EXCREMENT. — "We  are  too  apt  to  judge 
of  the  power  for  mischief  of  any  waste  matter  by  its  original  oft'ensiveness, 
and  the  world  at  large  regards  the  solid  and  liquid  exuviae  of  the  human 
body  as  the  most  dangerous  material  with  which  it  has  to  deal.  Doubt- 
less it  is  so  under  certain  exceptional  circumstances.  If  impregnated  with 
the  infective  principle  of  cholera  or  of  typhoid  fever,  for  example,  its 
influence  for  evil  may  be  widespread  and  active,  but  in  the  absence  of 
such  infection  these  substances  offer  a  less  serious  problem,  and,  as  their 
offensiveness  causes  them  to  be  more  carefully  avoided,  their  evil  in- 
fluence is  less,  and  is  less  widely  disseminated,  than  is  that  of  the  com- 
paratively inoffensive  wastes  of  the  kitchen-sink.  This  is  a  considera- 
tion important  to  be  borne  in  mind.  Nothing  is  more  common  than  the 
expression  of  the  opinion  that  the  wastes  of  a  population  are  offensive 
and  dangerous  in  proportion  to  the  degree  to  which  excrementitious 
matter  is  allowed  to  flow  away  with  its  general  drainage.  The  fact  is, 
that  the  drainage  from  a  house  or  from  a  town,  if  reasonably  diluted 
with  water,  is  very  slightly  offensive  until  it  has  passed  through  a  con- 
siderable degree  of  decomposition.  The  outflow  of  a  perfectly  sewered 
town,  where  the  whole  community  uses  water-closets,  is  less  offensive 
than  the  neglected  back-yard  drain  of  an  average  New ,  England  farm- 
house. The  trouble  begins  with  the  condition  of  putridity.  Fecal 
matter  and  urine  are  somewhat  quicker  than  the  other  wastes  of  the  house 
to  enter  into  putrefaction,  but  the  difference  is  only  one  of  degree,  and  the 
latter  rapidly  overtakes  the  former  in  the  foulness  of  its  condition ;  so 
that  where  a  house  is  provided  with  two  cesspools,  one  for  water-closet 
matter  and  the  other  for  kitchen  waste,  it  is  quite  impossible  to  determine 
from  the  character  of  their  contents  which  is  which ;  therefore  examina- 
tions of  the  drainage  of  a  house  should  by  no  means  be  confined  to  the 
manner  in  which  its  excrementitious  matters  are  disposed  of.  Setting 
aside,  in  this  connection,  the  peculiar  liability  of  these  matters  to  become 
the  seat  of  specific  infectious,  it  is  fair  to  assume  that  equally  com- 
plete and  cleanly  arrangements  are  needed  for  all  else  that  flows  to  waste, 
as  for  the  discharges  of  the  water-closet.  The  purpose  of  these  remarks 
is  of  course  not  to  belittle  the  importance  of  proper  care  in  the  disposal 
of  human  excreta,  but  to  prevent  the  giving  of  an  undue  importance  to 
this  branch  of  the  subject,  with  too  light  treatment  of  the  very  serious 
difficulties  presented  by  the  others. 

(a)  Modern  conveniences  may  fairly  be  said  to  be  the  bane  of  modern 
society,  or  at  least  of  such  of  its  members  as  have  the  questionable  good 
fortune  to  be  housed  within  the  same  four  walls  with  every  device  that  a 
misguided  talent  for  invention  has  led  the  American  mechanic  to  provide 
for  the  comfort  and  convenience  of  the  occupant.  Properly  regulated, 
there  is  no  element  of  modern  house-building  more  conducive  to  health 
than  such  a  system  of  plumbing  as  brings  Avithin  reasonable  limits  the 
labor  of  supplying  abundant  water  at  every  point  in  the  house,  and 
obviates  the  need  for  exposure  and  removes  the  temptation  to  neglect  and 
postponement  attending  the  use  of  out-of-door  houses  of  convenience. 
The  spigot  and  the  water-closet  are  the  two  essential  sanitary  agents 
which  the  plumber  offers  to  us.  The  bath  may  be  replaced  by  the 
sponge,  the  stationary  wash-basin  may  be,  and  generally  should  be, 
replaced  by  the  bowl  and  pitcher  of  our  fathers,  but  there  is  no  sufficient 


216  DRAINAGE  AND  SEWERAGE. 

substitute  for  an  ample  supply  of  water  on  each  floor  of  the  house  and 
for  a  cleanly  water-closet  placed  within  doors.  The  evil  that  the  plumber 
has  inflicted  upon  the  race  is  due  very  largely  to  his  not  having  held  his 
hand  when  he  had  fairly  provided  for  our  reasonable  requirements.  When 
he  fills  our  bedrooms  with  stationary  basins,  connects  our  refrigerators 
with  the  sewer,  provides  twenty  outlets  for  water  which  had  better  reach 
the  drain  through  less  than  half  that  number,  and  incidentally  under- 
lays all  our  floors  with  pipes,  every  foot  of  which  is  a  possible  source  of  _ 
danger,  he  turns  what  ought  to  be  a  blessing  into  what  is  too  often  an 
unmitigated  curse. 

It  will  not  be  easy  to  convert  persons  who  have  become  accustomed  to 
the  universal  diffusion  of  plumbing-works  throughout  the  house  to  a 
belief  that  their  best  sanitary  interest,  and,  perhaps  hardly  less,  the  best 
requirements  of  refinement,  point  to  the  abandonment  of  what  is  practi- 
cally superfluous  in  the  way  of  -\vash-bowls,  bidets,  foot-baths,  sitz-baths, 
urinals,  etc. ;  but  one  who  has  given  careful  attention  to  the  subject  cannot 
hesitate  to  recommend  that  in  a  house  which  is  "  strictly  first  class  "  it 
would  be  the  part  of  wisdom  to  reduce  by  at  least  three-fourths  the 
openings  which  lead  to  the  soil-pipe  and  drain  and  sewer,  and  to  concen- 
trate upon  the  remaining  fourth  the  flushing  effect  of  wastes  which  are 
now  so  widely  distributed.  Strenuous  effort  is  being  made,  not  only  by 
those  who  write  and  talk  in  the  interest  of  the  plumber  and  manufac- 
turer, but  by  many  who  honestly  believe  that  the  good  the  plumber  has 
to  give  us  cannot  be  given  with  too  free  a  hand,  to  prove  that  so  long  as 
they  are  properly  constructed  and  properly  arranged  we  may  use  plumb- 
ing appliances  at  every  point  in  the  house  with  the  utmost  freedom  and 
with  a  minimum  of  danger.  The  minimum  of  danger,  and  often  more 
than  the  minimum,  does,  however,  exist.  It  exists,  perhaps,  in  a  con- 
stantly increasing  degree  with  every  extension  of  the  work,  and  it  can 
only  be  the  part  of  wisdom  to  insist,  so  far  as  advice  can  have  influence, 
on  the  reduction  of  all  these  appliances  to  the  least  requirements  of  rea- 
sonable comfort  and  economy  of  labor.  My  own  advice  would  be,  in  all 
cases,  to  permit  the  use  of  no  wash-bowl  or  bath  or  other  vessel  at  a 
greater  distance  than  a  few  feet  from  a  vertical  soil-pipe,  and  not  to  per- 
mit their  use  in  any  case  in  bedrooms  or  in  closets  opening  only  into  bed- 
rooms. 

At  the  risk  of  seeming  extravagant,  I  would  say  that  the  station- 
ary wash-bowl  as  ordinarily  used  is  one  of  the  most  uncleanly  of 
modern  household  appliances.  Long  experience  in  the  inspection  of 
houses  and  in  the  examination  of  waste-  and  drain-pipes  has  led  me  to 
the  belief  that  servants,  by  no  means  rarely,  use  these  vessels  as  the 
most  convenient  means  of  voiding  and  cleansing  chamber  utensils.  Their 
overflow-pipes  are  coated  with  soap  and  with  the  exuvise  of  the  skin  to  a 
degree  which  makes  them  usually  the  seat  of  an  offensive  decomposition. 
Their  plugs  and  chains  are  almost  invariably  foul,  and  those  devices 
which  provide  for  closing  the  outlets  by  valves  or  plugs,  somewhat 
removed  from  the  strainers  at  the  bottom  of  the  bowl,  bring  the  water  in 
which  the  face  is  washed  into  an  interchanging  communication  with  a 
considerable  length  of  foul  and  uncleanable  waste-pipe — a  communication 
that  is  made  active  by  the  bubbling  of  the  contained  air  as  the  pipe  fills 
with  water.  The  labor  of  filling  pitchers  from  a  spigot  on  the  same 


REMOVAL  OF  HUMAN  EXCREMENT.  217 

floor,  and  the  labor  of  emptying  chamber-slops  into  a  water-closet  on 
the  same  floor,  are  not  to  be  considered  as  compared  with  the  greater- 
cleanliness  and  the  greater  sanitary  security  that  such  an  arrangement 
ensures.  There  is  no  serious  objection  to  the  placing  of  wash-basins  and 
baths  in  the  same  apartment  with  the  water-closet,  or  elsewhere  imme- 
diately adjoining  the  soil-pipe;  but  it  certainly  cannot  be  disputed  that 
the  extension  of  the  drainage  system  by  horizontal  lead  pipes  to  remote 
points  is  altogether  and  wholly  to  be  condemned. 

However,  the  question  more  immediately  at  hand  is  that  of  the  dis- 
posal of  human  excreta  by  the  use  of  water-closets ;  and  it  is  the  water- 
closet  that  first  attracts  the  attention  of  one  who  is  called  upon  to  examine 
the  sanitary  condition  of  the  work.  There  are  several  radical  defects  in 
water-closets,  which  are  so  widespread  and  which  have  become  so  familiar 
to  the  world  at  large  as  to  attract  less  attention  than  they  deserve.  For 
example,  it  is  a  radical  defect  of  a  water-closet  to  be  tightly  encased  in 
carpentry.  Nearly  all  the  water-closets  now  in  use  have  a  somewhat 
complicated  mechanism  about  their  bowls.  They  consist  in  ptfrt  of  earth- 
enware and  in  part  of  iron,  generally  with  an  unstable  connection  between 
the  two.  More  often  than  not  they  overflow  or  drip  or  leak,  and  what- 
ever may  escape  from  them,  whether  foul  air  or  foul  water,  is  confined 
within  an  un ventilated  space,  but  a  space  which  is  still  not  absolutely 
excluded  from  the  atmosphere  of  the  house.  The  removal  of  the 
"  riser "  or  vertical  board  under  the  front  of  the  seat  will  usually  dis- 
close at  once  a  condition  that  suggests  at  least  the  need  for  thorough  ven- 
tilation. It  also  discloses  in  some  cases  a  complication  of  machinery  and 
pipes  and  levers  and  chains  which  makes  a  thorough  dusting  and  clean- 
sing of  the  space  difficult,  even  \vere  it  accessible.  There  are  water- 
closets  which  are  essentially  good  in  their  construction  and  working, 
which  it  is  important  to  protect  by  a  "  riser,"  but  this  "  riser "  should 
never  be  of  close  work.  It  should  at  least  be  freely  perforated  with 
large  holes,  or,  better  still,  be  made  with  slats  or  blinds,  so  that  there 
may  be  the  freest  possible  circulation  of  air  under  the  seat.  If  there  is 
an  entire  absence  of  machinery,  so  that  the  whole  space  may  be  left  open, 
being  well  finished  with  tiles  or  hard  wood  or  other  suitable  material,  it 
is  better  that  it  should  be  unenclosed  and  that  the  seat  should  be  hung 
on  hinges,  so  that  it  may  be  turned  back,  exposing  the  whole  space  to 
easy  cleansing.  It  is  better  too,  in  all  cases,  that  the  ventilation  should 
not  even  be  interfered  with  by  a  cover  over  the  seat,  the  freest  possible 
exposure  to  the  air  being  of  great  importance. 

A  very  large  majority  of  the  water-closets  in  use  throughout  the  world 
are  either  very  imperfectly  flushed  "  hoppers,"  which  are  generally  foul 
and  which  are  often  defective  in  their  traps,  or  that  worst  of  all  forms, 
known  as  the  "  pan  "  closet,  where  a  slight  depth  of  water  is  held  in  the 
bowl  by  a  hinged  pan  closing  over  its  outlet.  This  pan  swings  in  an  iron 
chamber  under  the  bowl,  which  is  entirely  cut  off  from  ventilation,  which 
is  generally  foul  with  adhering  fecal  matter,  and  which  as  an  abomination 
has  no  equal  in  the  whole  range  of  plumbing  appliances.  The  closet  of 
which  it  forms  a  part  has  everything  to  condemn  it,  and  only  its  cheap- 
ness and  its  apparent  cleanliness,  and  the  habit  of  the  world  in  its  use,  to 
commend  it.  If  flushed,  as  it  usually  is,  by  a  valve  on  the  supply-pipe, 
it  is  rarely  flushed  adequately,  and  its  use  not  seldom  leads  to  an  indraft 


218  DRAINAGE  AND  SEWERAGE, 

of  foul  air  (or  worse)  into  the  main  water-supply  system  of  the  house. 
Such  closets  may  be  easily  inspected  as  to  their  condition  by  shutting  off 
the  water-supply,  opening  the  pan,  and  lowering  a  candle  into  the  con- 
tainer below.  Such  an  inspection  will  almost  invariably  disclose  an 
extremely  and  dangerously  filthy  condition.  Yet  the  worst  part  of  the 
container,  that  which  never  receives  an  adequate  flush,  is  even  then  con- 
cealed from  view  by  the  pan  being  thrown  back  against  it.  The  nose  will 
here  be  a  good  adjunct  to  the  eye,  and  the  odor  escaping  from  this  filthy 
interior  chamber  will  generally  afford  convincing  testimony  of  the  impro- 
priety of  allowing  such  a  vessel  to  remain  in  use. 

It  is  a  rule  almost  without  exception  that  closets,  except  perhaps  on  the 
first  floor  of  the  house,  which  are  flushed  by  valves  connected  with  the 
bowls,  are  to  be  condemned.  However  good  or  however  bad  the  state 
of  a  closet  thus  supplied  with  water,  its  condition  will  always  be 
improved  by  giving  it  a  copious  flush  from  an  elevated  cistern  delivering 
never  less  than  two  and  a  half  gallons  of  water  at  each  use,  and  deliver- 
ing it  through  a  pipe  so  large  and  so  direct  as  to  secure  a  thorough 
cleansing  at  every  discharge. 

It  would  be  out  of  place  here  to  enter  into  a  detailed  description  of  the 
various  closets  which  are  and  which  are  not  to  be  recommended  for  use. 
So  far  as  the  physician's  inspection  is  concerned,  it  is  perhaps  sufficient  to 
say  that  wherever  an  odor,  however  slight,  can  be  perceived,  and  wherever 
a  fouling  of  the  interior  surfaces  of  the  closets  or  of  the  spaces  under  the 
seat  can  be  detected  by  the  eye,  radical  reformation  is  necessary.  The 
only  safety  with  a  water-closet,  as  with  any  other  vessel  connected  with 
the  drainage  of  the  house,  is  to  secure  an  immediate  and  complete  wash- 
ing away  of  all  foul  matter  of  every  kind.  Where  this  result  is  not 
attained,  it  should  be  insisted  upon.  This  much  lies  within  the  province 
of  the  medical  attendant ;  the  manner  in  which  it  shall  be  secured  is  not 
necessarily  for  him  to  decide. 

One  other  branch  of  this  subject  is  worthy  of  attention.  The  cleanli- 
ness and  freedom  from  offence  of  the  water-closet  or  of  a  waste-pipe  or 
drain  is  in  proportion  to  the  frequency  with  which  it  is  used  and  to  the 
abundance  of  the  discharge  of  water  through  it.  A  dozen  closets  used 
by  a  dozen  persons  will  be  quite  likely  all  to  be  offensive.  If  the  dozen 
persons  all  used  only  one  closet — not  a  pan  closet — the  frequency  with 
which  its  trapping  water  is  removed  and  the  frequency  with  which  its 
walls  are  washed  would  secure  its  tolerable  condition,  even  if  not  of  the 
best  construction.  In  this  case,  as  in  all  others,  simplicity  should  be  the 
controlling  principle. 

(6)  Dry  conservancy  next  after  water-carriage  is  the  best  and  safest  sys- 
tem for  the  removal  of  human  excreta.  By  dry  conservancy  is  meant  the 
admixture  of  dry  earth,  ashes,  or  similar  material  with  the  matters  to  be 
disinfected  and  absorbed.  Theoretically,  the  effect  of  such  admixture  is 
entirely  satisfactory ;  under  very  careful  and  intelligent  regulation  it  is 
practically  so.  It  has  been  proved,  however,  by  much  experience  that 
under  ordinary  circumstances — that  is,  where  no  greater  care  is  given  than 
is  ordinarily  given  to  a  water-closet  or  to  a  common  privy — the  dry  con- 
servancy system  is  open  to  serious  objections,  though  always  an  improve- 
ment on  the  cruder  privy- vault.  The  theory  of  the  effect  of  a  sufficient 
admixture  of  earth  or  ashes  with  urine  and  fecal  matter  is,  that  by  the 


REMOVAL  OF  HUMAN  EXCREMENT.  219 

admission  of  air  thus  secured  to  every  part  of  the  material  there  is  a  com- 
plete oxidation  of  their  organic  constituents,  similar  to,  though  slower  in 
its  operation  than,  actual  combustion  in  an  active  fire.  In  isolated  houses 
and  in  hospitals,  factories,  and  other  buildings  not  provided  with  sewer- 
age facilities,  there  is  no  question  that  the  earth-closet  or  the  ash-closet 
affords  the  best  available  means  for  disposal,  if  we  except  a  system,  to  be 
described  hereafter,  for  the  distribution  of  water-carried  wastes  over  or 
under  the  surface  of  suitable  ground. 

Incidentally — and  this  is  of  special  interest  to  the  physician — the  use 
of  dry  earth  or  of  dry  ashes  in  the  close-stool  of  the  sick  chamber  effects 
not  only  an  immediate  and  complete  deodorizatiou,  but  without  doubt  a 
complete  disinfection  as  well.  A  quart  of  dry  earth  at  the  bottom  of  the 
vessel  to  receive  the  deposits,  and  rather  more  than  a  quart  with  which 
immediately  to  cover  them,  constitutes  a  means  of  relief  always  available 
and  always  efficient. 

Where  the  house  is  provided  only  with  an  old-fashioned  out-of-door 
privy  the  greatest  relief  and  the  most  complete  security  may  be  given  at 
little  cost  by  filling  the  vault,  and  placing  under  the  seat  a  movable  box 
to  receive  the  mixture  of  fecal  matter  and  of  the  absorbent  material, 
which,  if  it  is  desired  to  avoid  the  simple  patented  appliances  made  for 
the  purpose,  may  be  kept  in  a  box  or  barrel  in  the  apartment  and  thrown 
down  after  each  use  of  the  closet  with  the  haud-scoop.  The  objections  to 
the  common  privy  are  so  obvious,  so  universal,  and  so  well  understood 
that  the  practical  value  of  such  a  means  of  relief  should  be  appreciated 
without  argument. 

(o)  Privy-vaults  are  the  sole  reliance  for  the  disposal  of  fecal  matter,  and 
often  of  chamber-slops,  of  probably  95  per  cent,  of  the  population  of 
this  country,  and  of  Europe  as  well.  It  is  curious,  in  examining  the 
recommendations  of  public  health  officers  and  the  requirements  of  local 
boards  of  health,  to  observe  the  uniformity  with  which  this  most 
important  subject  is  passed  over  with  the  prescription  that  the  vault  shall 
be  tight,  sometimes  that  it  shall  be  vaulted  over,  and  sometimes  that  it 
shall  not  be  within  a  certain  small  number  of  feet  of  a  boundary-line  or 
of  a  drinking-water  well.  These  prescriptions  are  most  absurd.  It  is 
safe  to  say,  that  of  the  millions  of  privy-vaults  in  this  country  not  more 
than  hundreds  are  really  tight ;  that  a  still  smaller  number  are  so  vaulted 
over  as  to  prevent  the  free  exhalation  of  the  gases  of  decomposition ;  that 
those  which  are  so  vaulted  over  are  in  all  respects  of  worse  sanitary  effect 
than  those  which  have  freer  communication  with  the  air,  and  that  their 
possibilities  of  evil  reach  many  times  farther  than  the  limits  of  distance 
usually  required  to  intervene  between  them  and  the  well  or  the  neighbor- 
ing property.  In  view  of  the  universality  of  their  use  and  of  the  com- 
pleteness with  which  modern  communities  are  inured  to  their  presence,  it 
seems  almost  hopeless  to  attempt  to  secure  a  proper  realization  of  their 
great  defects.  They  are  always  the  seat  of  the  foulest,  and  even  of  the 
most  dangerous,  decomposition.  They  taint  not  only  the  air  and  the  soil, 
but  the  water  of  the  soil  which  goes  so  often  to  feed  our  sources  of  drink- 
ing-water, and  their  local  stench  is  of  itself  sufficient  to  sicken  all  who 
have  not  by  daily  and  lifelong  habit  become  accustomed  to  it.  Taking 
the  country  at  large — farm  houses  and  village  houses  as  well  as  the  dwell- 
ings of  cities — it  is  not  too  much  to  say  that  the  best  sanitary  service  that 


220  DRAINAGE  AND  SEWERAGE. 

can  be  rendered  by  those  interested  in  the  removal  of  causes  of  ill- 
health  would  be  in  securing  the  abolition  of  these  barbarous  domestic 
appliances.  In  many  ways  the  cesspool  is  as  bad  as  the  vault,  but  in 
some  respects  the  vault  is  facile  princeps  as  a  public  and  private  nuisance 
of  the  most  annoying  and  dangerous  character.  Wherever  a  public  or 
private  sewer  is  available,  wherever  disposal  by  irrigation  is  possible,  and 
wherever  even  the  crudest  attention  can  be  secured  for  an  automatic  or 
simpler  earth-closet,  the  strongest  eifort  should  be  directed  to  the  absolute 
inhibition  of  the  common  privy-vault. 

II.  THE  REMOVAL  OF  LIQUID  HOUSEHOLD  WASTES. — As  has 
been  stated  above,  the  liquid  household  wastes  are  of  much  more 
serious  consequence  from  a  sanitary  point  of  view,  as  compared  with 
excrementitious  matters,  than  the  public  has  been  wont  to  suppose. 
These,  owing  to  the  large  amount  of  wrater  which  they  contain,  are 
beyond  the  reach  of  any  system  of  dry  conservancy.  They  consist 
almost  invariably  of  a  flood  of  water  containing  but  a  small  percent- 
age of  refuse  food,  urine,  soap,  filth  of  the  laundry,  grease — everything, 
in  fact,  except  fecal  matter  and  the  coarser  garbage  and  ashes — con- 
stituting the  waste  of  the  household.  Where  water-closets  are  used 
fecal  matter  is  generally  added  to  the  flow,  but  its  relative  quantity  is 
small,  and  its  presence  or  absence  does  not  seriously  affect  the  problem  of 
disposal. 

In  a  house  provided  writh  abundant,  generally  superabundant,  plumb- 
ing appliances,  with  a  large  consumption  of  water,  the  whole  apparatus 
is  constructed  on  the  theory  that  all  manner  of  filth  is  to  be  taken  up  by 
running  water  and  carried  well  without  the  house.  Where  this  theoretical 
end  is  completely  attained  there  exists  a  condition  of  drainage  rarely  met 
with  and  little  to  be  criticised.  Unfortunately,  the  theoretical  excellence 
is  rarely  secured.  Running  water  confined  within  a  narrow  channel,  and 
so  compelled  to  move  with  force  sufficient  to  give  an  energetic  scouring 
to  the  walls  of  its  conduit,  may  be  trusted  to  carry  with  it  or  to  drive 
before  it  pretty  nearly  all  foreign  matter  that  may  have  been  contributed 
to  it,  but  the  moment  this  vigorous  current  is  checked,  that  moment  the 
tendency  to  excessive  deposit  begins.  It  is  checked  in  practice  in  various 
ways : 

First.  By  too  great  a  diameter  of  the  pipe :  a  volume  of  discharge  requir- 
ing a  velocity  of  4  feet  per  second  in  a  pipe  1  inch  in  diameter  would 
have  a  velocity  of  only  1  foot  per  second  in  a  channel  2  inches  in  diameter, 
and  of  less  than  6  inches  per  second  in  a  channel  3  inches  in  diameter. 
Ordinarily,  except  as  the  deposits  are  removed  by  decomposition  (always 
objectionable),  the  deposited  matters  accumulate  and  reduce  the  original 
bore  to  the  diameter  which  will  secure  a  cleansing  flow.  It  is  the  part 
of  wisdom  to  provide  only  this  bore  at  the  outset  or  not  greatly  to  exceed 
it,  and  it  is  one  of  the  earliest  recommendations  of  an  experienced  sanitary 
engineer  to  reduce  the  size  of  too  large  bores  where  they  exist. 

Second.  By  the  use  of  traps  larger  than  the  pipes  leading  to  them  and 
from  them,  thus  increasing  the  natural  tendency  of  all  traps  to  stagnation 
and  deposit. 

Third.  By  the  use  of  vertical  waste-pipes,  which  are  almost  universal,  and 
which  are  very  often  necessary.  The  velocity  of  a  current  measured  along 
the  axis  of  the  pipe  is  less  if  the  direction  is  vertical  than  if  it  is  laid  on 


REMOVAL   OF  LIQUID  HOUSEHOLD  WASTES.  221 

a  steep  slope,  because  of  the  tendency  of  liquids  flowing  through  vertical 
pipes,  which  they  do  not  fill,  to  adhere  to  the  walls  and  to  travel  with  a 
rotary  movement.  I  have  seen  vertical  soil-pipes  furred  with  excrement 
to  a  thickness  of  nearly  three-eighths  of  an  inch ;  I  have  never  seen  a 
corresponding  deposit  in  a  pipe  of  good  slope  where  the  current  was  direct. 
This  latter  point  is  rather  one  of  curious  interest  than  of  practical  value — 
certainly  from  the  physician's  point  of  view.  Even  in  original  construc- 
tion it  is  rarely  possible  to  give  soil-pipes  other  than  a  practically  vertical 
course  as  they  pass  from  one  story  to  the  next.  Indeed,  the  physician 
need  not  trouble  himself  to  consider  the  question  of  the  size  or  of  the 
direction  of  this  main  channel.  He  will  often  find  occasion  to  criticise 
the  use  of  unduly  large  waste-pipes  from  single  vessels ;  as,  for  example, 
two-inch  pipes  leading  from  bath-tubs ;  two  and  a  half-inch  pipes  leading 
from  laundry-tubs ;  and  three-inch  pipes  leading  from  kitchen-sinks. 
Where  reconstruction  is  to  be  undertaken,  he  may  with  advantage  exert 
himself  to  secure  in  these  lateral  waste-pipes  a  diameter  never  exceeding 
one  and  a  half  inches,  and  from  kitchen-  and  pantry-sinks,  whose  outflow 
is  loaded  with  grease,  preferably  not  exceeding  the  diameter  of  one  and 
a  half  inches,  with  traps  of  even  a  little  less  size.  Where  several  vessels 
lead  into  the  same  waste-pipe  these  small  diameters  may  increase  the 
tendency  to  the.  emptying  of  the  traps  by  siphonage,  but  if  proper 
mechanical  traps  are  used  for  baths,  wash-bowls,  and  laundry-tubs,  and 
if  ample  flushing  appliances  are  connected  with  kitchen-  and  pantry- 
sinks,  the  temporary  removal  of  the  trapping-water  by  siphonage  may 
generally  be  disregarded.  It  will  seldom  happen  that  the  removal  of 
water  will  be  so  complete  as  to  prevent  the  satisfactory  closing  of  the 
mechanical  valve  by  capillarity,  even  if  it  fails,  in  itself,  to  make  a 
perfectly  tight  fit. 

A  favorite  recent  requirement  of  theoretical  sanitarians,  and  one  which 
has  perhaps  for  business  reasons  been  eagerly  accepted  by  the  plumbing 
trade,  is  what  is  called  the  "  back  "  ventilation  of  traps ;  that  is,  the  car- 
rying of  a  vent-pipe  from  every  trap  in  the  house  to  a  point  above  the 
roof.  In  my  judgment,  there  is  more  to  condemn  than  there  is  to  com- 
mend this  practice,  for  I  believe  that  the  more  rapid  emptying  of  traps 
by  evaporation  where  they  are  not  constantly  supplied  by  frequent  use, 
the  dangers  of  accident  to  lead  pipe,  which  is  generally  used  for  ventilat- 
ing purposes,  and  the  misapplication  of  a  large  outlay  which  might  better 
be  applied  in  other  directions,  constitute  convincing  arguments  against 
this  favorite  new  method  of  preserving  the  integrity  of  the  water-seal. 
There  are  a  number  of  traps  which  are  closed  by  floating  balls,  or  by 
balls  bearing  upon  the  outlet,  which  seem  to  be  quite  satisfactory  and 
efficient.  The  worst  waste-pipes,  by  far,  are  those  of  kitchen-  and  pantry- 
sinks  which  pass  a  large  amount  of  hot  grease.  This  soon  cools  suffi- 
ciently to  congeal,  and  it  attaches  itself  to  the  walls  of  the  pipe,  where  it 
does  congeal  until  the  bore  is  reduced  to  what  is  barely  sufficient  to  fur- 
nish the  necessary  limited  water-way.  Grease-traps  of  various  forms 
have  been  invented  with  a  view  to  retaining  this  obstructing  material. 
After  much  experience  with  all  of  them  that  have  been  in  general  use,  I 
have  become  convinced  that  the  only  satisfactory  way  to  avoid  the  diffi- 
culty in  question  is  to  retain  the  outflow  of  the  sink  until  a  certain  con- 
siderable quantity  has  accumulated,  and  until  its  grease  has  entirely  con- 


222  DRAINAGE  AND  SEWERAGE. 

gealed,  then  to  discharge  the  whole  volume  rapidly  through  a  pipe  of 
small  calibre.  This  may  be  done  with  Carson's  grease-trap  by  throwing 
in  a  pail  of  water  to  start  a  siphon  action  when  the  vessel  has  become 
filled  to  its  overflow-point.  It  is  more  simply  accomplished  by  a  device 
of  my  own,  wherein  the  whole  outflow  is  retained  by  a  plug  at  the  bottom 
of  a  large  vessel  working  after  the  manner  of  the  plug  of  a  wash-basin, 
until  it  is  filled  to  the  level  of  the  sink,  and  then  opening  the  outlet  for 
its  sudden  discharge. 

Good  workmanship  is  as  important  as,  if  not  indeed  more  important 
than,  good  arrangement.  It  seems  a  very  simple  proposition  to  say  that 
all  waste-pipes,  whose  office  it  is  to  carry  foul  liquids  out  of  the  house, 
should  be  made  tight  in  material  and  in  joint.  It  is  a  remarkable  fact, 
however,  that  leaky  joints  in  soil-pipes  and  in  drains  are  by  no  means 
rare.  Probably  there  are  few  houses,  very  few,  in  which  they  do  not 
occur.  The  soil-pipe  is  put  together  by  inserting  the  small  end  of  each 
section  into  the  bell  at  the  top  of  the  section  below  it,  practically  like 
putting  the  outlet  of  one  funnel  into  the  larger  upper  portion  of  another. 
There  may  be  abundant  space  for  leakage  at  every  joint  from  the  top  to 
the  bottom  of  the  house,  without  there  being  the  least  show  of  the  leak- 
age of  water.  The  foul  air  within  the  pipe  may  escape  freely  through 
a  dozen  openings,  while  the  heavier  liquid  flow  takes  its  easiest  and  most 
direct  course  downward  from  the  point  of  one  pipe  through  the  bell  of 
the  one  below.  When  we  come  to  the  horizontal  run  of  the  soil-pipe  in 
the  basement,  if  an  imperfection  of  the  joint  occurs  on  the  lower  side 
there  is  an  obvious  drip,  which  continues  at  least  until  closed  by  rust. 
Similar  imperfections  in  other  parts  of  the  joint  would  not  be  so  mani- 
fested. It  has  recently  been  demonstrated  that  there  is  no  safety  in 
the  construction  of  soil-pipes  short  of  that  absolute  assurance  which 
can  be  secured  only  by  an  efficient  test.  Plugging  all  the  outlets 
of  the  soil-pipe  and  filling  it  with  water,  the  slightest  leak  will  be 
exposed. 

However  defective  may  be  the  condition  of  an  iron  soil-pipe,  vertical  or 
horizontal,  it  is  perfection  itself  compared  with  the  usual  state  of  a  drain 
laid  under  the  cellar  floor;  and  here  is  a  point  where  the  least  experienced 
inspector  of  house  drainage  cannot  be  mistaken.  Under  all  circum- 
stances, at  least  in  all  work  hitherto  executed,  he  should  demand  as  abso- 
lutely necessary  that  the  drains  under  the  cellar  floor  be  removed,  that 
the  earth  which  has  been  fouled  by  the  leakage  of  its  joints  and  its  breaks 
shall  be  taken  out  to  the  clean  untainted  soil  below,  and  refilled  with 
well-rammed  pure  earth  or  with  concrete,  the  drainage  being  carried 
through  a  properly-jointed  iron  pipe  above  the  pavement,  and  preferably 
with  a  fall  from  tjie  ceiling  of  the  cellar  to  near  the  floor  at  the  point  of 
outlet — in  full  sight  for  the  whole  distance.  It  sometimes  happens  that 
the  necessity  for  using  laundry-tubs  or  other  vessels  in  the  cellar  makes 
the  retention  of  an  underground  course  imperative.  "When  retained,  the 
drain  should  be  of  heavy  cast  iron  with  most  securely  leaded  joints 
tested  under  a  head  of  several  feet.  When  found  to  be  tight  and  secure, 
it  should  not  be,  as  ordinarily  recommended,  left  in  an  open  channel 
covered  with  boards  or  flags  and  surrounded  by  a  vermin-breeding, 
unventilated  and  uninspected  space,  but  closely  and  completely  imbedded 
in  the  best  hydraulic  cement  mortar.  Its  careful  testing  before  this 


REMOVAL  OF  LIQUID  HOUSEHOLD  WASTES.  221? 

enclosure  is  of  course  the  only  condition  under  which  the  work  can  bo 
permitted. 

Tightness  of  all  waste-pipes  being  secured,  the  next  point  in  order  is 
their  proper  ventilation.  A  good  deal  has  been  said,  and  little  has  been 
proved,  about  the  different  effects  on  the  human  system  of  the  gases  of 
decomposition  which  have  been  produced  in  the  absence  of  a  sufficient 
circulation  of  air,  and  those  produced  where  the  ventilation  and  dilution 
are  more  complete.  The  probabilities  of  the  case  are,  of  course,  entirely 
in  favor  of  the  latter  condition,  and  it  is  accepted  by  all  sanitarians  as  an 
axiom  that  all  water-ways  and  all  vessels  in  which  organic  decomposition, 
even  the  decomposition  of  adhering  slime,  takes  place,  should  be  venti- 
lated as  thoroughly  as  possible.  Until  about  ten  years  ago  nearly  all 
waste-pipes  were  tightly  closed  at  the  top,  and  were  shut  from  the  sewer 
by  a  trap  at  the  foot,  allowing  absolutely  no  communication  between  the 
outer  air  and  the  atmosphere  of  the  pipe  except  as  fresh  air  might  be 
carried  in  through  the  water-seals  of  the  traps  at  each  end.  At  about 
that  time  it  was  becoming  the  general  custoni  in  the  better  class  of  work 
to  carry  a  small  vent-pipe,  often  only  one  inch  in  diameter,  rarely  more 
than  two  inches  in  diameter,  through  the  roof  of  the  house,  closing  it  at 
the  top  and  perforating  it  with  a  few  inefficient  holes.  This  had  undoubt- 
edly the  effect  of  relieving  the  pressure  on  the  atmosphere  of  the  pipe 
caused  by  the  filling  of  unventilated  sewers  with  tide-water  or  storm- 
water,  or  by  a  sudden  increase  of  temperature  from  the  admission  of  hot 
water.  Later,  it  was  accepted  as  a  universal  rule,  and  it  became  a  quite 
general  practice,  to  carry  the  soil-pipe  above  the  roof  with  its  full  diam- 
eter, providing  its  summit  with  some  form  of  ventilating  cowl.  All 
this  constituted  not  ventilation,  but  venting.  Real  ventilation  was 
introduced  only  with  the  very  recent  improvement  of  admitting  fresh 
air  at  the  foot  of  the  soil-pipe,  so  as  to  make  a  complete  circulation  from 
one  end  to  the  other — a  circulation  sufficient  to  produce,  by  the  diffusion 
of  gases,  a  very  fair  ventilation  of  lateral  waste-pipes  of  moderate 
length.  It  is  now  coming  to  be  understood  that  ventilating  cowls,  of 
whatever  form,  are  an  obstruction  to  the  movement  of  air  in  the  absence 
of  wind,  and  that,  as  what  is  needed  is  never  a  vigorous  current,  but 
always  a  living  one,  these  cowls  had  better  be  dispensed  with.  We  have 
learned,  too,  that  the  most  efficient  means  for  increasing  the  flow  of  air 
through  the  top  is  to  increase  its  diameter  at  the  top,  enlarging  the  high- 
est length  of  a  four-inch  pipe,  for  example,  to  a  diameter  of  six  inches. 
With  this  arrangement,  and  with  a  foot-ventilation  four  inches  in  diameter 
opening  at  a  point  where  it  can  never  be  obstructed  by  rubbish  or  by  snow, 
there  will  be  secured  a  condition  perhaps  more  efficient  in  improving  the 
condition  of  an  imperfectly  drained  house  than  any  other  one  thing  that 
may  be  done. 

I  have  sketched  above,  in  a  very  hurried  manner,  the  main  outline  of 
a  system  of  house-drainage  which  may  be  accepted  or  which  may  be 
recommended  by  a  physician  with  confidence  of  securing  a  good  result. 
To  go  more  into  detail  in  technical  matters  would  be  out  of  place  in  a 
paper  of  this  character.  Before  leaving  this  subject,  however,  it  is 
important  to  call  attention  to  the  fact  that  what  is  recognized  in  our 
houses  as  sewer  gas  is  in  far  greater  degree  the  product  of  decompo- 
sition taking  place  within  the  house-drains  themselves  than  the  product 


224  DRAINAGE  AND  SEWERAGE. 

of  decomposition  in  the  distant  sewer  forced  into  the  house  through  its 
connecting  drain.  It  is  emphatically  a  case  of  the  beam  in  our  own  eye 
as  compared  with  the  mote  in  the  eye  of  our  neighbor.  It  is  a  rule 
which  has  exceptions,  but  they  are  few,  that  the  contained  air  of  the 
house-pipes  is  far  worse  than  the  contained  air  of  the  sewer ;  and  the 
conviction  is  growing  that  the  use  of  a  trap  to  the  main  drain  between 
the  house  and  the  public  sewer  is  more  often  objectionable  than  advan- 
tageous. Such  a  trap  always  tends  to  check  the  flow  of  the  drain  and  to 
induce  deposits  whose  decomposition  is  objectionable.  Wherever  the 
abandonment  of  the  trap  is  anything  like  universal  the  considerable  ven- 
tilation of  the  sewer  thereby  secured  brings  its  atmosphere  to  a  condition 
which  makes  it  not  objectionable,  and  generally  useful,  as  a  source  of 
movement  in  the  air  of  the  interior  drain-  and  soil-pipe. 

(a)  Public  sewers  are  more  or  less  good  or  bad  entirely  according  to 
their  character  and  condition.  As  a  rule,  a  well-flushed  sewer  which  is 
used  for  no  other  purpose  than  the  removal  of  foul  waste,  built  on  what 
is  called  the  separate  system,  and  automatically  flushed  at  least  daily, 
may  be  considered  to  be,  if  well  laid  and  tightly  jointed,  absolutely  safe. 
A  public  sewer  of  large  size  and  of  irregular  construction,  receiving  not 
only  household  Avastes,  but  the  wash  of  streets  as  well,  may  be  regarded 
at  least  as  an  object  of  grave  suspicion.  These  general  statements  may 
be  so  far  qualified  by  the  character  of  the  sewers  of  each  class  as  to  run 
very  nearly  together ;  that  is  to  say,  separate  sewers,  with  leaky  joints, 
irregular  grades,  defective  alignment,  insufficient  flushing,  and  inadequate 
restriction  as  to  the  matters  they  are  to  receive,  will  be  an  intolerable  and 
dangerous  nuisance ;  on  the  other  hand,  a  large  brick  sewer  built  in  the 
best  manner  and  of  the  best  material,  with  sufficient  fall  and  sufficient 
supply  to  maintain  itself  in  a  cleanly  condition,  is  free  from  the  serious 
drawbacks  which  usually  attach  to  sewers  of  this  class. 

With  sewerage  as  with  house-drainage  it  is  not  worth  while  to  attempt 
here  to  give  anything  like  detailed  directions  for  inspection  and  for 
refoimation.  It  will  suffice  to  call  attention  to  this  one  broad  and  gen- 
eral rule :  Every  sewer  or  drain  having  for  its  object  the  removal  of 
putrescible  organic  matters  must  be  so  arranged  as  to  maintain  itself  in  a 
condition  of  practically  absolute  cleanliness,  without,  as  in  the  case  of 
storm-water  sewers,  waiting  for  the  flushing  effect  of  storms,  which  often 
come  only  at  long  intervals,  during  which  the  worst  condition  of  decom- 
position may  be  established.  Whether  the  sewer  be  intended  for  drainage 
only  or  for  both  drainage-  and  storm-water,  if  it  contains  at  any  time 
deposits  of  any  kind,  it  is  defective — more  or  less  so,  of  course,  accord- 
ing to  the  extent  and  duration  of  the  accumulation. 

Although  it  should  be  rigidly  insisted  upon  in  every  case  that  the 
sewer  should  maintain  itself  free  from  deposits,  there  will  still  be,  una- 
voidably, a  certain  amount  of  foul  gas  produced  by  the  decomposition  of 
the  matters  coating  its  walls,  and  in  order  to  dilute  and  to  remove  this, 
and  perhaps  in  order  to  modify  their  original  character,  the  most 
thorough  ventilation  is  necessary. 

Any  sewer  or  other  drain  which  at  any  time  gives  forth  the  odor  of 
putrid  decomposition  is  in  bad  condition  and  should  be  at  once  rendered 
inoffensive.  So  far  as  I  know,  there  is  no  exception  to  this  rule.  I  have 
met  no  conditions  in  towns  of  any  size  where  absolute  self-cleansing  may 


REMOVAL   OF  LIQUID  HOUSEHOLD  WASTES.  225 

not  be  secured.  It  is  worth  while,  however,  to  repeat  here  the  state- 
ment made  above,  that  sewer  gas,  in  so  far  as  it  is  a  serious  factor  in 
connection  with  the  drainage  of  houses,  is  the  product  of  the  interior 
pipes  of  the  house  much  more  frequently  than  of  the  public  sewer  in  the 
street. 

(6)  The  disposal  of  liquid  wastes  by  irrigation,  so  far  as  this  method  is 
applied  to  the  outflow  of  public  sewers,  is  not  of  especial  interest  here, 
but  an  important  modification  has  been  made  of  the  system  of  irrigation 
which  is  of  the  greatest  consequence  in  considering  the  sanitary  improve- 
ment of  isolated  country-houses,  of  hospitals,  prisons,  etc.,  and  of  houses 
in  towns  about  which  there  is  a  small  amount  of  available  land.  The 
process  which  has  been  found  best  suited  to  the  purpose  is  the  invention 
of  the  Rev.  Henry  Moule,  the  inventor  of  the  earth-closet.  He  found 
it  a  serious  drawback  to  the  dry-earth  system  that  it  was  incapable  of 
taking  care  of  the  liquid  wastes  of  the  house.  He  devised  a  method  of 
conducting  the  liquid  into  very  shallow  drains  made  with  open-jointed 
agricultural  drain-tiles,  so  porous  in  their  character  as  to  allow  the  liquid 
carried  by  them  to  escape  at  the  joints  into  the  soil,  and  thus  get  the 
benefit  of  its  purifying  qualities  without  the  unsightly  and  often  offensive 
process  of  allowing  the  liquid  to  flow  over  the  surface.  The  first  use  made 
of  this  system  was  about  1866.  Since  that  time  its  use  has  extended  very 
considerably  both  here  and  in  England,  and  many  improvements  have 
been  made  in  its  details,  so  that  it  may  now  be  accepted  as  entirely 
satisfactory. 

The  process  in  its  best  development,  as  applied  to  the  drainage  of  single 
houses,  may  be  thus  described,  many  of  the  appliances  used  being  the 
subject  of  patents :  The  outflow  from  the  house  is  delivered  into  a  settling- 
basin  or  grease-trap  of  sufficient  size  to  still  the  flow,  to  cause  solids  to 
settle  to  the  bottom,  and  grease  and  other  light  matters  to  float  at  the  top. 
The  outlet  from  this  basin  is  through  a  pipe  having  its  inlet  at  some  dis- 
tance below  its  overflow-point ;  that  is,  at  the  level  of  the  comparatively 
clarified  liquid,  below  the  grease  and  above  the  sediment.  The  outflow 
passes  into  another  vessel  known  as  a  flush-tank,  where  it  accumulates 
until  it  reaches  the  summit  of  a  self-acting  siphon.  This  height  being 
reached,  any  considerable  addition  to  the  flow  sets  the  siphon  in  action, 
and  the  whole  contents  of  the  flush-tank  are  discharged  with  rapidity 
into  the  drain  beyond.  The  discharge  completed,  air  is  automatically 
admitted  to  the  siphon,  and  no  further  flow  can  take  place  until  the 
flush-tank  has  again  been  filled.  The  drain,  of  iron  or  vitrified  pipes 
tightly  joined,  is  continued  to  the  edge  of  the  ground  prepared  for  puri- 
fication. It  here  delivers  into  a  series  of  open-jointed  agricultural  tiles, 
laid  with  their  bottoms  not  more  than  ten  inches  below  the  surface  of  the 
ground.  The  total  length  of  these  tile-drains  is  regulated  according  to 
the  discharging  capacity  of  the  flush-tank,  with  a  view  to  their  becoming 
entirely  filled  at  each  discharge.  Within  a  short  time  after  the  flow  has 
ceased  the  liquid  has  all  left  the  pipes  and  entered  the  soil,  its  impurities 
being  retained  and  its  filtered  water  settling  away  into  the  porous  or 
artificially  drained  ground  below.  During  the  interval  between  the  dis- 
charges of  the  flush-tank,  a  day  or  more,  the  process  of  purification  (oxi- 
dation) of  the  retained  impurities  goes  on  in  the  soil,  and  its  thorough 
aeration  prepares  it  to  purify  the  next  discharge.  This  method  of  dis- 

VOL.  I.— 15 


226  DRAINAGE  AND  SEWERAGE. 

posal  is  now  employed  in  connection  with  hundreds  of  houses,  and  its 
use,  which  has  in  some  cases  continued  for  a  dozen  years,  is  constantly 
increasing.  Its  application  implies  a  certain  amount  of  fall,  but  this 
amount  need  not  be  great.  The  discharging  height  of  the  tank  need  not 
be  more  than  twelve  inches.  The  main  outlet  need  not  fall  more  rapidly 
than  at  the  rate  of  1  to  300,  and  the  absorption-drains  ought  not  to  full 
more  rapidly  than  at  the  rate  of  1  to  600.  If  the  tank  can  be  built  on 
the  top  of  the  ground,  an  average  surface  fall  of  1  to  400  can  usually  be 
made  to  meet  all  the  requirements.  Where  waste  matters  are  to  be 
removed  from  cellars  and  basements  below  the  level  of  the  ground,  a 
greater  fall  is  necessary,  or  the  wastes  which  are  there  collected  must  be 
thrown  to  the  tank  by  pumping  or  otherwise. 

Where  there  is  a  bit  of  grass-land  a  little  removed  from  the  house 
(and  from  sight),  it  answers  a  perfectly  satisfactory  purpose  to  dispense 
with  the  absorption-drains  and  to  deliver  the  main  outlet  directly  on  to 
the  surface  of  the  ground.  The  eifect  in  both  cases  is  entirely  different 
from  what  it  would  be  were  the  flow  of  the  drains  not  regulated  by  the 
use  of  the  flush-tank.  The  moment  we  have  a  constant  slight  discharge, 
either  on  the  surface  of  the  ground  or  into  the  absoq)tion-drains,  we 
establish  a  condition  of  constant  saturation  which  leads  to  the  over-fouling 
of  a  small  area,  which  is  rarely  if  ever  purified  by  aeration.  For  an 
intermittent  discharge  some  form  of  flush-tank  is  an  absolute  necessity. 
It  is  often  found  in  practice,  where  the  flow  from  the  house  is  consider- 
able, that  the  discharge  of  the  house-drains  into  the  settling-basin  pro- 
duces such  an  agitation  of  its  contents  as  to  set  in  motion  and  to  carry 
into  the  flush-tank  bits  of  paper  partly  macerated,  grease,  etc.  This  has 
been  met  by  a  recent  improvement,  which  consists  in  building  a  transverse 
wall  in  the  settling-basin,  which  checks  the  current  from  the  house-drain 
and  causes  the  flow  from  the  house  side  of  the  wall  to  pass  over  its  top 
in  a  thin  small  current  which  does  not  materially  agitate  the  contents  of 
that  part  of  the  basin  from  which  the  outflow  pipe  is  fed. 

(c)  The  cesspool  is  still  the  chief  reliance  of  the  world  at  large.  There 
is  nothing  to  be  said  in  its  favor  save  what  may  be  based  on  the 
old  adage  that  "what  is  out  of  sight  is  out  of  mind."  There  is 
everything  to  be  said  in  its  condemnation,  whether  we  regard  its  contents 
as  a  great  mass  of  putrefying  and  infecting  filth,  as  the  source  of  oozings 
which  travel  through  crevices  of  rocks,  through  layers  of  gravel,  through 
seams  in  clay,  or  through  lighter  soils  into  and  under  cellars  and  into 
drinking-water  wells  and  defectively  constructed  cisterns,  or  as  an  ever- 
active  gas-retort  supplying  the  pipes  of  the  house  with  the  foulest  prod- 
ucts of  putrefaction.  It  is  in  all  respects  and  under  all  circumstances  a 
curse,  unless  placed  far  away  from  the  possibility  of  tainting  the  air  we 
breathe  or  the  soil  over  which  \ve  live,  or  from  wrhich  we  or  others  take 
our  drinking-water,  and  even  then  it  had  better  be  abandoned. 

The  simple  drainage  of  the  soil  involves  a  question  of  the  greatest  import- 
ance. If  the  ground  under  the  house  or  about  it  is  at  any  time,  unless 
perhaps  immediately  after  heavy  rains,  saturated  with  moisture,  we  have 
to  apprehend  a  condition  of  insalubrity  more  or  less  serious  in  proportion 
to  the  degree  of  saturation  and  the  degree  of  foulness  with  which  this  is 
associated.  The  drainage  requirements  of  land  outside  of  the  house  are 
less  easily  determined,  but  it  requires  nothing  more  than  a  casual  examin- 


REMOVAL  OF  LIQUID  HOUSEHOLD  WASTES.  227 

ation  of  the  cellar  in  ordinarily  wet  weather  to  determine  whether  or  not 
an  improvement  of  its  soil-water  drainage  is  necessary.  If  it  is  at  such 
times  wet,  or  even  persistently  damp,  thorough  drainage  is  demanded ; 
and  it  is  only  necessary  to  say  that  this  should  be  secured  by  some  process 
which  can  under  no  circumstances  bring  the  air  of  the  cellar  into  commu- 
nication with  the  air  of  a  sewer  or  foul  drain. 

I  have  purposely  abstained  in  the  foregoing  remarks  from  invading 
the  province  of  the  physician  or  the  physiologist  by  discussing  the  influ- 
ence of  bad  drainage  on  the  health  of  those  living  subject  to  it.  It  may 
safely  be  assumed  that  physicians  who  care  enough  about  the  subject  to 
interest  themselves  in  investigating  the  condition  of  local  or  general 
drainage  have  convictions  concerning  it  which  could  not  be  strengthened 
by  the  opinion  of  one  belonging  to  another  profession.  The  assumption 
is  also  confidently  made  that  no  intelligent  medical  man  will  hesitate  for 
a  nromeut  to  accept  the  dictum  that  the  site  of  the  house  must  be  dry,  and 
that  it  and  its  neighborhood  must  be  entirely  exempt  from  the  influence 
of  foul  organic  decomposition. 


GENERAL  DISEASES. 


FROM  SPECIAL  MORBID  AGENTS  OPERATING  FROM  WITHOUT, 


SIMPLE  CONTINUED  FEVEE. 

TYPHOID  FEVER. 

TYPHUS  FEVEE. 

RELAPSING  FEVEE. 

VARIOLA. 

VACCINIA. 

VARICELLA. 

SCARLET  FEVER. 

RUBEOLA. 

ROTHELN. 

MALARIAL  FEVERS. 

PAROTITIS. 

ERYSIPELAS. 

YELLOW  FEVER. 

DIPHTHERIA. 


CHOLERA. 

PLAGUE. 

LEPROSY. 

EPIDEMIC      CEREBRO-SPINAL 
MENINGITIS. 

PERTUSSIS. 

INFLUENZA. 

DENGUE. 

RABIES  AND  HYDROPHOBIA. 

GLANDERS  AND  FARCY. 

MALIGNANT  PUSTULE. 

PYAEMIA  AND   SEPTICAEMIA. 

PUERPERAL  FEVER. 

BERIBERI. 

229 


BY  JAMES  H.  HUTCHINSON,  M.  D. 


DEFINITION. — A  continued,  non-contagious  fever,  varying  in  duration 
from  one  to  twelve  days,  and  in  temperate  climates  almost  invariably  end- 
ing in  recovery.  It  may  arise  from  any  non-specific  cause  capable  of 
producing  a  temporary  derangement  of  one  or  more  of  the  important 
functions  of  the  body,  is  generally  easily  distinguished  from  the  other 
continued  fevers  by  the  absence  of  the  characteristic  symptoms  of  these 
diseases,  and  presents  in  fatal  cases  no  specific  lesions. 

SYNONYMS. — Synocha,  vel  Synochus  Simplex,  Febricula,  Ephemera  or 
Ephemeral  Fever,  Irritative  Fever,  Ardent  Continued  Fever,  Sun  Fever. 

HISTORY. — Much  difference  of  opinion  continues  to  prevail,  even  at  the 
present  time,  in  regard  to  the  existence  of  a  simple  continued  fever,  which, 
on  the  one  hand,  occurs  independently  of  local  inflammations  or  trau- 
matic causes,  and,  on  the  other,  is  distinct  from  typhoid,  typhus,  and 
relapsing  fevers ;  many  observers  contending  that  the  condition  to  which 
this  name  is  given  is  only  a  mild  or  modified  form  of  one  or  other  of  the 
graver  varieties  of  continued  fever,  from  which  the  characteristic  symp- 
toms are  absent.  Prominently  among  modern  writers,  Dr.  Tweedie1 
has  taken  this  view  of  the  subject,  for,  after  reviewing  the  arguments 
for  and  against  the  recognition  of  simple  continued  fever  as  a  distinct 
disease,  he  asserts  that  there  is  not  sufficient  evidence  to  justify  us  in 
encumbering  our  nosology  with  a  doubtful  novelty.  If,  however,  there 
is  room  for  doubt  as  to  its  right  to  a  place  in  the  list  of  diseases,  there  is 
certainly  no  good  reason  for  characterizing  it  as  a  novelty,  since  it  has 
been  referred  to,  according  to  Murchison,2  by  many  authors  from  the 
time  of  Hippocrates  down  to  the  present  day,  who  not  only  separate  it 
from  the  graver  forms  of  fever,  and  give  a  very  accurate  description  of 
its  symptoms,  but  seem  to  have  been  perfectly  familiar  with  the  causes 
which  give  rise  to  it,  and  to  have  had  very  correct  notions  as  to  its  proper 
management.  Thus,  Riverius3  was  aware  of  the  existence  of  two  forms 
of  simple  fever — the  ephemeral,  which  lasts,  as  its  names  implies,  only  a 
single  day,  and  the  Synochus  Simplex,  arising  from  the  same  causes,  but 
in  which  the  fever  continues  for  from  four  to  seven  days.  Strother4  and 
Ball 5  also  allude  to  this  fever  in  terms  that  leave  no  doubt  upon  the  mind 
but  that  they  distinguished  it  clearly  from  other  forms  of  continued  fever. 

1  Lectures  on  the  Continued  Fevers. 

2  A  Treatise  on  the  Continued  Fevers  of  Great  Britain,  London,  1873. 

3  The  Practice  of  Physick,  being  chiefly  a  Translation  of  the  Works  of  Lazarus  Riverius, 
London,  1678. 

4  A  Critical  Essay  on  Fever,  1718.  5  A  Treatise  on  Fevers,  London,  1758. 

231 


232  SIMPLE  CONTINUED  FEVER. 

Among  more  recent  writers  who  have  made  this  distinction  may  be  men- 
tioned Lyons,1  Jenner,2  G.  B.  Wood,3  Flint,4  Murchison,5  and  J.  C. 
"Wilson.6  Indeed,  the  weight  of  authority  is  decidedly  on  the  side  of 
those  who  claim  for  it  a  recognition  as  a  distinct  and  separate  disease. 

Unquestionably,  many  cases  which  have  been  classed  under  the  head  of 
simple  continued  fever,  are  really  mild  or  abortive  cases  of  typhoid  or 
typhus  fever,  in  which,  in  consequence  of  partial  protection  on  the  part 
of  the  patient,  the  characteristic  symptoms  of  these  diseases  have  not  been 
developed.  Such  cases  are  seen  in  numbers  during  epidemics  of  these 
diseases.  But,  making  due  allowance  for  this  source  of  error,  there 
yet  remain  many  cases  which  cannot  be  thus  explained.  Moreover,  the 
disease  occurs  at  times  when  no  such  epidemics  exist.  It  may,  therefore, 
be  safely  assumed  that  there  is  such  a  fever,  and  that,  consequently,  it 
must  be  accorded  full  recognition. 

CAUSES. — Any  non-specific  cause  which  is  capable  of  producing  a  pro- 
found derangement  of  one  or  more  of  the  important  functions  of  the 
body  may  give  rise  to  simple  continued  fever.  It  may  follow,  therefore, 
upon  excesses  of  the  table,  extreme  mental  or  bodily  fatigue,  exposure  to 
the  direct  rays  of  the  sun,  or  to  great  heat  or  cold,  or  upon  the  suppres- 
sion of  a  secretion.  One  of  its  most  frequent  causes  is  over-exer- 
tion in  warm  weather.  James  C.  Wilson  has  called  attention  to  its 
frequent  occurrence  as  a  consequence  of  the  combined  influence  of  the 
excitement,  the  physical  exhaustion,  and  the  exposure  to  the  direct  rays 
of  the  mid-day  sun  which  are  attendant  upon  surf-bathing.  It  is  often 
due  in  young  children  to  the  irritation  involved  in  the  process  of  teething 
or  to  that  caused  by  the  presence  of  worms  in  the  alimentary  canal. 
Wood  taught  that  it  might  also  sometimes  occur  during  the  prevalence  of 
contagious  diseases  as  an  effect  of  the  epidemic  influence  in  those  who 
were  partially  protected  by  a  previous  attack  of  the  disease,  or  from  some 
other  cause,  but  it  is  more  probable  that  cases  arising  under  these  circum- 
stances are  either  mild  cases  of  the  prevalent  disease  or  else  are  attribu- 
table to  fatigue  from  nursing  or  to  over-anxiety.  The  disease  is  more 
common  in  the  young  than  in  the  old,  and  in  children  than  in  adults — 
probably  from  the  greater  impressionability  of  the  nervous  systems  of 
the  latter. 

The  causes  of  the  ardent  continued  fever  of  the  tropics,  which  is 
usually  recognized  as  a  form  of  simple  continued  fever,  do  not  differ 
materially,  except  in  degree,  from  those  of  the  simpler  forms  of  the  dis- 
ease ;  but  exposure  to  the  direct  rays  of  the  sun  would  seem  to  be 
especially  prone  to  give  rise  to  the  disease  in  those  who  are  unaccustomed 
to  the  heat  of  a  tropical  climate.  Robust  young  Europeans  lately  arrived 
in  a  warm  country  are,  it  is  said,  peculiarly  liable  to  suffer  from  it.7  It  is 
most  common  in  those  parts  of  India  which  do  not  experience  much  of 
the  benefit  of  the  monsoon  rains,  and  whose  hot  season  is  not  tempered 
by  regular  breezes  from  the  sea.  It  is  hence  more  frequently  met  with 

1  A  Treatise  on  Fever,  London,  1861.  z  Medical  Times,  March  22,  1851. 

3  A  Treatise  on  the  Practice  of  Medicine,  Philadelphia,  1855. 

4  A  Treatise  on  the  Principles  and  Practice  of  Medicine,  Philadelphia,  1868. 

6  Ibid.  6  A  Treatise  on  the  Continued  Fevers,  New  York,  1881. 

7  Morehead,  Clinical  Researches  on  Diseases  in  India,  London,  1856 ;  also  Twining,  Clin- 
ical Illustrations  of  the  More  Important  Diseases  of  Bengal,  Calcutta,  1835. 


SYMPTOMS  AND  COURSE.  233 

in  inland  districts  in  which  the  temperature  is  high,  but  in  which  malaria- 
generating  conditions  are  absent. 

SYMPTOMS  AND  COURSE. — Simple  continued  fever  occurs  in  this  country 
only  as  a  sporadic  disease,  and  almost  invariably  ends  in  recovery ;  in 
tropical  climates,  however,  it  may  prevail  epidemically,  and  sometimes 
presents  symptoms  of  a  very  grave  character.  In  its  mildest  form  it  not 
infrequently  runs  its  course  in  a  few  hours,  and  is  rarely  prolonged  much 
beyond  twenty-four,  and  is  hence  called  ephemera.  It  then  usually  begins 
somewhat  abruptly  with  a  chill,  but  in  a  few  instances  this  is  preceded  by 
feelings  of  languor  and  weariness.  Febrile  reaction  is  soon  established, 
and  is  generally  well  marked ;  the  pulse  is  quick  and  full,  the  tempera- 
ture rises  rapidly,  and  the  face  is  flushed.  The  tongue  is  coated  with  a 
whitish  fur,  the  urine  is  scanty  and  high-colored,  and  the  bowels  are  con- 
stipated. Other  symptoms  are  excessive  thirst,  headache,  restlessness,  and 
sleeplessness,  or,  on  the  other  hand,  a  tendency  to  somnolence.  Vomiting 
is  not  common  except  in  those  cases  which  follow  upon  an  error  of  diet, 
but  there  is  generally  some  nausea  and  anorexia.  Muscular  pains  are 
also  occasionally  present,  and  may  give  rise  to  a  good  deal  of  distress. 
The  subsidence  of  these  symptoms  is  often  quite  as  abrupt  as  their  onset, 
the  crisis  being  frequently  marked  by  a  copious  perspiration. 

In  other  cases,  however,  the  fever  is  more  prolonged,  and  the  symp- 
toms, although  not  differing  in  kind,  are  apt  to  be  more  severe  than  those 
above  detailed.  The  pulse  is  often  full,  hard,  and  bounding ;  the  head- 
ache throbbing  or  darting  in  character ;  the  tendency  to  somnolence  in- 
creases, or  gives  place  to  delirium ;  and  the  pyrexia  is  more  marked. 
Frequently  an  eruption  of  herpes  is  observed  upon  the  lips  and  upon 
other  parts  of  the  face,  from  which  circumstance  the  disease  is  sometimes 
called  herpetic  fever.  Davasse 1  also  observed  in  a  few  cases  pale  bluish 
spots,  not  elevated  above  the  surface  and  not  disappearing  under  pressure, 
which  are  identical  with  the  tachcs  bleuatres  sometimes  seen  in  typhoid 
fever  and  other  diseases,  and  therefore  have  no  diagnostic  value.  In  this 
form  the  duration  of  the  disease  may  be  from  four  to  ten  or  twelve  days. 
The  defervescence  is  usually  less  rapid  than  the  rise  in  temperature,  and 
is  generally  accompanied  by  a  free  perspiration,  diarrhoea,  a  copious  deposit 
of  urates  in  the  urine,  or  less  frequently  by  hemorrhage  from  the  uterus 
or  rectum,2  or  from  the  nose,  mouth,  or  urethra.  This  constitutes  the 
synocha  or  inflammatory  fever  of  the  older  writers.  In  children  in  whom 
there  is  no  reason  to  suspect  malarial  poisoning  the  disease  sometimes 
assumes  a  remittent  form,  and  then  constitutes  a  variety  of  the  infantile 
remittent  fever  of  authors — a  name,  however,  which,  it  must  be  remem- 
bered, has  been  made  to  include  a  great  many  distinct  diseases.3 

When  the  disease  occurs  in  individuals  who  are  broken  down  in  health 
from  any  cause4 — as,  for  instance,  previous  illness,  deficient  food,  long- 
continued  anxiety,  or  great  fatigue — it  not  infrequently  presents  symp- 
toms of  an  asthenic  character.  The  febrile  reaction  is  then  less  intense, 
and  the  pulse  feebler  and  more  frequent,  than  in  the  variety  just  described. 
The  duration  of  the  disease  in  this  form  is  also  generally  longer.  Mur- 
chison  has  proposed  for  it  the  name  of  simple  asthenic  fever. 

Under  the  name  of  ardent  continued  fever,  Indian  medical  writers  have 
described  a  variety  of  the  disease  which  is  frequently  met  with  in  tropical 

1  Quoted  by  Murchison.  *  Murchison.  *  Lyons.  4  Wood, 


234  SIMPLE  CONTINUED  FEVER. 

countries,  and  which  is  usually  much  more  severe  than  the  varieties  already 
referred  to.  In  addition  to  the  symptoms  presented  by  these,  Morehead l 
says  that  there  is  often  intolerance  of  light  and  sound,  contracted  and  sub- 
quently  dilated  pupils,  ringing  noises  in  the  ears,  anxious  respiration, 
pains  in  the  limbs  and  loins,  and  a  sense  of  oppression  at  the  epigastrium. 
The  bowels  are  sometimes  confined ;  at  others  vitiated  bilious  discharges 
take  place.  The  tongue  is  white,  often  with  florid  edges,  and  the  urine 
scanty  and  high-colored.  At  the  end  of  from  forty-eight  to  sixty  hours 
the  febrile  phenomena  may  subside,  the  skin  become  cold,  and  death  take 
place  from  exhaustion  and  sudden  collapse.  In  some  cases  the  symptoms 
of  cerebral  disturbance  are  greater  in  degree,  and  in  these  coma  may  soon 
supervene  upon  delirium.  Convulsions,  epileptiform  in  character,  with 
relaxation  of  the  sphincters  and  suppression  of  urine,  also  frequently 
occur,  and  occasionally  cerebral  hemorrhage.  In  other  cases  the  symptoms 
of  gastritis  are  more  prominent,  or  jaundice  may  appear  and  aggravate 
the  disease. 

Symptoms  closely  resembling  those  just  described  are  occasionally  met 
with  in  this  country  in  patients  who  have  been  exposed  for  some  time  to 
the  direct  rays  of  the  summer  sun,  but  who  have  escaped  a  sunstroke. 
Indeed,  a  few  writers  have  been  so  much  impressed  with  the  general 
resemblance  which  this  latter  condition  bears  to  the  fevers  that  they  have 
insisted  upon  including  it  in  this  group,  and  have  given  it  the  name  of 
thermic  or  heat  fever.  This  view  of  the  pathology  of  sunstroke  has, 
however,  never  been  generally  accepted. 

One  of  the  most  characteristic  symptoms  of  the  disease  in  all  its  forms 
is  the  rapid  rise  of  temperature,  which  may  in  ephemera  be  as  great  as 
from  four  to  seven  degrees  in  the  course  of  a  few  hours,  and  which  may 
be  followed  in  a  few  hours  more  by  an  equally  abrupt  defervescence. 
When  the  fever  is  more  prolonged,  although  the  temperature  rises  rapidly, 
it  may  not  attain  its  greatest  elevation  for  from  forty  to  sixty  hours  after 
the  onset  of  the  symptoms,  and  its  fall  will  be  more  gradual  than  in  the 
preceding  variety.  Unfortunately,  there  are  no  reliable  thermometric 
records  of  ardent  continued  fever.  The  urine  is  usually  scanty  and  high- 
colored  during  the  height  of  the  fever,  especially  in  the  severer  forms  of 
the  disease.  Its  specific  gravity  is  high,  and  it  contains  a  large  amount 
of  solids,  especially  of  urea.  With  the  fall  of  the  temperature  it  rapidly 
increases  in  quantity,  and  is  very  apt  to  let  fall  a  copious  lateritious  sedi- 
ment on  cooling.  According  to  Parkes,2  who  closely  observed  six  cases 
Avith  the  view  of  determining  this  question,  albuminuria  does  not  occur 
at  any  stage  of  the  disease.  Convalescence  is  usually  rapid,  and  is  not 
liable  to  be  interrupted  by  the  occurrence  of  sequela?. 

DIAGNOSIS. — The  diagnosis  in  those  cases  of  simple  continued  fever  in 
which  the  connection  between  the  disease  and  some  one  of  the  conditions 
which  have  been  referred  to  above  as  capable  of  exciting  it  has  been  dis- 
tinctly made  out,  presents  little  difficulty.  It  is  otherwise,  however, 
when  this  relationship  is  not  apparent.  Indeed,  the  symptoms  of  the 
disease  so  closely  resemble  those  of  an  abortive  or  mild  attack  of  typhoid 
or  typhus  fever,  in  which  the  characteristic  eruption  is  wanting,  that  the 

1  Clinical  Researches  on  Disease  in  India,  London,  1856.     See  also  "Croonian  Lectures," 
by  Sir  Joseph  Fayrer,  Brit.  Med.  Jour.,  April  29,  1882. 

2  The  Composition  of  the  Urine,  by  Edmund  A.  Parkes,  M.D.,  London,  1860. 


PROGNOSIS.— ANATOMICAL  LESIONS.  235 

physician  may  sometimes  remain  in  doubt  as  to  the  nature  of  the  disease 
he  has  been  called  upon  to  treat,  even  after  the  recovery  of  the  patient. 
This  difficulty  will  of  course  be  especially  likely  to  present  itself  during 
the  epidemic  prevalence  of  these  diseases.  Simple  continued  fever  may, 
however,  generally  be  distinguished  from  either  of  the  latter  by  the  much 
greater  severity  of  its  initial  symptoms,  and  particularly  by  the  rapid 
rise  of  temperature — a  rise  of  from  four  to  seven  degrees  in  the  course 
of  a  few  hours — which  does  not  take  place  in  these  fevers,  but  which,  it 
must  be  remembered,  may  occur  in  erysipelas,  measles,  pneumonia,  and 
some  other  diseases.  The  absence  of  a  characteristic  eruption,  although 
it  would  not  render  it  certain,  would  be  in  favor  of  the  diagnosis  of 
simple  continued  fever,  as  would  also  the  absence  of  diarrhoea  in  cases 
in  which  there  was  difficulty  in  deciding  between  this  disease  and  typhoid 
fever.  On  the  other  hand,  Murchison  regards  the  presence  of  an  herpetic 
eruption  on  the  lips  as  almost  pathognomonic  of  simple  continued  fever; 
but  in  this  country  such  an  eruption  is  not  an  infrequent  attendant  upon 
fevers  of  malarial  origin,  and  many  observers  attach  great  importance  to 
it  in  the  diagnosis  of  these  diseases. 

Simple  continued  fever  is  not  likely  to  be  mistaken  for  relapsing  fever, 
except  during  epidemics  of  the  latter  disease.  It  may  be  discriminated 
from  relapsing  fever,  the  first  paroxysm  of  which  it  closely  resembles, 
by  the  absence  of  severe  articular  pains,  of  tenderness  in  the  epigastric 
zone,  of  enlargement  of  the  liver  and  spleen,  and  of  jaundice.  It  may 
be  mistaken  for  tubercular  meningitis,  especially  in  those  cases  in  which 
the  nervous  symptoms  are  more  than  usually  prominent,  or  in  which  a 
hereditary  predisposition  to  tuberculosis  exists ;  but  its  true  nature  may 
generally  be  recognized  by  its  more  abrupt  commencement,  and  by  the 
absence  of  the  constant  vomiting,  screaming  fits,  strabismus,  and  paral- 
ysis so  characteristic  of  the  latter  disease. 

It  is  scarcely  necessary  to  add  that  a  local  inflammation  or  a  traumatic 
cause  may  give  rise  to  symptoms  simulating  those  of  simple  continued 
fever,  and  that  the  diagnosis  of  this  disease  must  be  uncertain  until  these 
conditions  have  been  positively  ascertained  to  be  absent,  or,  if  present, 
until  they  have  been  proved  to  be  complications,  and  not  the  causes  of 
the  disease. 

PROGNOSIS. — The  prognosis  of  this  disease,  as  it  is  met  with  in  this 
country,  is  favorable.  Indeed,  when  uncomplicated  it  may  be  said  to 
end  invariably  in  recovery,  except  in  the  aged  and  feeble,  in  whom,  when 
it  occurs  during  the  great  heat  of  the  summer  season,  it  is  apt  to  assume 
the  asthenic  form,  and  to  be  accompanied  by  symptoms  of  a  grave  cha- 
racter. The  ardent  continued  fever  of  the  tropics,  on  the  other  hand, 
not  infrequently  terminates  fatally,  or  may  leave  the  sufferer  from  it  a 
chronic  invalid  for  life,  which  is  frequently  shortened  by  obscure  cerebral 
or  meningeal  changes,  which  give  rise  to  irritability,  impaired  memory, 
epilepsy,  headache,  mania,  partial  or  complete  paraplegia,  or  blind- 
ness.1 

ANATOMICAL  LESIONS. — Death  so  rarely  occurs  in  this  latitude  from 
simple  continued  fever  that  the  opportunities  for  making  post-mortem 
examinations  do  not  often  occur.  There  are,  however,  a  sufficient 
number  of  such  examinations  on  record  to  show  that  the  disease  gives 

1  Sir  Joseph  Fayrer,  K.  C.  S.  I.,  M.  D.,  F.  R.  S.,  Brit.  Med.  Jour.,  April  29,  1881,  p.  607. 


236  SIMPLE  CONTINUED  FEVER. 

rise  to  no  specific  lesions.  According  to  Murchison  and  Martin,1  inspec- 
tion in  fatal  cases  of  ardent  continued  fever  usually  reveals  the  presence 
of  great  congestion  of  all  the  internal  organs  and  of  the  sinuses  of  the 
brain  and  pia  mater,  of  an  increased  amount  of  intracranial  fluid,  and 
occasionally  of  an  effusion  into  the  abdominal  cavity,  and  more  rarely 
into  the  thoracic  cavity. 

TREATMENT. — In  the  milder  forms  of  the  disease  little  or  no  treatment 
is  required — a  fact  which  seems  to  have  been  recognized  and  acted  upon 
long  ago,  since  Strother  remarks  that  the  cure  of  it  is  so  easy  that  phy- 
sicians are  seldom  consulted  about  such  patients.  An  emetic  when  the 
attack  has  been  caused  by  excesses  of  the  table,  and  there  is  reason  to 
believe  that  there  is  undigested  food  in  the  stomach,  a  purgative  when 
constipation  exists,  and  cooling  drinks,  the  effervescing  draught  or  some 
other  saline  diaphoretic,  are  usually  the  only  remedies  that  are  called  for. 
In  cases  in  which  the  febrile  action  is  more  intense  and  prolonged,  in 
addition  to  the  use  of  these  remedies  an  effort  should  be  made  to  reduce 
the  heat  of  the  skin  and  the  frequency  of  the  pulse  by  sponging  with 
cold  water  and  by  the  administration  of  digitalis  and  aconite.  The  head- 
ache which  is  often  a  distressing  symptom  may  usually  be  relieved  by  the 
application  of  evaporating  lotions,  and  restlessness  quieted  by  the  bro- 
mides.- Subsequently,  quinia  may  be  given  with  advantage.  The  patient 
should  be  restricted  to  liquid  diet  during  the  continuance  of  fever. 

In  the  asthenic  form  quiuia  and  the  mineral  acids,  nutritious  food,  and 
very  frequently  alcoholic  stimulants,  must  be  given  from  the  beginning. 
In  the  treatment  of  the  ardent  continued  fever  of  the  tropics  the  cold 
affusion  or  the  cold  bath,  with  quinia,  would  appear  to  be  indicated,  but 
Morehead  and  other  Indian  physicians  advise  the  use  of  evacuants  with 
copious  and  repeated  venesections,  cupping,  and  leeches,  aided  by  tartar 
emetic,  till  all  local  determination  and  the  chief  urgent  symptoms  are 
removed ;  and  Murchison  expresses  the  belief,  founded  on  his  own 
observations,  that  life  is  often  sacrificed  by  adopting  less  active 
measures. 

1  The  Influence  of  Tropical  Climates  on  European  Constitutions,  by  James  Eanald  Martin, 
F.  E.  S.,  London,  1856. 


TYPHOID  FEVER. 

BY  JAMES  H.   HUTCHINSON,  M.  D. 


DEFINITION. — An  endemic  infectious  fever,  usually  lasting  between  three 
and  four  weeks,  and  associated  with  constant  lesions  of  the  solitary  and 
agminate  glands  of  the  ileum,  and  with  enlargement  of  the  spleen  and 

lesenteric  glands.  Its  invasion  is  usually  gradual  and  often  insidious. 
Sometimes  the  only  symptoms  present  in  the  beginning  are  a  feeling  of 
lassitude,  some  gastric  derangement,  and  a  slight  elevation  of  tempera- 
ture ;  at  others  there  are  slight  rigors  or  chilly  sensations,  headache,  epis- 
taxis,  diarrhoaa,  and  pain  in  the  abdomen.  The  principal  symptoms  of 
the  fully-formed  disease  are  a  febrile  movement  possessing  certain  charac- 
ters, headache  passing  into  delirium  and  stupor,  diarrho3a  associated  with 
ochrey-yellow  stools,  tympanites,  pain  and  gurgling  in  the  right  iliac 
fossa,  a  red  and  furred  tongue,  which  later  often  becomes  dry,  brown,  and 
fissured ;  a  frequent  pulse ;  an  eruption  of  rose-colored  spots,  occurring 
about  the  seventh  or  eighth  day,  slightly  elevated  above  the  surface,  dis- 
appearing under  pressure,  and  coming  out  in  successive  crops,  each  spot 
lasting  about  three  days ;  prostration  not  marked  in  the  beginning,  but 
rapidly  increasing;  and  occasionally  deafness,  sweats,  and  intestinal 
hemorrhages.  When  recovery  takes  place,  the  convalescence  is  usually 
tedious,  and  may  sometimes  be  protracted  by  the  occurrence  of  one  or 
more  relapses. 

SYNONYMS. — The  following  are  a  few  of  the  many  names  which 
have  been  given  to  the  disease  at  diifereut  times.  Most  of  them  have 
ceased  to  be  applied  to  it,  and  only  three  or  four  of  them  are  at  present 
in  general  use:  Febris  Mesenterica,  1696;  Slow  Nervous  Fever,  1735; 
^ebricula  or  Little  Fever,  1740;  Typhus  Nervosus,  1760;  Miliary 

''ever,  1760;  Typhus  Mitior,  1769;  Synochus,  1769 ;  Common  Con- 
tinued Fever,  1816;  Gastro-Enterite,  1816;  Entero-Mesenteric  Fever, 
L820;  Abdominal  and  Darm  Typhus,  1820;  Typhus  Fever  of  New 
England,  1824;  Dothienteric,  1826;  Enterite-folliculeuse,  1835;  Infan- 
tile Remittent  Fever,  1836  ;  Enterite  Septic6mique,  1841 ;  Mucous  Fever, 
1844;  Enteric  Fever,  1846;  Intestinal  Fever,  1856;  Ileo-Typlms,  1857; 

^ythogenic  Fever,  1858 ;  Mountain  Fever,  1870. 
NAME. — It  has  been  objected  to  the  name  "typhoid  fever;>  as  a  desig- 

lation  for  this  disease  that  it  tends  to  perpetuate  among  the  laity  the 

listakeii  impression  that  typhoid  fever  is  only  a  modified  typhus 
fever,  and  also  that  the  word  typhoid  has  been  generally  applied  to  a 

jndition  of  system  which  is  common  to  a  great  many  different  diseases, 

237 


238  TYPHOID  FEVER. 

and  which  is  not  of  necessity  present  in  this.  In  spite  of  these  objections, 
and  although  it  must  be  admitted  that  they  are  not  without  force,  I  prefer 
to  retain  the  name  typhoid  fever,  and  for  the  following  reasons  :  1st.  It 
was  the  name  given  to  the  disease  by  Louis,  to  whom  we  owe  the  first 
full  and  accurate  description  of  it.  2d.  It  is  the  name  by  which  it  is 
best  known  to  the  profession,  not  only  in  this  country  but  abroad.  3d. 
No  other  name  has  been  proposed  for  it  which  is  not  quite  as  much 
open  to  criticism.  Thus  the  term  enteric  fever,  originally  suggested 
by  the  late  George  B.  Wood,  and  adopted  by  the  London  College  of 
Physicians  in  its  Nomenclature  of  Diseases,  is  objectionable  because  it 
brings  into  undue  prominence  the  intestinal  lesions  and  implies  that  they 
are  the  cause  of  the  fever.  The  same  objection  may  be  urged  against 
the  name  "intestinal  fever,"  proposed  by  Budd.  The  name  "pytho- 
genic  fever"  rests  upon  a  theory  of  the  disease  which  has  never  been 
proven,  and  is  regarded  by  most  observers  as  untenable.  Under  these 
circumstances  even  the  influence  of  its  distinguished  proposer,  the  late 
Dr.  Murchison,  has  been  insufficient  to  secure  its  adoption  by  the  pro- 
fession at  large. 

HISTORY. — Certain  passages  in  the  writings  of  Hippocrates  have  been 
appealed  to  by  Murchisou  and  other  physicians  in  support  of  the  opinion 
that  typhoid  fever  was  a  disease  of  at  least  occasional  occurrence  in  ancient 
times ;  but,  although  from  the  nature  of  its  causes  it  is  probable  that  it 
has  occurred  in  all  ages  and  wherever  men  have  congregated  in  towns 
and  villages,  the  descriptions  given  by  the  Father  of  Medicine  in  the 
passages  alluded  to  are  not  sufficiently  full  to  render  it  at  all  'certain  that 
typhoid  fever  had  ever  come  under  his  observation.  Indeed,  there  is  no 
author  of  an  earlier  date  than  Spigelius1  whose  writings  furnish  any 
positive  evidence  that  he  ever  met  with  the  disease.  Spigelius,  however, 
in  spite  of  the  doubt  thrown  upon  his  observation  by  Hirsch,2  would 
seem  to  have  had  opportunities  for  examining  the  bodies  of  those  who 
had  died  of  it,  since  he  gives  an  account  of  several  autopsies,  in  which  he 
says  that  the  small  intestine  was  inflamed  and  that  that  part  of  it  next 
to  the  ca3cum  and  colon  was  frequently  sphacelated.  Panarolus*  also 
says  that  the  intestines  had  the  appearance  of  being  cauterized  ("  appar- 
ebaut  tanquam  exusta  ")  in  some  cases  observed  by  him  in  Rome  a  little 
later  in  the  same  century.  Willis 4  would  certainly  appear  to  have  been 
familiar  with  two  forms  of  fever,  which,  from  the  description  he  gives 
of  them,  could  have  been  nothing  else  but  typhoid  and  typhus  fevers. 
Sydeuham5  also  described  a  fever  in  which  the  prominent  symptoms 
were  diarrhoea,  vomiting,  delirium,  a  tendency  to  coma,  and  epistaxis, 
and  which  was  distinguishable  from  the  febris  pestilens  by  the  absence 
of  a  petechial  eruption.  Baglivi 6  of  Rome  in  the  latter  part  of  the 
seventeenth  century  described  the  li£emitritseus  of  previous  writers 

1  De  Febre  Semiterliana,  Frankf.,  1624;  Op.  Om.,  Amsterdam,  1745.     Quoted  by  Mur- 
chison. 

2  Handbuch  der  Historisch-  Geographischen  Pathologie,  von  Dr.  August  Hirsch,  Stuttgart, 
1881. 

3  Observat.  Med.  Penlecostce  ;  Homos,  1652.     Quoted  by  Murchison. 

4  Dr.  Willis's  Practice  of  Physick,  translated  by  Samuel  Pordage,  London,  1 684. 

5  The  Works  of  Thomas  Sydenham,  M.  D.,  on  Acute  anfi  Chronic  Diseases,  with  a  Variety 
of  Annotations  by  George  Wallis,  M.  D.,  London,  1788. 

8  Opera  Omnia  Medico-practica  et  Anatomica,  Paris,  1788. 


HISTORY.  239 

under  the  title  of  febris  mesenterica,  and  maintained  that  it  was 
always  accompanied  by  and  dependent  on  inflammation  of  the  intestines 
and  enlargement  of  the  meseuteric  glands.  A  similar  observation  was 
made  soon  after  by  Hoffmann,1  and  by  LancisiMn  1718.  The  latter 
seems  to  have  fully  recognized  the  characteristics  of  the  eruption,  for  he 
says  that  it  consisted  of  "  elevated  papules  which  disappeared  completely 
on  pressure."  In  1759,  Huxham  described,  under  the  title  "slow,  nerv- 
ous fever,"  a  disease  which  there  can  be  no  doubt  was  typhoid  fever.  He 
moreover  pointed  out  very  clearly  the  distinctions  between  this  disease 
and  another  to  which  he  gave  the  name  of  "putrid,  malignant,  petechial 
fever,"  and  which  was  unquestionably  typhus.  Sir  Richard  Manning- 
ham  3  also  described  typhoid  fever  under  the  title  of  "  febricula,  or  little 
fever."  In  the  preface  of  his  work  he  calls  attention  to  its  insidious 
origin,  and  to  _the  fact  that  its  gravity  was  often  underrated  at  its  com- 
mencement, "  till,  at  length,  more  conspicuous  and  very  terrible  symptoms 
arise,  and  then  the  Physician  is  sent  for  in  the  greatest  hurry,  and  happy 
for  the  Patient  if  the  Symptoms,  which  are  most  obvious,  do  not,  at  this 
Time,  mislead  the  Physician  to  the  Negle.ct  of  the  little  latent  Fever,  the 
true  Cause  of  these  violent  Symptoms."  About  the  same  time  Morgagni4 
described  certain  post-mortem  examinations  in  which  the  lesions  of  the 
intestines  were  evidently  those  of  typhoid  fever.  Other  authors,  whose 
works  bear  evidence  that  they  were  familiar  with  the  symptoms  or  lesions 
of  typhoid  fever,  are  Riedel,  Roederer  and  Wagler,  Stoll,  Rutty,  Sarcone, 
Pepe,  Fasano,  Mayer,  Wrenholt,  Sutton,  Bateman,  Muir,  Edmonstone, 
Prost,  Petit  and  Serres,  Cruveilhier,  Lerminier,  and  Andral. 

To  Bretouneau5  of  Tours  appears  to  belong  the  credit  of  having  first 
distinctly  pointed  out  the  association  between  certain  symptoms  and  the 
lesions  of  the  solitary  and  agminated  glands  of  the  ileum.  He  regarded 
the^  disease  of  the  intestinal  glands  as  inflammatory,  and  therefore  gave 
to  it  the  name  " dothienenterie "  or  "dothienenterite"  (from  dodiyv,  a 
tumor,  and  evrspov,  intestine),  but,  unlike  Prost,  fully  recognized  the  fact 
that  there  was  no  necessary  relation  between  the  extent  of  the  intestinal 
lesions  and  the  gravity  of  the  febrile  symptoms.  Hirsch,  however,  claims 
this  honor  for  Pommer,  whose  little  work  on  Sporadic  Typhus  he  thinks 
has  not  received  the  consideration  its  merits  deserve.  Louis,  to  whom 
for  his  careful  study  of  typhoid  fever  we  owe  a  large  debt  of  gratitude, 
was  also^  fully  aware  of  the  lesions  of  the  intestinal  glands  which  occur 
in  this  disease. 

The  progress  in  pathology  which  observers  were  making  was  tempo- 
rarily impeded  about  this  time  by  the  fact  that  while  typhoid  fever  was 
of  frequent  occurrence  in  Paris,  typhus  fever  was  comparatively  rarely 
met  with  and  had  not  been  epidemic  there  for  several  years.  Bretonneau, 
Louis,6  Chomel,  and  indeed  the  greater  number  of  contemporary  French 
physicians,  therefore  fell  into  the  error  of  supposing  that  the  fever  which 
was  then  common  in  England  was  identical  with  that  which  they  were  de- 
scribing, while  the  English  physicians  of  the  period,  with  but  few  excep- 

1  Opera  Omnia  Physico-Medico,  1699.     Quoted  by  Murchison. 

2  Opera  Omnia,  Geneva,  1718. 

3  The  Symptoms,  Nature,  etc.  of  the  Febricula  or  Little  Fever,  London,  1746. 

*  Quoted  by  Hirsch.  5  Quoted  by  Trousseau,  Archives  Generales,  1826. 

'  Researches  Anatomiquex,  Pathologiques  et  Therapeutiques  sur  la  Maladie  connue  sur  lee 
Noms  de  gastro-entente,  etc.,  par  P.  C.  A.  Louis,  Paris,  1829. 


240  TYPHOID  FEVER. 

tious,  contended  with  equal  strenuousness  that  there  was  but  one  form  of 
continued  fever,  and  that  this  was  very  seldom  associated  with  disease  of 
the  intestines.  In  the  second  edition  of  his  work  Louis  abandoned  his 
former  opinion,  and  admitted  that  the  typhus  fever  of  the  English  was  a 
very  different  disease  from  that  which  formed  the  subject  of  his  treatise ; 
but  the  confusion  which  existed  in  England  in  regard  to  this  disease  was 
not  completely  dispelled  until  the  appearance  in  1849  and  the  following 
two  years  of  several  papers  on  this  subject  by  Sir  "William.  Jeuner,1  in 
which  it  was  conclusively  demonstrated  that  typhoid  and  typhus  fevers 
were  separate  and  distinct  diseases.  In  Germany,  however,  the  non- 
identity  of  these  diseases  was  recognized  as  early  as  1810.  Murchison 
says  that  the  names  by  which  they  are  still  generally  known  in  that 
country,  typhus  exanthematicus  and  typhus  abdominalis,  were  given  to 
them  not  long  after. 

The  contributions  made  by  American  physicians  to  the  knowledge  of 
typhoid  fever  have  been  both  numerous  and  important.  In  1824  it  was 
described  by  Nathan  Smith2  under  the  name  of  typhus  fever  of  New 
England,  and  in  1833,  E.  Hale,  Jr.,3  of  Boston,  published  in  the 
Medical  Magazine  for  December  an  account  of  three  dissections  of  per- 
sons considered  by  him  to  have  died  of  the  disease.  In  reference  to  these 
cases,  Bartlett4  says  that  if  the  diagnosis  could  be  looked  upon  as 
certain  and  positive  they  would  constitute  the  first  published  examples 
of  intestinal  lesion  in  New  England.  In  February,  1835,  William  S. 
Gerhard  of  Philadelphia,  who  was  then  under  the  impression  that  the 
two  diseases  were  identical,  reported  two  cases  under  the  name  of  typhus 
fever,  the  symptoms  and  post-mortem  appearances  of  which  he  showed 
differed  in  no  respect  from  those  he  had  been  accustomed  to  see  in  the 
cases  of  typhoid  fever  he  had  observed  with  Louis  during  his  studies 
in  Paris.  The  year  after  Gerhard  had,  however,  the  opportunity  of 
observing  an  epidemic  of  true  typhus  fever,  and  was  at  once  struck  with 
the  difference  between  the  symptoms  of  the  cases  which  then  fell  under 
his  care  and  of  those  he  had  seen  in  Paris.  In  an  admirable  paper  which 
appeared  in  the  numbers  of  the  American  Journal  of  the  Medical  Sciences 
for  February  and  August,  1837,  he  points  out  very  clearly  the  differ- 
ential diagnosis  between  the  two  diseases.  He  particularly  insisted  on 
the  marked  difference  between  the  petechial  eruption  of  typhus  and  the 
rose-colored  eruption  of  typhoid  fever.  He  showed  that  the  latter 
disease  was  invariably  associated  with  enlargement  and  ulceration  of 
Fever's  patches  and  with  enlargement  of  the  mesenteric  glands,  and  that 
these  conditions  were  never  presented  in  the  former.  He  also  fully 
recognized  the  fact  that  typhus  fever  was  eminently  contagious,  while, 
on  the  other  hand,  he  was  fully  aware  that  typhoid  fever  was  not 
contagious  under  ordinary  circumstances,  "although  in  some  epidemics," 
he  says,  "  we  have  strong  reason  to  believe  it  becomes  so."  The  appear- 
ance of  this  paper  marks  an  epoch  in  the  history  of  typhoid  fever. 
Murchison,  when  speaking  of  it,  says  that  to  Gerhard,  and  Pennock 
(who  was  associated  with  Gerhard  in  his  observations)  certainly 

1  Med.  Chir.  Trans.,  vol.  xxxiii. ;   Edinburgh  Monthly  Jour,  of  Med.  Sci.,  vols.  ix.  and  x., 
1849-50;  and  Med.  Times,  vols.  xx.,  xxi ,  xxii.,  xxxiii.,  1849-51. 

2  Medical  and  Surgical  Memoirs,  Baltimore,  1831. 

8  Obxermtions  on  the  Typhoid  Fever  of  New  England,  Boston,  1839. 

*  The  History,  Diagnosis,  and  Treatment  of  the  Fevers  of  the  United  States,  1842. 


GEOGRAPHICAL  DISTRIBUTION.  241 

belongs  the  credit  of  first  clearly  establishing  the  most  important  points 
of  distinction  between  this  disease  and  typhus  fever,  and  M.  Yalleix 
alludes  to  it  in  terms  equally  complimentary.  It  is  undoubtedly  owing 
to  it,  more  than  to  any  other  cause,  that  the  differential  diagnosis  of  these 
two  diseases  was  perfectly  understood  by  the  great  body  of  the  profession 
in  this  country  long  before  the  question  of  the  relation  which  they  bore 
to  each  other  was  definitely  settled  in  Great  Britain,1  or  even  in  France. 

Bartlett  gave  in  the  Medical  Magazine,  June,  1835,  a  short  account 
of  the  entero-mesenteric  alterations  in  five  cases  of  unequivocal  typhoid 
fever,  which  alterations,  he  said,  corresponded  exactly  to  those  described 
by  Louis.  In  the  same  year,  James  Jackson,  Jr.,  of  Boston,  published 
an  account  of  the  intestinal  lesions  observed  by  him  in  cases  during  the 
years  1830,  1833,  and  1834;  and  again  in  a  Report  of  Typhoid  Fever, 
communicated  to  the  Massachusetts  Medical  Society  in  June,  1838,  says 
that  the  alterations  of  Peyer's  patches  had  been  noticed  at  the  Massa- 
chusetts General  Hospital  previous  to  1833  in  cases  which  were  carefully 
examined.  In  1840,  Shattuck  of  Boston  published  in  the  American 
Medical  Examiner  an  account  of  some  cases  of  typhoid  and  typhus  fever 
which  he  had  observed  at  the  London  Fever  Hospital  during  the  previous 
year.  In  this  paper,  which  had  been  already  communicated  to  the  Medi- 
cal Society  of  Observation  of  Paris,  and  which  had  unquestionably  exerted 
a  marked  influence  upon  medical  thought  there,  he  pointed  out  very  fully 
the  distinguishing  characteristics  of  each  disease.  In  1842,  Dr.  Bartlett 
issued  the  first  edition  of  his  work  on  The  History,  Diagnosis,  and 
Treatment  of  the  Fevers  of  the  United  States,  which  contains  very  full 
descriptions  of  both  of  these  diseases,  and  of  the  means  by  which  they  may 
be  distinguished  from  each  other.  Since  then  there  have  been  numerous 
additions  in  this  country  to  the  literature  of  typhoid  fever,  among  the 
most  important  of  which  may  be  mentioned  the  chapter  on  the  disease  in 
the  respective  works  on  The  Practice  of  Medicine  by  Professors  Wood  and 
Flint,  the  article  on  typho-malarial  fever  in  the  Transactions  of  the  Inter- 
national Medical  Congress  of  1876,  and  the  article  in  the  work  on  The 
Continued  Fevers,  by  James  C.  Wilson.  Abroad,  the  medical  press 
has  been  no  less  active.  Within  the  last  twenty  or  thirty  years  Jaccoud 
and  Trousseau  in  France,  Liebermeister  and  Hirsch  in  Germany,  and 
Tweedie  and  Cayley  in  England,  have  all  made  important  additions  to 
our  knowledge  of  the  disease.  To  the  late  Dr.  Murchison  a  of  London, 
however,  is  justly  due  the  honor  of  having  produced  the  best  treatise  on 
typhoid  fever  in  any  language,  and  the  writer  cheerfully  acknowledges 
that  he  has  drawn  largely  upon  it  for  the  material  of  the  present  article. 

GEOGRAPHICAL  DISTRIBUTION. — Although  it  will  be  generally  admit- 
ted that  the  conditions  of  civilization  favor  the  occurrence  and  extension  of 
typhoid  fever,  yet  there  is  abundant  evidence  that  they  are  not  absolutely 
necessary  to  its  production,  as  there  is  no  country,  whether  civilized  or 
not,  of  the  diseases  of  which  we  have  any  knowledge,  in  which  it  has 
not  occasionally  made  its  appearance,  being  met  with  in  every  variety  of 
climate.  It  is  endemic  in  North  America,  attacking  alike  the  inhabitants 

1  The  honor  of  having  first  clearly  pointed  out  the  distinguishing  characters  of  typhoid 
and  typhus  fevers  has  been  recently  claimed  for  Sir  William  Jenner,  but,  as  we  have  seen 
above,  his  papers  on  this  subject  were  not  published  until  thirteen  years  after  that  of 
Gerhard.  2  A  Treatise  on  Continued  Fevers,  London,  1873. 

VOL.  I.— 16 


242  TYPHOID  FEVER. 

of  Greenland  and  British  America  and  those  of  Mexico.  In  our  own 
country  it  prevails  from  time  to  time  in  every  State  of  the  Union,  com- 
mitting its  ravages  as  well  among  the  rocks  and  hills  of  New  England 
as  in  the  more  fertile  valleys  of  the  West  and  South.  In  many  of  the 
newly-settled  portions  of  our  country  malarial  fevers  are,  as  is  well 
known,  exceedingly  rife.  In  proportion,  however,  as  towns  and  cities 
spring  up,  and  as  the  land  is  properly  drained,  they  diminish  in  frequency, 
and  are  gradually  replaced,  to  a  certain  extent  at  least,  by  typhoid  fever ; 
but  the  influences  which  produced  them  retain  for  a  long  time  enough  of 
power  to  stamp  their  impress  upon  all  other  diseases.  In  large  portions 
of  the  AVestern  and  Southern  States  typhoid  fever  is  therefore  rarely 
uncomplicated,  and  is  much  more  likely  to  assume  the  form  which  will  be 
fully  described  later  as  typho-malarial  fever. 

Typhoid  fever  has  also  occurred  frequently  in  Central  America  and  the 
West  India  Islands.  It  has  prevailed  from  time  to  time  in  the  states  of 
South  America,  and  occasionally  assumed  in  some  of  them — as,  for 
instance,  Brazil  and  Chili — an  epidemic  form. 

Typhoid  fever  is  endemic  in  the  British  Isles,  but,  according  to  Mur- 
chison,  is  most  common  in  England,  more  common  in  Ireland  than  in 
Scotland,  and  in  Scotland  more  common  on  the  west  than  on  the  east 
coast.  It  also  exists  as  an  endemic  disease  in  every  country  of  the  con- 
tinent of  Europe,  from  Sweden  and  Norway  on  the  north  to  Turkey  on 
the  south,  and  in  some  of  them — as,  for  instance,  France  and  Germany — 
would  seem  to  be  of  much  more  frequent  occurrence  than  in  this  country, 
or  even  in  England.  Medical  literature  is  also  not  deficient  in  evidence 
that  it  has  prevailed  at  various  times  in  all  the  different  countries  of  Asia 
and  Africa  and  in  Australia.  Morehead  asserted  in  the  first  edition  of 
his  Clinical  Researches  on  Diseases  in  India  that  India  enjoyed  an  abso- 
lute immunity  from  typhoid  fever,  but  in  the  second  edition  of  this  work 
he  acknowledged  that  a  larger  experience  had  led  him  to  change  his  opinion 
on  this  point.  Moreover,  the  writings  of  Annesley,  Twining,  and  other 
Indian  authors  furnish  convincing  proof  that  the  disease  is  by  no  means 
unknown  in  that  country.  Indeed,  even  the  relative  immunity  from  it 
which  it  has  been  claimed  that  tropical  and  subtropical  countries  possess 
has  been  found,  upon  a  fuller  study  of  the  diseases  of  these  countries,  not 
to  exist  to  anything  like  the  degree  that  was  formerly  supposed. 

The  occasional  occurrence  of  typhoid  fever  in  islands  separated  from 
the  main  land  by  a  considerable  distance — as,  for  instance,  the  island  of 
Norfolk,1  which  is  situated  in  the  Pacific  Ocean  four  hundred  miles  west 
of  South  America — is  an  interesting  fact,  and  one  which,  with  the  present 
limits  to  our  knowledge  on  the  subject,  it  is  impossible  to  explain  satis- 
factorily. 

The  ETIOLOGY  of  typhoid  fever  may  be  considered  under  the  heads  of — 
1,  predisposing,  2,  exciting  causes. 

1.  PREDISPOSING  CAUSES. — All  observers  agree  that  the  predisposition  to 
typhoid  fever  is  greater  in  childhood  and  early  adult  life  than  after  thirty 
years  of  age.  Thus,  Murchisou  states  that  during  twenty-three  years 
nearly  one-half  the  admissions  to  the  London  Fever  Hospital  were  of 
patients  between  fifteen  and  twenty-five  years  of  age,  and  that  in  more 
than  a  fourth,  the  patients  were  under  fifteen  years.  On  the  other  hand, 
1  Metcalfe,  Brit.  Med  Jour.,  Nov.,  1830. 


PREDISPOSING  CAUSES.  243 

in  less  than  a  seventh  were  they  over  thirty,  and  in  only  one  in  seventy-one 
did  their  ages  exceed  fifty.  Taking  these  facts  in  connection  with  the  cir- 
cumstance that  the  entire  population  of  England  and  Wales  in  1861  was 
12,481,323  persons  under  thirty  years  of  age  and  7,584,901  above  thirty, 
it  follows,  he  says,  that  persons  under  thirty  are  more  than  four  times  as 
liable  to  enteric  fever  as  persons  over  thirty.  Jackson  found  that  the  average 
age  of  the  patients  in  two  hundred  and  ninety-one  cases  observed  at  the 
Massachusetts  General  Hospital  was  a  little  over  twenty-two  years,  the 
average  age  in  the  fatal  cases  being  somewhat  greater  than  in  thosfe  in 
which  recovery  took  place.  Liebermeister,  from  an  analysis  of  a  large 
number  of  cases  treated  at  the  hospital  in  Basle,  has  arrived  at  the  same 
conclusion.  No  age,  however,  enjoys  a  complete  immunity  from  the  dis- 
ease. Manzini l  has  recorded  a  case  in  which  lesions  of  Peyer's  patches 
similar  to  those  of  typhoid  fever  were  found  in  a  seventh-month  foetus 
which  died  within  half  an  hour  after  its  birth.  Cases  are  also  on  record  in 
which  death  has  occurred  from  this  disease  in  the  first  few  weeks  of  life.  I 
have  myself  observed  several  cases  in  young  children  at  the  Children's 
Hospital  in  Philadelphia.  The  probability  is,  that  it  is  of  even  more 
frequent  occurrence  in  children  than  is  generally  supposed,  as  this  class 
of  patients  is  not  often  admitted  into  general  hospitals,  and  as  from  the 
absence  of  some  of  its  characteristic  symptoms  when  it  occurs  in  the 
very  young  the  nature  of  the  disease  is  often  unrecognized. 

On  the  other  hand,  the  disease  occurs  not  infrequently  in  advanced  life  : 
83  cases  out  of  5911  were  observed  at  the  London  Fever  Hospital  in 
persons  over  fifty,  27  in  persons  over  sixty,  and  in  2  the  age  was  seventy- 
five.  In  a  case  recorded  by  D'Arcy  the  age  of  the  patient  was  eighty- 
six,  and  in  one  reported  by  Hamernyk  it  was  ninety.2  Bartlett  long  ago 
contended  that  the  disease  was  not  so  rare  as  was  generally  supposed 
among  people  over  forty  years  of  age  ;  and  there  is  really  no  good  reason 
to  believe  that  the  susceptibility  to  the  causes  of  the  disease  in  an  unpro- 
tected person  diminishes  with  advancing  years,  the  immunity  from  this 
disease  which  elderly  people  appear  to  enjoy  being  probably  due  to  the 
fact  that,  as  the  disease  is  not  uncommon  in  early  life,  they  are  in  many 
instances  protected  by  having  already  passed  through  an  attack. 

The  mean  age  of  the  male  patients  treated  at  the  London  Fever 
Hospital  was  slightly  in  excess  of  that  of  the  female,  but  in  the  cases 
analyzed  by  Jackson  the  reverse  of  this  was  observed. 

The  statistics  of  all  general  hospitals,  with  very  few  exceptions,  show 
a  greater  or  less  preponderance  of  males  over  females  among  the  typhoid 
fever  patients  treated  in  them.  According  to  Murchison,  of  5988  cases 
admitted  into  the  London  Fever  Hospital  during  twenty-three  years, 
3001  were  males  and  2987  were  females.  Of  891  cases  admitted  into 
the  Glasgow  Infirmary  during  twelve  years,  527  were  males  and  364 
females.  Liebermeister  states  that  1297  male  typhoid  patients  and  751 
female  were  treated  in  the  hospital  at  Basle  from  1865  to  1870.  Occa- 
sionally, the  difference  is  even  greater  than  is  indicated  by  these  figures. 
Thus,  of  138  cases  observed  by  Louis,  all  but  32  occurred  in  males. 
When,  however,  we  consider  that  the  proportion  of  men  who  apply  for 
admission  to  hospitals  when  sick  is  much  larger  than  that  of  women, 
we  should  hesitate  before  accepting  these  statistics  as  proof  that  the  former 
1  Quoted  by  Murchison.  v  Quoted  by  Murchison. 


241  TYPHOID  FEVER. 

are  more  liable  to  be  attacked  by  typhoid  fever  than  the  latter.  Indeed, 
the  opinion  which  Murchisou  expresses  is  generally  accepted  as  correct  by 
authors,  that  neither  sex  is  more  likely  than  the  other  to  contract  the  dis- 
ease. Liebermeister  asserts  that  pregnant  and  puerperal  women  and 
those  who  are  nursing  infants  enjoy  a  relative  immunity.  On  the  other 
hand,  Nathan  Smith  says  that  while  the  sexes  are  equally  liable  to  it, 
more  women  are  cut  off  by  it  than  men,  in  consequence  of  its  appearance 
during  pregnancy  or  soon  after  parturition. 

It  was  long  ago  pointed  out  by  certain  French  observers  that  new- 
comers are  much  more  liable  to  be  attacked  by  typhoid  fever  than  persons 
who  have  lived  for  some  time  in  an  infected  locality.  In  129  cases 
examined  with  reference  to  this  point  by  Louis,  the  patients  in  73  had  not 
resided  in  Paris  more  than  ten  months,  and  in  102  not  more  than  twenty 
months.  Bartlett  noticed  that  during  an  epidemic  in  Lowell  which  he 
had  the  opportunity  of  observing  the  disease  attacked  the  recent  residents 
in  much  larger  proportion  than  the  old.  Liebermeister  also  calls  atten- 
tion to  this  peculiarity  of  the  disease.  Murehison's  experience  in  refer- 
ence to  this  point  has  been  somewhat  similar,  for  he  found  upon  examina- 
tion of  the  records  of  the  London  Fever  Hospital  that  21.84  per  cent, 
of  the  patients  admitted  there  for  typhoid  fever  had  been  residents  of 
London  for  less  than  two  years.  Almost  all  of  these  patients  came,  he 
says,  from  the  provinces  of  England,  and  were  in  good  health  and  com- 
fortable circumstances  at  the  date  of  their  arrival  in  London  and  for  some 
time  after.  Moreover,  a  large  proportion  of  them  were  first  attacked 
within  a  few  weeks  after  changing  their  residence  from  one  part  of  London 
to  another.  He  also  refers  to  instances  in  which  successive  visitors  at 
the  same  house  at  intervals  of  months,  or  even  years,  have  been  seized 
shortly  after  their  arrival  with  typhoid  fever  or  with  diarrhoea,  from 
which  the  ordinary  occupants  were  exempt.  These  facts  indicate  with 
sufficient  clearness  that  habitual  exposure  to  the  causes  of  the  disease 
confers,  to  a  certain  extent  at  least,  an  immunity  from  their  effects,  just 
as  it  does  in  the  various  forms  of  disease  arising  from  malaria.  It  is  not 
unlikely,  as  has  been  suggested  by  Wilson,1  that  one  of  the  causes  of 
the  frequency  of  typhoid  fever  in  the  early  autumn  in  our  American 
cities  among  well-to-do  people  is  to  be  formed  in  the  circumstance  that 
during  an  absence  of  two  months  or  more  in  the  mountains  or  by  the  sea 
they  have  to  some  extent  lost  the  immunity  acquired  by  habitual  exposure 
to  sewer  emanations,  and  return  to  the  atmosphere  of  the  city  unprotected. 

There  is  no  evidence  that  any  particular  occupation  acts  as  a  predis- 
posing cause  of  typhoid  fever.  Among  the  621  patients  treated  at  the 
Pennsylvania  Hospital  during  the  last  ten  years,  were  representatives  of 
every  branch  of  industry,  ami  the  same  fact  has  been  observed  at  every 
general  hospital,  not  only  in  this  country,  but  abroad.  There  is  also  no 
reason  to  believe  that  the  station  in  life  of  itself  exerts  much  influence  in 
predisposing  to  the  disease.  The  rich  suffer  equally  with  the  poor.  It 
would  appear,  indeed,  that  since  the  recent  general  introduction  of  ill- 
ventilated  water-closets  and  stationary  washstands  into  the  houses  of  the 

1  The  occurrence  of  typhoid  fever  in  the  early  fall  among  persons  who  have  spent  the 
summer  out  of  town  is,  however,  susceptible  of  another  explanation.  In  many  instances 
they  have  returned  to  houses  which  have  been  not  only  unoccupied,  but  closed,  during 
several  months,  and  which,  in  consequence  of  the  more  or  less  complete  evaporation  of 
the  water  in  the  traps  of  the  drain-pipes,  have  been  thoroughly  permeated  by  sewer  gas. 


PREDISPOSING   CAUSES.  245 

better  classes  the  liability  of  the  former  to  suffer  from  the  disease  is 
greater  than  that  of  the  latter. 

Persons  recovering  from  an  illness  or  in  an  infirm  condition  of  health 
do  not  appear  to  be  more  liable  than  others  to  be  attacked  by  typhoid  fever. 
Among  the  many  patients  who  have  fallen  under  my  care  only  a  very 
few  were  in  ill-health  at  the  time  of  their  seizure.  The  same  fact  has 
been  noticed  by  Murchison  and  other  observers.  Indeed,  Liebermeister 
goes  so  far  as  to  say  that  typhoid  fever  attacks  by  preference  strong  a  ad 
healthy  persons,  while  it  avoids  those  suffering  with  chronic  ailments. 
That  this  latter  class  of  patients  enjoys  no  immunity  from  the  disease 
when  exposed  to  its  causes  is  shown  by  a  fact  which  he  himself  records. 
During  his  service  at  the  hospital  at  Basle  from  1865  to  1871  several  of 
the  patients  in  the  medical  and  surgical  wards  were  attacked  by  typhoid 
fever,  the  cases  being  especially  numerous  in  two  rooms  which  were 
situated  one  directly  over  the  other.  Upon  investigation  it  was  found 
that  a  wooden  pipe  which  extended  from  the  sewer  to  the  roof  ran  by 
both  of  these  rooms.  The  sewer  at  the  point  where  this  pipe  ran  into 
it  was  of  faulty  construction,  and  was  turned  at  a  right  angle,  so  that 
the  refuse  matter  collected  there.  Since  this  source  of  infection  was 
made  known  repeated  cleansings,  washings,  and  disinfections  have  been  fol- 
lowed by  satisfactory  improvement,  and  Liebermeister  believes  that  if  the 
sewer  were  entirely  altered  the  infection  would  disappear. 

It  would  seem  only  natural  that  intemperance,  by  diminishing  the 
powers  of  resistance  in  the  individual,  would  increase  his  liability  to  con- 
tract typhoid  fever,  but  there  is  no  proof  that  it  does  so.  Few  of  the 
patients  who  have  come  under  my  care  were  intemperate,  and  still  fewer 
were  broken  down  by  this  cause.  There  is  also  no  evidence  that  grief, 
fear,  or  any  other  depressing  emotion  is  a  predisposing  cause  of  the  dis- 
ease, and  the  same  may  be  said  of  bodily  fatigue  and  overcrowding.  On 
the  other  hand,  much  importance  has  been  attached  by  writers  to  idiosyn- 
crasy as  a  predisposing  cause  of  typhoid  fever.  What  the  peculiarities 
of  constitution  are  which  increase  the  liability  to  the  disease  are  not  def- 
initely known,  but  there  can  be  no  question  that  it  occurs  much  more  fre- 
quently, and  is  much  more  fatal,  in  some  families  than  in  others. 

Typhoid  fever  occurs  with  the  greatest  frequency  in  this  country,  as 
it  does  with  very  few  exceptions  elsewhere,  during  the  latter  half  of 
summer  and  the  early  part  of  autumn.  Indeed,  its  greater  prevalence 
at  this  season  than  at  other  times  has  given  to  it  the  name  of 
"  autumnal "  and  "  fall  fever,"  by  which  it  is  popularly  known  in  many 
sec  ions  of  this  country  as  well  as  of  England.  On  the  other  hand, 
the  disease  is  usually  at  its  minimum  in  May  and  June.  The  number  of 
cases,  however,  does  not  usually  immediately  diminish  upon  the  onset  of 
cold  weather.  On  the  contrary,  E.  D.  Cleemann,1  from  a  comparison  of  the 
mortality  returns  of  Philadelphia  for  a  period  of  ten  years,  observed  that 
after  diminishing  in  November  they  not  infrequently  underwent  a  marked 
increase  in  December.  Of  621  cases  treated  at  the  Pennsylvania  Hos- 
pital during  the  last  ten  years,  89  were  admitted  during  spring,  259 
during  summer,  182  during  autumn,  and  91  during  winter.  Of  5988 
cases  treated  at  the  London  Fever  Hospital,2  759  were  admitted  in  the 

1  Transactions  of  the  College  of  Physicians  of  Philadelphia,  3d  S.  vol.  iii. 
1  Murchison. 


246  TYPHOID  FEVER. 

spring,  1490  in  summer,  2461  in  autumn,  and  1278  in  winter.  Of  the 
whole  number,  27.7  per  cent,  were  admitted  in  the  two  mouths  of  October 
and  November,  and  in  April  and  May  only  7.3  per  cent.  Hirsch1  has 
published  statistics  which  do  not  differ  materially  from  these.  He  also 
mentions  the  interesting  fact  that  in  Rio  Janeiro  the  maximum  of  the 
disease  occurs  in  the  months  from  March  to  June,  or,  in  other  words,  in 
the  season  which  in  that  latitude  corresponds  to  our  autumn.  There  are, 
however,  some  exceptions  to  the  general  rule  of  the  greater  prevalence  of 
the  disease  during  the  autumn.  Bartlett,  who  was  aware  of  its  greater 
frequency  at  that  time,  refers  to  an  extensive  and  fatal  epidemic  which 
occurred  in  the  city  of  Lowell  in  Massachusetts  during  the  winter  and 
early  spring ;  and  similar  visitations  have  been  observed  in  other  places. 

Most  authors  agree  with  the  statement  made  by  Murchison,  that  typhoid 
fever  is  unusually  prevalent  after  summers  remarkable  for  their  dryness 
and  high  temperature,  and  that  it  is  unusually  rare  in  summers  and 
autumns  which  are  wet  and  cold.  Certainly,  the  severest  epidemic  of  the 
disease  which  has  been  observed  in  Philadelphia  in  several  years  occurred 
in  the  year  1876,  during  and  after  a  summer  of  exceptionally  high  tem- 
perature, and  one  characterized  by  a  decidedly  diminished  rainfall.  Still, 
there  can  be  no  question  that  the  increased  prevalence  of  the  disease  at 
this  time  was  due,  in  part  at  least,  to  the  crowded  condition  of  the  city 
consequent  upon  the  Centennial  Exhibition.  In  1872,  although  the  mean 
of  the  summer  temperature  was  slightly  higher  than  that  of  1876,  the 
disease  did  not  prevail  in  an  epidemic  form.  This  may  be  explained  by 
the  fact  that  the  rainfall  of  the  summer  months  of  this  year  was  decid- 
edly greater  than  the  average.  Hirsch,  however,  attaches  much  less 
importance  to  temperature  as  a  factor  in  the  production  of  typhoid  fever 
than  most  other  authors.  He  says  that  he  has  found,  from  a  comparison 
of  a  large  number  of  epidemics,  that  the  disease  occurs  almost  as  often 
in  cool  as  in  hot  summers,  in  cold  as  in  warm  autumns,  and  in  mild  as 
in  severe  winters.  Murchison,  moreover,  admits  that  mere  dryness  of 
the  atmosphere  is  net  conducive  to  an  increase  of  typhoid  fever.  On  the 
contrary,  he  says,  warm,  damp  weather,  when  drains  are  most  offensive,  is 
often  followed  by  an  outbreak  of  the  disease. 

The  relation  which  temperature  and  moisture  bear  to  the  causation  of 
typhoid  fever  is  therefore  not  definitely  ascertained.  It  is  certain,  how- 
ever, that  the  largest  number  of  cases  does  not  occur  at  the  period  of  the 
greatest  heat,  but  is  usually  not  observed  until  from  six  weeks  to  two 
months  afterward,  and  the  minimum  is  not  reached  until  about  the  same 
length  of  time  after  that  of  the  most  intense  cold.  This  difference  in 
time  Murchison  explains  by  the  hypothesis  that  the  cause  of  the  dis- 
ease is  exaggerated  or  only  called  into  action  by  the  protracted  heat  of 
summer  and  autumn,  and  that  it  requires  the  protracted  cold  of  winter 
and  spring  to  impair  its  activity  or  to  destroy  it.  On  the  other  hand, 
Liebermeister,  who  belives  that  the  breeding-places  of  typhoid  fever  lie 
deep  in  the  earth,  holds  that  the  time  is  consumed  in  the  penetration  of 
the  changes  of  temperature  to  the  place  where  the  typhoid  poison  is 
elaborated,  in  the  development  of  the  poison  without  the  human  body, 
and  in  the  period  of  incubation.  In  some  places  the  maximum  of  the 
disease  is  observed  earlier  in  the  year  than  in  others.  In  Berlin,  for 

1  Handbuch  Jer  Historisch-Geographischen  Pathologic,  Stuttgart,  1881. 


PREDISPOSING  CAUSES.  247 

instance,  the  largest  number  of  fatal  cases  occurs  in  October,  while  in 
Munich  it  does  not  occur  until  February.  This  depends,  he  thinks,  upon 
the  difference  in  the  distance  beneath  the  earth's  surface  of  these  breeding- 
places  in  different  localities,  and  the  deeper  they  are  the  longer,  he  says, 
will  it  be  before  they  are  affected  by  the  heat  of  summer  or  the  cold  of 
winter,  since  the  changes  of  the  temperature  of  the  air  are  followed  by 
corresponding  changes  in  the  temperature  of  the  earth  more  and  more 
slowly  the  deeper  we  go  beneath  the  surface. 

Buhl  and  Pettenkofer  have,  as  the  result  of  a  series  of  observations 
carried  on  in  Munich  over  a  number  of  years,  reached  the  conclusion  that 
an  intimate  relation  exists  between  the  variations  in  the  degree  of  prev- 
alence of  typhoid  fever  and  the  rise  and  fall  of  water  in  the  soil. 
When  the  springs  were  low  they  found  that  there  was  a  marked  increase 
in  the  number  of  cases ;  when,  on  the  other  hand,  they  were  high,  there 
was  just  as  decided  a  diminution.  Out  of  this  fact  they  have  evolved  the 
theory  that  the  cause  of  typhoid  fever  lies  deep  in  the  soil,  and  has  the 
power  of  multiplying  itself  there,  and  that  this  property  is  very  much 
increased  when  the  water-level  sinks,  and  the  upper  layers  of  the  earth 
are  consequently  exposed  to  the  air.  It  is,  on  the  contrary,  diminished 
when  the  water-level  rises  and  the  earth  is  again  saturated  with  moisture. 
It  is  unquestionably  true,  as  has  already  been  stated,  that  it  is  principally 
after  hot  and  dry  weather,  when  the  springs  are  of-course  low,  that 
typhoid  fever  is  most  prevalent,  and  that  it  very  frequently  subsides  after 
the  occurrence  of  very  heavy  rains ;  but  it  is  not  necessary  to  adopt  the 
theory  of  Buhl  and  Pettenkofer  to  explain  these  facts.  It  seems  quite  as 
probable  that  the  increased  prevalence  of  the  disease  after  dry  weather  is 
due,  as  suggested  by  Buchanan  and  Liebermeister,  to  the  greater  amount 
of  solid  matter  which  is  then  suspended  in  the  water  of  the  springs.  A 
larger  proportion  of  the  germs  of  the  disease,  if  there  should  be  any  present 
in  the  soil,  will  therefore  be  contained  in  any  given  quantity  of  the  drink- 
ing-water. The  theory  fails  to  account,  as  pointed  out  by  Murchison, 
for  the  connection  which  is  frequently  observed  between  defective  house- 
drainage  and  outbreaks  of  typhoid  fever,  occurring  irrespectively  of  any 
variations  in  the  subsoil  water.  And,  moreover,  outbreaks  of  the  disease 
have  occurred  under  precisely  opposite  circumstances,  as  the  outbreak  at 
Terling  in  1867,  recorded  by  Thorne,1  which  was  coincident  with  a  rise 
in  the  subsoil  water  after  drought. 

It  is  believed  in  many  parts  of  our  country  that  there  is  an  antagonism 
between  typhoid  fever  and  the  various  forms  of  malarial  fever,  and  it  is 
unquestionably  true  that  in  many  districts  in  which  the  latter  were  for- 
merly prevalent  they  have  ceased  to  be  frequent,  and  have  been  replaced 
apparently  by  the  former.  In  the  cultivation  of  the  soil  the  causes  of 
malarial  fever  disappear,  or  at  least  become  less  potent.  On  the  other 
hand,  the  increase  of  population  and  the  neglect  of  all  sanitary  laws  in 
the  building  of  towns,  and  the  construction  of  sewers  with  their  house 
connections,  seem  to  favor  the  occurrence  of  typhoid  fever.  But  there  is 
no  real  antagonism  between  the  diseases.  During  the  recent  Civil  War 
typhoid  fever  was  not  infrequently  developed  in  soldiers  suffering  from 
malarial  disease.  Indeed,  so  frequent  was  it  to  have  the  manifestations 
of  the  two  diseases  in  the  same  individual  that  many  observers  at  that 

1  Quoted  by  Murchison. 


248  TYPHOID  FEVER. 

time  supposed  they  had  a  new  disease  to  deal  with,  to  which  they  gave 
the  name  of  tvpho-malarial  fever. 

2.  EXCITING  CAUSES. — Much  diversity  of  opinion  has  existed  in  times 
past  and  to  a  certain  extent  continues  to  exist,  in  regard  to  the  contagious- 
ness of  typhoid  fever.  In  the  early  part  of  this  century  there  was  quite 
a  number  of  good  observers,  including  Nathan  Smith  in  this  country, 
and  Bretonneau  and  Gendron  of  Chateau  du  Loir  in  France,  who  held  the 
opinion  it  was  an  eminently  contagious  disease.  Indeed,  Smith  went 
so  far  as  to  say  that  its  contagiousness  was  as  fully  demonstrated  as  that 
of  measles,  small-pox,  or  any  other  disease  universally  admitted  to  be 
contagious.  This  was  also  the  opinion  of  \Villiam  Budd,  who  main- 
tained that  the  contagious  nature  of  typhoid  fever  was  the  master  truth 
in  its  history.  The  late  Sir  Thomas  AVatson  was  also  a  warm  supporter 
of  the  same  view.  At  the  present  time,  however,  the  large  majority  of 
physicians,  whose  opportunities  for  observation  give  weight  to  their 
opinions,  do  not  regard  the  disease  as  contagious  in  the  strict  sense  of  the 
word.  During  the  past  twenty-four  years  I  have  been  almost  uninter- 
ruptedly connected  with  large  general  hospitals,  and  during  that  time 
have  had  a  large  number  of  cases  of  typhoid  fever  under  my  care,  and  a 
still  larger  number  more  or  less  under  my  observation.  During  all  this 
time  I  have  never  known  but  one  case  to  originate  within  a  hospital,  and 
that  occurred  in  a  servant  whose  duties  did  not  bring  her  in  immediate 
contact  with  the  sick.  Murchison's  experience  with  a  much  larger  num- 
ber of  cases  has  been  very  similar.  In  twenty-three  years,  in  Avhich 
5988  cases  were  treated  in  the  London  Fever  Hospital,  only  17  residents 
contracted  the  disease,  and  most  of  these  had  no  personal  contact  with  the 
sick.  Liebermeister  asserts  that  he  has  never  known  a  case  to  originate 
in  a  hospital  from  direct  contagion.  AVhen  such  cases  appeared  to  have 
occurred,  they  could  generally  be  traced,  he  says,  to  some  defective  sani- 
tary condition  of  the  hospital. 

There  are,  nevertheless,  many  facts  on  record  which,  unless  duly 
weighed,  appear  to  lend  a  good  deal  of  supjjort  to  the  theory  of  the  con- 
tagiousness of  typhoid  fever.  Among  the  most  important  of  these  are 
(1)  the  occurrence  in  rapid  succession  of  several  cases  in  the  same  house, 
and  (2)  the  limited  epidemics  which  occasionally  follow  the  arrival  of  an 
infected  person  into  a  previously  healthy  locality.  These  facts  are.  how- 
ever, susceptible  of  an  entirely  different  explanation. 

1.  In  those  instances  in  which  several  cases  of  the  disease  have  occurred 
in  the  same  house,  it  not  infrequently  happens  that  some  defect  in  its 
sanitary  conditions  is  detected,  or  that  the  drinking-water  is  found  to  be 
impure.     The  same  cause  which  produced  the  first  case  may,  therefore, 
also  have  produced  those  which  succeeded  it.     Indeed,  the  interval  between 
the  cases  is  sometimes  so  short  that  for  this  reason  alone,  if  there  were  no 
other,  they  could  scarcely  be  attributed  to  contagion.     It  not  infrequently 
happens  that  the  seizure  of  one  member  of  a  large  family  is  followed  on 
the  next  day  by  that  of  another,  and  on  the  third  or  fourth  by  that  of 
still  another.     Now,  while  it  is  undoubtedly  true  that  the  period  of  incu- 
bation has  appeared  in  some  cases  to  be  very  short,  we  know  that  under 
ordinary  circumstances  it  is  usually  about  two  weeks. 

2.  The  explanation  of  the  second  fact  is  not  more  difficult,  but  in  order 
that  it  may  be  clear  to  the  reader  it  will  be  well  to  give  in  detail  a  few 


EXCITING  CAUSES.  249 

of  the  instances  on  record  in  which  the  arrival  of  an  individual  sick  with 
typhoid  fever  in  a  previously  healthy  locality  has  been  followed  by  an 
outbreak  of  the  disease.  Nathan  Smith  refers  to  two  cases  of  this 
character.  In  both  of  these  the  disease  appeared  to  be  communicated  to 
several  individuals  by  patients  who  had  contracted  the  disease  elsewhere. 
So  little  is  said  in  the  reports  of  these  cases  of  the  water-supply  of  the 
localities  in  which  they  occurred,  or  of  the  manner  of  disposing  of  the 
discharges  of  the  patients,  that  they  would  scarcely  now  be  used  as  argu- 
ments in  favor  of  the  contagiousness  of  the  disease.  The  report  of  a 
local  epidemic  by  Austin  Flint,  Sr.,  is  more  satisfactory  in  this  respect, 
and  is  as  follows :  A  stranger  was  detained  in  a  small  village  near  Buifalo 
by  an  illness  which  proved  fatal  in  the  course  of  a  few  days,  and  which 
was  recognized  as  typhoid  fever  by  his  attending  physicians.  Up  to  this 
time,  it  is  stated,  typhoid  fever  had  never  been  known  in  the  neighbor- 
hood. In  the  course  of  a  month  more  than  one-half  of  the  population, 
numbering  forty-three,  was  attacked  by  the  disease,  and  ten  had  died. 
The  family  of  the  tavern-keeper  at  whose  house  the  stranger  lodged  was 
the  first  to  suffer,  and  of  the  families  immediately  surrounding  the  tavern 
but  one  wholly  escaped,  that  of  a  man  named  Stearns.  Upon  investiga- 
tion, it  was  ascertained  that  this  family  alone,  of  all  these  families,  did 
not  use  the  well  belonging  to  the  tavern,  but  had  its  own  water-supply. 
The  occurrence  of  the  disease  naturally  produced  great  excitement,  and 
Stearns,  between  whom  and  the  tavern-keeper  a  quarrel  existed,  was  sus- 
pected of  having  poisoned  the  well ;  but  an  examination  of  the  water 
showed  this  suspicion  to  be  unfounded.  There  can,  however,  be  little 
doubt  that  the  water  of  the  well,  which  was  in  all  probability  contam- 
inated by  the  discharges  of  the  stranger,  was  the  means  of  propagating 
the  disease ;  for  although  it  is  said  that  the  family  of  Stearns  was  cut  off 
by  the  quarrel  from  all  intercourse  with  that  of  the  tavern-keeper — a  fact 
upon  which  some  stress  is  laid  by  Flint — it  does  not  appear  that  a 
similar  isolation  existed  as  regards  the  other  families  affected.1 

The  manner  in  which  the  arrival  of  a  sick  person  may  cause  the  dis- 
semination of  the  disease  in  a  previously  healthy  community  is  even  better 
shown  by  the  following  histories  of  local  outbreaks : 2 

"  The  water-supply  pipes  of  the  town  of  Over  Darwen  were  leaky,  and 
the  soil  through  which  they  passed  was  soaked  at  one  spot  by  the  sewage 
of  a  particular  house.  No  harm  resulted  till  a  young  lady  suffering  from 
typhoid  fever  was  brought  to  this  house  from  a  distant  place.  Within 
three  weeks  of  her  arrival  the  disease  broke  out  and  1500  persons  were 
attacked.  At  Nunney  a  number  of  houses  received  their  water-supply 
from  a  foul  brook  contaminated  by  the  leakage  of  a  cesspool  of  one  of 
the  houses,  but  no  fever  showed  itself  till  a  man  ill  with  typhoid  came 
from  a  distance  to  this  house.  In  about  fourteen  days  an  outbreak  of 
fever  took  place  in  all  the  houses." 

There  are  many  other  observations  which  seem  to  render  it  certain  that 
the  alvine  dejections  are  a  most  important  medium  by  which  typhoid 
fever  is  communicated  to  others;  and  yet  there  is  no  evidence  that  they 
possess  this  power  in  a  fresh  condition.  They  have  been  repeatedly  exam- 
ined, and  even  handled,  with  impunity,  and,  as  has  already  been  stated,  it 

1  A  Treatise  on  the  Principles  and  Pr/ictice  of  Medicine,  by  Austin  Flint,  M.  D.,  Phila- 
delphia, 1868.  *  Wm.  Cayley,  M.  D.,  Brit.  tied.  Jour.,  March  15,  1880. 


250  TYPHOID  FEVER. 

is  rare  for  the  disease  to  be  imparted  to  the  immediate  attendants  upon 
the  sick,  or  in  a  well-ventilated  hospital  to  the  other  patients  in  the  same 
ward,  provided  that  the  discharges  are  disinfected  and  removed  imme- 
diately after  being  passed,  and  the  bed-linen  and  clothes  of  the  patient 
changed  whenever  they  are  soiled.  The  feces  must  therefore  undergo 
some  changes  before  they  become  possessed  of  virulent  properties.  This 
appears  to  be  shown  conclusively  by  the  following  facts  :  (1)  laundresses 
who  wash  the  soiled  clothes  of  typhoid  fever  patients  not  infrequently 
contract  the  disease ;  (2)  the  occupants  of  houses  connected  by  ill-trapped 
drains  with  sewers  into  which  the  discharges  of  such  patients  have  found 
their  way  often  suffer  severely  from  the  disease ;  and  (3)  the  use  of  water 
polluted  by  such  discharges  is,  as  has  already  been  shown,  almost  cer- 
tain to  induce  the  disease  in  persons  not  protected  by  a  previous  attack. 

The  following  histories  of  outbreaks  of  typhoid  fever  will  show 
clearly  how  the  dejections  of  patients  may  be  the  means  of  propagating 
the  disease  to  others  : 

ILLUSTRATIVE  CASES. — Lausen1  is  a  village  lying  on  the  railway  between 
Basle  and  Olten  shortly  before  coming  to  the  great  Hauenstein  Tunnel.  It 
is  situated  in  the  Jura,  in  the  valley  of  the  Ergolz,  and  consists  of  103 
houses  with  819  inhabitants.  It  was  remarkably  healthy,  and  resorted  to 
on  that  account  as  a  place  of  summer  residence.  With  the  exception  of  six 
houses  it  is  supplied  with  water  by  a  spring  with  two  heads  which  rises 
above  the  village  at  the  southern  foot  of  a  mountain  called  the  Stock- 
halder,  composed  of  oolite.  The  water  is  received  into  a  well  built 
covered  reservoir,  and  is  distributed  by  wooden  pipes  to  four  public 
fountains,  whence  it  was  drawn  by  the  inhabitants.  Six  houses  had  an 
independent  supply— five  from  wells,  one  from  the  mill-dam  of  a  paper- 
factory.  On  August  7,  1872,  ten  inhabitants  of  Lausen,  living  in  dif- 
ferent houses,  were  seized  by  typhoid  fever,  and  during  the  next  nine 
days  fifty-seven  cases  occurred,  the  only  houses  escaping  being  those  six 
which  were  not  supplied  by  the  public  fountains.  The  disease  continued 
to  spread,  and  in  all  130  persons  were  attacked,  and  several  children  who 
had  been  sent  to  Lausen  for  the  benefit  of  the  fresh  air  fell  ill  after  their 
return  home.  A  careful  investigation  was  made  into  the  causes  of  this 
epidemic,  and  a  complete  explanation  was  given.  Separated  from  the 
valley  of  the  Ergolz,  in  which  Lausen  lies,  by  the  Stockhalder,  the 
mountain  at  the  foot  of  which  the  spring  supplying  Lausen  rises,  is  a 
side  valley  called  the  Furjust,  traversed  by  a  stream,  the  Furleubach, 
which  joins  the  Ergolz  just  below  Lausen,  the  Stockhalder  occupying 
the  fork  of  the  valley.  The  Furlenthal  contains  six  farm-houses,  which 
were  supplied  with  drinking-water,  not  from  the  Furleubach,  but  by  a 
spring  rising  on  the  opposite  side  of  the  valley  to  the  Stockhalder.  Now, 
there  was  reason  to  believe  that  under  certain  circumstances  water  from 
the  Furlenbach  found  its  way  under  the  Stockhalder  into  one  of  the 
heads  of  the  fountain  supplying  Lausen.  It  was  noticed  that  when  the 
meadows  on  one  side  of  the  Furlenbach  were  irrigated,  which  was  done 
periodically,  the  flow  of  water  into  the  Lausen  spring  was  increased, 
rendering  it  probable  that  the  irrigation  water  percolated  through  the 
superficial  strata  and  found  its  way  under  the  Stockhalder  by  sub'erra- 
nean  channels  in  the  limestone  rock.  Moreover,  some  years  before  a 
1  William  Cay  ley,  M.  D.,  British  Medical  Journal,  Mar.  15,  1880. 


ILLUSTRATIVE  CASES.  251 

hole  011  one  occasion  formed  close  to  the  Furlenbach  by  the  sinking  in 
of  the  superficial  strata,  and  the  stream  became  diverted  into  it  and  dis- 
appeared, while  shortly  afterward  the  spring  of  Lausen  began  to  flow 
much  more  abundantly.  The  hole  was  filled  up,  and  the  Furlenbach 
resumed  its  usual  course.  The  Furlenbach  was  unquestionably  contam- 
inated by  the  privies  of  the  adjacent  farm-houses ;  the  soil-pits  communi- 
cated with  it.  Thus,  from  time  immemorial,  whenever  the  meadows  of 
the  Furlenthal  were  irrigated  the  contaminated  water  of  the  Furlenbach, 
after  percolation  through  the  superficial  strata  and  a  long  underground 
course,  helped  to  feed  one  of  the  two  heads  of  the  fountain  supplying 
Lausen.  The  natural  filtration,  however,  which  it  underwent  rendered 
it  perfectly  bright  and  clear,  and  chemical  examination  showed  it  to  be 
remarkably  free  from  organic  impurities,  and  Lausen  was  extremely 
healthy  and  free  from  fever.  On  June  10th  one  of  the  peasants  of  the 
Furleuthal  fell  ill  with  typhoid  fever,  the  source  of  which  was  not  clearly 
made  out,  and  passed  through  a  severe  attack  with  relapses,  so  that  he 
remained  ill  all  summer ;  and  on  July  10th  a  girl  in  the  same  house,  and 
in  August  a  boy,  were  attacked.  Their  dejections  were  certainly,  in  part, 
thrown  into  the  Furlenbach ;  and,  moreover,  the  soil-pit  of  the  privy 
communicated  with  the  brook.  In  the  middle  of  July  the  meadows  of 
the  Furleuthal  were  irrigated  as  usual  for  the  hay  crop,  and  within  three 
weeks  this  was  followed  by  the  outbreak  at  Lausen. 

In  order  to  demonstrate  the  connection  between  the  water-supply  of 
Lausen  and  the  Furlenbach,  the  following  experiments  were  performed. 
The  hole  mentioned  above  as  having  on  one  occasion  diverted  the  Fur- 
lenbach into  the  presumed  subterranean  channels  under  the  Stockhalder 
was  cleared  out,  and  18  cwt.  of  salt  were  dissolved  in  water  and  poured 
in,  and  the  stream  again  diverted  into  it.  The  next  day  salt  was  found 
in  the  spring  at  Lausen.  Fifty  pounds  of  wheat  flour  were  then  poured 
into  the  hole,  and  the  Furlenbach  again  diverted  into  it,  but  the  spring 
at  Lausen  remained  clear,  and  no  reaction  of  starch  could  be  obtained, 
showing  that  the  water  must  have  found  its  way  under  the  Stockhalder,' 
in  part  by  percolation  through  the  porous  strata,  and  not  by  distinct 
channels. 

Volz1  refers  to  an  epidemic  which  occurred  at  Gerlachsheim,  a  village 
of  Germany,  some  years  ago,  in  which,  in  the  course  of  three  weeks,  52 
persons  residing  on  one  of  the  principal  streets  were  attacked  by  the 
disease.  It  was  found,  upon  investigation,  that  they  all  got  their 
water  from  a  well  which  was  polluted  by  the  stools  of  the  first  patient. 
A.  Pasteur2  reports  an  epidemic  caused  by  the  contamination  of  a  well 
by  typhoid  dejections,  and  which  ceased  when  the  use  of  the  water  was 
discontinued.  Niericker3  also  reports  an  outbreak  which  was  found  to 
be  due  to  a  similar  pollution  of  the  drinking-water,  and  whith  likewise 
ceased  when  the  water-supply  was  derived  from  another  source. 

An  outbreak  of  the  disease  which  occurred  in  a  farm-house  situ- 
ated about  eight  miles  from  the  city  of  Philadelphia  came  under  my 
own  observation.  The  first  case  occurred  in  a  young  girl  of  sixteen, 
who,  with  the  exception  of  an  occasional  visit  to  the  city,  had  not 
been  away  from  her  own  home  for  several  months  before  she  was 

1  Schmidt's  Jahrbuch.  2  Revue  med.  de  la  Suisse,  Mars  15,  1881. 

*Schweiz.  Corr.  EL,  ix.  1,  1879. 


252  TYPHOID  FEVER. 

taken  ill.  The  disease  ran  in  her  a  severe  course,  and  eventually  ter- 
minated fatally.  About  three  weeks  afterward  four  other  members  of 
the  family  were  attacked,  one  of  whom  died.  Two  other  persons,  living 
in  a  house  on  the  opposite  side  of  the  road,  but  who  were  in  the  habit 
of  drinking  water  from  the  same  well,  also  took  the  disease.  There 
was  no  other  case  of  typhoid  fever  in  the  immediate  vicinity,  nor  had 
there  been  for  some  time.  The  farm-house  is  situated  in  a  cup-shaped 
depression,  so  that  water  flowed  toward  it  from  all  directions.  The  cellar 
was  constantly  filled  with  water  during  the  winter,  and  just  before  the 
outbreak  had  contained  not  only  an  unusually  large  quantity,  but  also  a 
large  amount  of  decaying  vegetable  matter.  The  well  from  which  the 
family  drew  their  drinking-water  is  situated  within  a  few  feet  of  the 
kitchen  door,  and  at  some  distance  from  the  cesspool  used  by  the  family, 
so  that  there  was  no  reason  to  believe  that  there  was  any  communication 
between  the  two.  The  wall  of  the  well  was  found  to  be  very  much 
loosened  by  the  roots  of  two  trees  growing  in  the  immediate  vicinity. 
As  the  ground  was  also  very  much  cut  up  by  the  burrows  of  rats,  the 
water  used  for  the  various  household  purposes,  and  which  Avas  habit- 
ually thrown  into  a  gutter  which  ran  past  the  well,  found  a  ready  access 
to  it.  There  would  seem  to  be  but  little  doubt  that  the  first  patient  con- 
tracted the  disease  in  some  way  during  her  visits  to  the  city,  and  that 
the  disease  in  the  other  patients  arose  from  their  drinking  the  water  of 
the  well  which  had  been  polluted  by  that  used  in  washing  her  soiled 
linen. 

Ballard1  has  shown  very  clearly  that  milk  may  also  be  a  medium 
of  communication  of  the  disease.  He  found  that  an  epidemic  which 
occurred  in  the  parish  of  Islington,  London,  in  1871  was  (1)  almost 
entirely  confined  to  a  district  comprised  within  a  circle  having  a  radius 
of  not  more  than  a  quarter  of  a  mile ;  (2)  that  out  of  62  families  living 
within  this  district,  who  were  known  to  have  suffered  from  typhoid  fever, 
54  were  constantly  supplied  with  milk  from  a  particular  dairy,  and  it  was 
'satisfactorily  proved  that  at  least  three  of  the  remaining  eight  had  occa- 
sionally partaken  from  the  same  source ;  and  (3)  that  out  of  142  families, 
comprising  all  the  customers  of  this  dairy,  and  living  not  only  within 
the  district  above  specified,  but  in  other  parts  of  the  parish,  70,  or  very 
nearly  one-half,  were  invaded  by  typhoid  fever  within  the  ten  weeks 
during  which  the  outbreak  lasted.  Upon  a  visit  to  the  farm  from  which 
the  milk  came  it  was  ascertained  that  a  member  of  the  dairyman's  family 
had  been  ill  with  typhoid  fever,  and  that  the  water  of  the  well  which 
supplied  the  family  with  drinking-water  had  been  polluted  by  his 
discharges.  Although  the  dairyman  denied  that  this  water  had  ever 
been  mixed  with  the  milk,  he  admitted  that  it  had  been  used  to 
wash  the  inilk-pans.  Murchison  was  also  able,  in  an  outbreak  which 
occurred  in  another  district  of  London,  to  trace  the  disease  to  the  same 
source. 

Typhoid  fever  may  be  likewise  propagated  in  consequence  of  the  con- 
tamination of  the  atmosphere  by  the  typhoid  poison.  This  may  be  the 
result  of  allowing  the  undisinfected  stools,  or  linen  soiled  by  them,  to 
remain  for  some  time  exposed  to  the  air,  or  may  arise  from  pollution 

1  On  a  Localized  Outbreak  of  Typhoid  Fever  in  Islington,  London,  1871. 


ILLUSTRATIVE  CASES.  253 

of  the  soil  from  the  same  cause  or  from  defective  sewage.  Hermann 
Schmidt1  refers  to  several  epidemics  breaking  out  in  garrisons  which  he 
believed  to  be  due  to  pollution  of  the  soil.  In  the  citadel  of  Wurzburg 
typhoid  fever  occurred  through  several  years,  and  persisted  in  spite  of 
the  cutting  oif  of  the  water-supply,  which  was  believed  to  be  impure. 
It  was  finally  found  that  the  ground  upon  which  it  was  built  was  satu- 
rated with  all  kinds  of  impurities.  Volz  refers  to  outbreaks  of  the  dis- 
ease from  the  same  cause. 

But  perhaps  the  most  striking  example  of  this  mode  of  propagation 
of  the  disease  is  that  recorded  by  Budd,2  and  is  as  follows :  Two  adjacent 
cottages,  which  for  the  sake  of  convenience  may  be  designated  as  Nos. 
1  and  2,  had  a  privy  in  common,  which  was  in  the  form  of  a  lean-to 
against  the  gable  end  of  No.  2.  Through  this  privy  there  flowed  with 
very  feeble  current  a  small  stream  which  formed  the  natural  drain  for  it. 
Having  already  performed  this  office  for  some  twenty  or  thirty  other 
houses  higher  up  its  course,  the  stream  had  acquired  all  the  character  of 
a  common  sewer  before  reaching  the  cottages  in  question.  About  a  quar- 
ter of  a  mile  farther  on  it  acted  as  a  drain  for  a  privy,  common  as  before, 
for  two  other  cottages,  Nos.  3  and  4.  Notwithstanding  the  condition  of 
the  stream,  which  was  so  foul  that  it  was  said  that  the  stink  from  it  was 
often  enough  "  to  knock  a  man  down,"  no  evil  result  appeared  to  have 
occurred  until  a  man  living  in  No.  1  contracted  typhoid  fever — else- 
where, it  was  believed.  As  a  matter  of  course,  all  his  discharges  were 
thrown  into  the  common  privy.  In  this  way  for  more  than  a  fortnight 
the  stream  which  passed  through  it  was  daily  fed  with  the  specific  excreta 
from  the  diseased  intestines  of  the  patient.  No  further  cases  occurred 
until  the  latter  end  of  the  third  week  or  the  beginning  of  the  fourth 
week,  when  several  persons  were  simultaneously  attacked  by  the  same 
fever  in  all  four  cottages.  From  first  to  last,  the  outbreak  was  confined 
to  these  four  cottages,  and  there  was  no  other  case  of  typhoid  fever  at 
this  time  in  the  neighborhood. 

The  mattrass  used  by  typhoid-fever  patients,  their  bed-linen  and  clothes, 
have  each  been  the  medium  by  which  the  disease  has  been  communicated 
to  others.  This  is,  as  has  already  been  pointed  out,  unquestionably  due  to 
the  fact  that  these  articles  are  generally  soiled  by  their  discharges,  and 
that  time  has  been  allowed  for  the  latter  to  acquire  infective  properties. 
It  seems  not  improbable  that  the  few  cases  in  which  the  disease  appears 
to  have  been  contracted  from  the  dead  body  may  be  explained  in  the  same 
way.  The  statistics  of  the  London  Fever  Hospital  show  that  laundresses 
are  more  liable  to  contract  typhoid  fever  than  the  immediate  attendants 
upon  the  sick.  This  liability  is  greatest  in  those  cases  in  which  the  bed- 
linen  and  clothes  of  patients  are  not  immediately  disinfected  after  use. 
According  to  Budd,  the  sputa  in  cases  of  typhoid  fever  where  bron- 
chitis is  excessive  may  sometimes  contain  the  germs  of  the  disease,  and 
mentioned  a  case  in  which  he  believed  they  were  the  means  by  which  the 
disease  was  propagated. 

The  question  naturally  arises  here,  whether  this  is  the  only  way  in 

1  Die  Typhus  Epidemic  in  Fusilier  Bat.  zn  Tubingen  in  Winter  1876-77,  enstanden  durch 
tinaihmung,  gif tiger  Grundluft,  Tubingen,  1880. 

2  Typhoid  Fever :  Its  Nature,  Mode  of  Spreading,  and  Prevention,  by  William  Budd,  M.  D., 
F.  K,  S,  London,  1873. 


254  TYPHOID  FEVER. 

which  the  disease  can  originate.  This  is  a  subject  which  has  given  rise 
to  a  good  deal  of  controversy,  and  therefore  demands  some  consideration 
at  our  hands.  On  the  one  hand,  it  is  argued  that  typhoid  fever  never 
occurs  in  the  absence  of  the  specific  poison  or  germ  of  the  disease,  and 
that  this  is  contained  principally,  if  not  wholly,  in  the  alvine  dejections. 
On  the  other  hand,  it  is  contended  that  it  may,  and  often  does,  originate 
spontaneously,  and  that  all  that  is  necessary  to  produce  it  is  the  presence 
of  decomposing  fecal  or  other  organic  matter,  and  the  consequent  contam- 
ination of  the  food,  drink,  or  atmosphere.  Both  of  these  views  have 
found  able  advocates.  Among  the  upholders  of  the  latter  view  is  Mtir- 
chison,  who  cites  the  histories  of  several  outbreaks  of  typhoid  fever  which 
occurred  in  localities  which  had  not  been  visited  by  it  for  many  years, 
and  which,  after  a  careful  investigation  of  all  the  circumstances  attending 
them,  he  was  forced  to  conclude  had  no  connection  with  any  previous 
case  of  the  disease,  and  could  only  be  explained  by  admitting  that  it 
might  occasionally  have  an  independent  origin.  Among  the  more  remark- 
able of  these  outbreaks  is  the  following,  which  we  give  in  Murchison's 
own  words : 

"In  August,  1829,  20  out  of  22  boys  at  a  school  at  Clapham  within 
three  hours  were  seized  with  fever,  vomiting,  purging,  and  excessive  pros- 
tration. One  other  boy,  aged  three,  had  been  attacked  with  similar  symp- 
toms two  days  before,  and  had  died  comatose  in  twenty-three  hours; 
another  boy,  aged  five,  died  in  twenty-five  hours ;  all  the  rest  recovered. 
Suspicions  were  entertained  that  they  had  been  poisoned,  and  a  rigorous 
investigation  ensued.  The  only  cause  which  could  be  discovered  was, 
that  a  drain  at  the  back  of  the  house,  which  had  been  choked  up  for 
many  years,  had  been  opened  two  days  before  the  first  case  of  illness, 
cleared  out,  and  its  contents  spread  over  a  garden  adjoining  the  boys' 
playground.  A  most  offensive  effluvium  escaped  from  the  drain,  and 
the  boys  had  watched  the  workmen  cleaning  it  out.  This  was  consid- 
ered to  be  the  cause  of  the  disease  by  Latham  and  Chambers,  and  by 
others  who  investigated  the  matter,  and  also  by  Sir  Thomas  Watson. 
The  morbid  appearances  in  the  two  fatal  cases  were  described  as  like 
those  of  the  common  fevers  of  this  country.  Peyer's  patches  and  the 
solitary  glands  of  the  small  and  large  intestines  were  enlarged  like 
'condylomatous  elevations,'  and  in  one  case  the  mucous  membrane  over 
them  was  slightly  ulcerated.  The  mesenteric  glands  were  enlarged  and 
congested." 

"A  remarkable  instance  of  a  circumscribed  outbreak  of  fever  was 
recorded  by  Sir  R.  Christison  in  1846.  It  occurred  in  an  isolated  farm- 
house in  the  thinly-peopled  county  of  Peebles,  N.  B.  Every  one  of 
the  fifteen  residents  was  seized  with  fever,  and  three  died.  Many  of  the 
servants  who  worked  during  the  day  at  the  farm  were  also  affected,  but 
none  communicated  the  disease  to  their  families  who  did  not  visit  the 
farm.  There  was  no  evidence  that  the  disease  was  imported  from  with- 
out, and  the  only  explanation  of  the  outbreak  was,  that  the  drains  and 
sewers  were  found  all  closed  and  obstructed  with  the  accumulated  filth 
proceeding  from  the  privies  and  farm-yard,  the  effluvia  from  which  was 
very  offensive." 

"About  Easter,  1848,  a  formidable  outbreak  of  fever  occurred  in  the 
Westminster  School  and  the  Abbey  Cloisters,  and  for  some  days  there 


ILLUSTRATIVE  CASES.  255 

was  a  panic  in  the  neighborhood  respecting  the  '  Westminster  fever.'  No 
case  of  fever  had  occurred  in  the  Abbey  Cloisters  for  three  years,  and 
there  was  no  evidence  of  its  having  been  imported.  Within  little  more 
than  eleven  days  it  affected  thirty-six  persons,  all  of  the  better  class,  and 
in  three  instances  it  proved  fatal.  Shortly  before  its  first  appearance 
there  occurred  two  or  three  days  of  peculiarly  hot  weather,  and  a  dis- 
agreeable stench,  so  powerful  as  to  induce  nausea,  was  complained  of  in 
the  houses  in  question.  It  was  found  that  the  disease  followed  very 
exactly  in  its  course  the  line  of  a  foul  and  neglected  private  sewer  or 
immense  cesspool,  in  which  fecal  matter  had  been  accumulating  for  years 
without  any  exit,  and  into  which  the  contents  of  several  small  cesspools 
had  been  pumped  immediately  before  the  outbreak  of  fever.  This  elon- 
gated cesspool  communicated  by  direct  openings  with  the  drains  of  all 
the  houses  in  which  it  occurred ;  the  only  exception  was  that  of  several 
boys,  who  lived  in  a  house  at  a  little  distance,  but  who  were  in  the  habit 
of  playing  every  day  in  a  yard  in  which  there  were  several  gully-holes 
opening  into  the  foul  drain." 

The  following  cases  would  seem,  however,  to  furnish  stronger  evidence 
in  favor  of  the  occasional  spontaneous  origin  of  typhoid  fever  than  any 
of  those  referred  to  by  Murchison.  The  first  is  recorded  by  P.  Her- 
bert Metcalfe,1  and  occurred  in  Norfolk  Island  in  the  Pacific  Ocean, 
400  miles  from  the  nearest  inhabited  land.  The  patient  was  a  gentle- 
man who  had  come  from  England  four  months  previously.  To  Met- 
calfe's  certain  knowledge,  there  had  been  no  typhoid  fever  on  the  island 
for  fifteen  months.  Three  years  previously  a  man  is  reported  to  have 
died  of  it,  and  in  1868  there  had  been  an  epidemic  of  fever,  but  he 
could  not  ascertain  of  what  kind.  Upon  inquiry,  he  found  that  his 
patient  had  been  drinking  water  from  a  well  which  had  the  reputation  of 
being  unclean,  and  that  he  was  the  only  person  who  had  done  so.  He 
also  found  that  at  a  distance  of  seven  feet  there  was  an  open  sewer,  and 
that  just  opposite  to  the  well  much  of  the  sewage- water  became  so  stag- 
nant as  to  form  an  offensive  cesspool.  The  well  was  cleaned  out,  and  at 
the  bottom  of  it  were  found  four  feet  of  stinking  sewage  mud,  the  skele- 
ton of  a  duck,  a  pig's.jaw,  etc.  The  well  was  so  situated  that  had  there 
been  any  typhoid  fever  previously  to  this  case  the  water  could  not  have 
been  contaminated  by  the  specific  poison,  as  the  above-named  sewer  only 
conveyed  water  from  the  kitchen,  which  is  a  building  detached  from  the 
dwelling-houses  of  the  mission,  and  is  far  from  and  on  a  higher  level 
than  the  open  closets  in  use. 

In  the  second  case,  which  is  reported  by  R.  Bruce  Low,2  Medical 
Officer  of  Health,  Helmsley,  Yorkshire,  occurred  in  a  lad  who  had  not 
been  away  from  his  home  for  months.  No  stranger  had  visited  his 
house,  and  there  was  no  fever  in  the  district,  the  last  case  having  occurred 
eight  months  previously  in  a  sequestered  valley  eight  miles  away.  The 
patient's  habits  and  those  of  his  family  were  revoltingly  dirty.  The 
garden  privy  was  in  bad  repair,  the  filth  level  with  the  seat,  and  the  smell 
from  it  very  offensive.  Thirty  years  before  there  had  been  five  cases  of 
slow  typhus  in  the  house.  In  his  remarks  on  this  case  Low  says: 
"  This  case  did  not  owe  its  origin  to  direct  infection,  and  the  question 
naturally  arises,  was  this  a  case  originating  de  novo,  or  had  the  poison 

1  British  Medical  Journal,  Nov.  6,  1880.  *  Brit.  Med.  Jour.,  1880. 


256  TYPHOID  FEVER. 

been  due  to  infection  in  some  way  or  another  from  the  cases  which 
occurred  thirty  years  previously  ?" 

There  can  be  but  little  doubt  that  in  many  of  the  cases  cited  by 
Murchison  as  instances  of  the  spontaneous  origin  of  typhoid  fever  there 
was  an  introduction  of  the  germs  of  the  disease  from  without.  At  all 
events,  the  evidence  to  the  contrary  is  by  no  means  convincing.  Foi 
example,  in  the  account  of  the  outbreak  at  the  Westminster  School  it  is 
expressly  stated  that  "  the  contents  of  several  small  cesspools  had  been 
pumped  before  the  outbreak  of  the  fever"  into  the  large  cesspool,  the 
emanations  from  which  it  was  believed  had  caused  the  fever.  It  does 
not  seem  that  it  was  positively  ascertained  that  none  of  these  small  cess-- 
pools had  been  used  by  a  typhoid-fever  patient,  or  that  typhoid  stools 
had  not  found  their  way  into  them  in  some  other  way.  Moreover,  in  dis- 
eases generally  admitted  to  be  contagious  it  is  not  always  possible  to  ascer- 
tain positively  the  source  of  infection  in  a  particular  instance.  But 
after  the  elimination  of  all  doubtful  cases  there  yet  remains  a  certain 
number  in  which  it  is  reasonably  certain  that  there  has  been  no  recent 
importation  of  the  typhoid-fever  germs,  as  in  the  case  which  is  reported 
by  Metcalfe  and  which  occurred  on  Norfolk  Island,  and  in  that 
recorded  by  Low.  The  assumption  does  not  seem  an  unwarranted 
one  that  in  these  cases  the  poison  of  the  disease,  which  had  been  present 
before  in  a  latent  condition,  had  been  suddenly  called  into  activity  by 
favoring  influences.  The  following  observation  of  Von  Gietl l  shows  the 
length  of  time  typhoid-fever  stools  may  retain  their  infective  properties  : 
"  To  a  village  free  from  typhoid  an  inhabitant  returned  suffering  from 
the  disease,  which  he  had  acquired  at  a  distant  place.  His  evacuations 
were  buried  in  a  dunghill.  Some  weeks  later  five  persons,  who  were 
employed  in  removing  dung  from  this  heap,  were  attacked  by  typhoid 
fever ;  their  alvine  discharges  were  again  buried  deeply  in  the  same  heap, 
and  nine  months  later  one  of  two  men  who  were  employed  in  the  com- 
plete removal  of  the  dung  was  attacked  and  died."  If  we  assume — and 
there  is  no  reason  to  doubt  that  this  point  was  fully  investigated  by  Von 
Geitl — that  the  patient  in  the  latter  case  had  not  been  otherwise  exposed 
to  the  causes  of  the  disease,  the  observation  shows  that  the  stools  in 
typhoid  fever  retain  their  virulence  for  nine  months.  If  for  nine  months, 
why  may  they  net  do  so  for  a  much  longer  period — for  as  many  years,  for 
example  ?  No  probability  is  violated  by  this  hypothesis.  On  the  con- 
trary, it  is  in  full  accordance  with  what  we  know  of  some  of  the  lower 
forms  of  life,  and  will  serve  to  explain  many  outbreaks  of  the  disease 
which  would  otherwise  be  inexplicable — for  example,  the  outbreak  at  Clap- 
ham  referred  to  by  Murchison.  Admitting  that  the  disease  in  this 
instance  was  really  typhoid  feveri — and  this  has  been  denied  by  some 
observers,  among  whom  is  Sir  Thomas  Watson — the  assumption  does 
not  seem  an  unwarrantable  one  that  the  germs  of  typhoid  fever  had  been 
present  in  this  choked-up  drain  long  before  it  was  cleared,  but  that  in 
consequence  of  their  exclusion  from  the  air  their  infecting  power  was  at  a 
minimum.  It  was,  on  the  contrary,  much  increased  when  the  contents 
of  the  drain  were  exposed  to  the  vivifying  influence  of  the  atmosphere. 

On  the  other  hand,  it  is  alleged  that  an  individual  may  be  exposed  to 
the  direct  emanations  of  sewers  or  of  foul  privies,  or  even  drink  water 
1  Quoted  by  Cayley,  Brit.  Med.  Jour.,  Mar.  15,  1880. 


ILLUSTRATIVE  CASES.  257 

contaminated  by  leakage  from  them,  without  contracting  typhoid  fever, 
so  long  as  they  do  not  contain  the  specific  germ  of  the  disease.  Every 
physician  in  large  practice,  either  in  the  city  or  country,  can  call  to  mind 
instances  in  which  the  air  of  houses  or  the  water-supply  has  been  polluted 
in  this  way,  and  yet  no  typhoid  fever  has  occurred.  Let,  however,  the 
specific  cause  of  the  disease  be  introduced  from  without,  and  this  immu- 
nity almost  invariably  disappears.  There  is  no  reason  to  believe  that 
the  contamination  of  the  water  used  by  the  family  which  suffered  in  the 
outbreak  of  the  disease  which  has  been  already  referred  to  as  having 
come  under  my  own  observation  last  year  was  of  recent  origin.  On  the 
contrary,  there  was  evidence  to  the  contrary,  and  yet  no  disease  occurred 
until  it  was  imported  by  a  member  of  the  family  who  was  in  the  habit  of 
making  frequent  visits  to  the  city.  Even  more  strongly  corroborative  of 
this  view  is  the  history  of  the  epidemic  reported  by  Ballard,  in  which 
milk  was  the  medium  of  communication.  The  water  which  had  been 
used  with  impunity  to  wash  the  milk-pans,  or  perhaps  to  dilute  the  milk, 
became  a  source  of  danger  only  after  the  occurrence  of  the  disease  in  the 
family  of  the  dairyman. 

Several  epidemics  of  typhoid  fever  have  been  recently  reported  in  which 
the  disease  appears  to  have  been  caused  by  the  use  of  the  flesh  of  diseased 
animals  or  of  meat  in  a  condition  of  putrefaction.  In  some  of  these  the 
symptoms  were  rather  those  of  irritant  poisoning  than  of  typhoid  fever, 
and  consisted  principally  in  violent  vomiting  and  purging  coming  on 
very  shortly  after  the  ingestion  of  the  unwholesome  food.  There  yet 
remains  a  certain  number  in  which  the  symptoms  cannot  be  thus 
explained.1  One  of  the  most  remarkable  of  these  occurred  in  1878  at 
a  festival  which  was  held  at  Kloten,  a  place  about  seven  miles  north  of 
Zurich,  of  which  the  following  is  a  condensed  description :  Out  of  690 
persons  who  sat  down  to  the  collation,  290  were  taken  ill ;  378  other 
persons,  who  did  not  attend  the  festival,  but  who  partook  of  the  meat 
provided  for  it,  were  also  affected.  In  addition  these,  49  secondary 
cases  occurred — i.  e.  of  persons  who  subsequently  became  affected  with- 
out having  eaten  of  the  meat.  All  other  sources  of  infection  could  be 
certainly  excluded,  as  Kloten  was  quite  free  from  typhoid  fever  at  the 
time,  and  as  it  was  clearly  shown  that  the  water  was  not  the  cause  of  the 
outbreak.  All  the  visitors  at  the  festival  who  ate  no  meat  escaped,  as 
did  also  several  persons  who  drank  wine  to  excess  and  subsequently 
vomited.  The  period  of  incubation  was  short,  as  in  other  epidemics 
arising  from  the  same  cause.  Some  of  the  people  were  ill  on  the  second 
day,  with  loss  of  appetite,  nausea,  headache,  pain  and  swelling  of  the 
belly,  and  slight  fever.  These  cases  were  slight,  and  generally  ended  in 
recovery.  The  greater  number  were  affected  between  the  fifth  and  ninth 
days.  The  symptoms  in  these  cases,  which  usually  ran  a  rapid  course, 
and  generally  ended  in  recovery,  were  chills,  fever,  diarrhoea,  great  pros- 
tration, frequently  violent  delirium,  and  also  profuse  intestinal  hemor- 
rhage. The  rose-colored  eruption  was  present  in  almost  all  of  tnem,  and 
in  a  few  the  taches  bleuatres  were  detected.  On  post-mortem  examina- 

1  On  Some  Points  in  the  Pathology  and  Treatment  of  Typhoid  Fever,  by  William  Cayley, 
London,  1880;  also  Prof.  Huguenin,  Schmidts  Jahrbuch,  from  Schweiz.  Corr.  Bl.,  viii.  15, 
1878 ;  Carl  Walder,  Schmidt's  Jahrbuch,  from  Berl.  klin.  Wochenschr.,  xv.  39,  40,  1878 ; 
George  E.  Shattuck,  M.  D.,  Supplement  to  Ziemssen's  Cyclopaedia,  New  York,  1881. 

VOL.  I.— 17 


258  TYPHOID  FEVER. 

tion  the  characteristic  appearances  of  typhoid  fever  were  found.  With 
regard  to  the  meat  supplied,  the  following  facts  were  ascertained  :  Forty- 
two  pounds  of  veal  were  furnished  by  a  butcher  at  Seebach,  taken  from 
a  calf  which  appears  to  have  been  at  the  point  of  death  when  it  received 
the  coup  de  grace  from  the  hands  of  the  butcher.  All  the  flesh  of  the 
animal  was  sent  to  supply  the  festival  at  Kloten,  but  the  liver  was  eaten 
by  an  inhabitant  of  Seebach,  and  he  was  attacked  by  typhoid  fever. 
The  brain  was  sent  to  the  parsonage  at  Seebach,  and  all  the  household 
became  affected  by  the  same  disease.  It  was  also  ascertained  that  another 
of  the  calves  was  diseased.  The  veal  from  this  calf  had  been  kept  fourteen 
days,  and  was  in  a  decomposed  state.  All  the  meat  was  placed  together 
in  the  meat-receptacle  of  the  inn  at  which  the  festival  was  held.  This 
receptacle  was  in  a  horribly  filthy  state,  and  Cayley  thinks  there  can 
be  no  doubt  that  the  putrefying  flesh  of  this  last  calf,  together  with  the 
state  of  the  receptacle,  would  rapidly  excite  decomposition  in  the  whole 
supply. 

Geissler,  it  is  true,  doubts  whether  the  epidemic  above  described  was 
really  typhoid  fever,  and  points  out  that  the  symptoms  occurred  too  soon 
after  the  ingestion  of  the  diseased  meat,  and  reached  their  full  develop- 
ment too  rapidly.  The  cases  were  also  accompanied  by  more  pain  in  the 
abdomen  than  is  generally  met  with  in  typhoid  fever.  The  proportion 
of  recoveries  also  appears  to  have  been  unusually  large.  Unquestionably, 
the  patients  in  the  Kloten  epidemic  were  in  a  large  number  of  instances 
simply  suffering  from  the  action  of  an  irritant  poison ;  but  the  presence 
of  the  characteristic  lesions  of  typhoid  fever  in  some  of  the  fatal  cases 
renders  it  certain  that  this  disease  also  existed  in  the  village  at  the  same 
time. 

In  the  report  of  this  epidemic  it  is  not  stated  that  either  of  the  calves 
which  furnished  a  part  of  the  meat  for  the  entertainment  were  suffering 
from  typhoid  fever  at  the  time  they  were  slaughtered.  It  is  now  known 
positively  that  this  animal  is  liable  to  be  attacked  by  this  disease,  and  a 
certain  number  of  cases  are  on  record  in  which  the  eating  of  the  flesh  of 
such  animals  has  been  followed  by  typhoid  fever.1  That  it  does  not 
oftener  occur  from  this  cause  is  probably  due  to  the  fact  that  a  certain 
time  must  elapse  before  the  flesh  of  sucli  an  animal  acquires  infective 
properties,  and  that  it  is  usually  used  as  food  before  this  has  been  allowed 
to  pass. 

Ludwig  Letzench 2  asserts  that  he  has  produced  some  of  the  intestinal 
appearances  of  typhoid  fever,  as  well  as  a  high  degree  of  pyrexia,  in 
rabbits  by  the  subcutaneous  injection  of  the  sputa  and  stools  of  typhoid 
fever  patients. 

THE  BACILLUS  TYPHOSUS. — From  what  has  preceded,  it  will  be  seen 
that  the  writer  is  disposed  to  range  himself  with  those  who  hold  that  the 
exciting  cause  of  typhoid  fever  is  an  organized  germ,  or,  in  other  words, 
a  contagium  vivum.  Although  this  view  cannot  be  regarded  as  positively 
proven  as  yet,  it  has  recently  received  some  support  through  the  investi- 
gations of  Klebs,  Eberth  of  Zurich,  and  others,3  who  believe  that  they 

1  Medical  Times  and  Gazette,  Feb.  8,  1879,  p.  149,  from  Berl.  Min.  WochenKchrift,  No. 
39,  1878.  2  Arch.f.  exper.  Pathol.  u.  Phai-mak.,  1878  and  1881. 

8  Klebs  (Philadelphia  Medical  Times,  Dec.  3,  1881,  from  Archivfdr  experimenielle  Pathol- 
ogie  und  Pharmakoloyie,  Bd.  xiii.  H.  5  and  6)  claims  that  he  has  proved  "  that  there  exists  in 
typhoid  fever  a  separate  and  distinct  bacillus — the  Bacillus  typhosus ;  that  it  undergoes 


PERIOD  OF  INCUBATION.  259 

have  Found  in  the  bodies  of  those  who  have  died  of  typhoid  fever  a  micro- 
organism peculiar  to  that  disease. 

PERIOD  OF  INCUBATION. — The  conditions  under  which  typhoid  fever 
occurs  in  large  cities  render  it  difficult,  if  not  impossible,  to  arrive  at  a 
definite  conclusion  as  to  its  period  of  incubation.  Occasionally,  however, 
the  time  which  has  intervened  between  the  exposure  to  the  cause  and  the 
invasion  of  the  disease  may  be  ascertained  with  precision  in  the  outbreaks 
which  occur  in  small  towns  or  in  isolated  country-houses.  Under  these 
circumstances  it  has  been  found  to  vary  within  very  wide  limits.  In  the 
three  cases  related  by  Griesinger  the  attack  began  the  day  after  exposure 
to  the  infection,  and  in  the  outbreak  at  the  school  at  Clapham,  referred  to 
by  Murchison,  twenty  out  of  twenty-two  boys  were  seized  with  the  dis- 
ease within  four  days  of  exposure  to  the  causes.  Other  instances  of  a 
similar  character  are  on  record.  In  cases  like  the  above  the  rapidity  with 
which  the  attack  follows  upon  exposure  to  the  cause  is  no  doubt  due  to 
the  intensity  of  the  poison — a  view  which  is  to  a  certain  extent  at  least 
supported  by  the  fact  that  the  invasion  of  the  disease  under  these  circum- 
stances is  very  apt  to  be  abrupt ;  the  attack  being  often  ushered  in  with 
vomiting  and  purging  or  with  grave  cerebral  symptoms.  Sometimes, 
indeed,  the  gastro-intestiual  symptoms  have  been  so  violent  as  to  have 
given  rise  to  suspicions  of  criminal  or  accidental  poisoning.  In  the 
majority  of  cases,  however,  the  period  of  incubation  is  probably  very 
much  longer  than  in  those  above  referred  to.  In  the  outbreak  which 
recently  occurred  in  a  farm-house  about  seven  miles  distant  from  Phila- 

certain  transformations,  consisting  at  first  of  little  rods  and  small  fine  threads,  containing 
a  spore  in  the  centre  and  often  at  the  end,  which  spores  divide  off  and  form  new  bacilli. 
It  later  assumes  a  larger  thread-like  form,  twisted  at  the  end,  and  frequently  taking  a 
beautiful  spiral  shape ;  that  the  bacilli  are  observed  first  in  the  masses  of  epithelial  cells 
which  accumulate  in  the  alimentary  tract  or  in  the  air-passages ;  that  they  later  penetrate 
the  tissues,  and  are  carried  along  by  the  blood-vessels  and  the  lymphatics,  and  form  a 
large  network  among  the  tissues  they  invade:  that  under  a  certain  procedure,  which 
never  causes  this  same  staining  in  any  other  living  organism  or  tissue,  they  appear  of  a 
blue  color  ;  that  they  are  found  only  in  enteric  fever,  in  which  disease  every  part  of  the 
human  body  is  the  seat  of  masses  *of  these  bacilli,  their  quantity  corresponding  exactly 
with  the  severity  of  the  symptoms ;  and  that  they  produce,  when  carried  into  the  system 
of  animals,  exactly  the  same  disease  with  the  same  morbid  alterations  as  in  men."  He 
says,  further,  that  "the  Bacillus  typhosus  enters  the  system  by  the  respiratory  passages 
and  by  the  alimentary  canal.  This  is  the  cause  that  in  some  cases  of  typhoid  fever 
almost  no  abdominal  symptoms  are  present,  but  a  low  form  of  pneumonia,  developing 
from  the  very  beginning,  so  that  the  lung  seems  alone  to  bear  the  brunt  of  the  disease." 
He  has  found  these  bacilli  in  greatest  numbers  in  Peyer's  patches. 

Eberth  (British  Medical  Journal,  Nov.  26,  1881,  from  Virchow's  Archiv,  Bd.  Ixxxi.  and 
Ixxxiii.)  has  shown  that  in  typhoid  fever  the  intestinal  mucous  membrane,  the  mesen- 
teric  glands,  and  the  spleen  contain  rod  bacteria,  differing,  as  he  believes,  from  organisms 
found  in  the  body  in  other  conditions  (among  others  in  phthisis  with  extensive  ulceration 
of  the  intestinal'mucous  memDrane).  In  seventeen  cases  of  typhoid  these  ^bacilli  were 
found  in  six  and  wanting  in  eleven.  In  the  six  cases  the  number  of  bacilli  were  in 
inverse  proportion  to  the  duration  of  the  disease.  They  were  not  found  in  the  spleen  in 
the  cases  of  the  longest  duration,  and  only  scantily  in  the  mesenteric  glands.  These  bacilli 
appear  not  to  differ  in  shape  and  size  from  the  ordinary  rod  bacteria,  but  Eberth  believes 
that  they  differ  from  them  in  their  small  capacity  for  taking  on  the  staining  of  haema- 
toxylon,  methyl-violet,  and  Bismarck  brown. 

Wernich's  views  ( Vjhrschr.f.  Off.  Geshpfl.,  xiii.  4,  p.  513,  T881)  in  regard  to  the  nature 
of  the  Bacillus  typhosus  differ  from  those  held  by  the  two  authors  just  quoted.  He 
regards  the  specific  Bacillus  typhosus  as  nothing  but  the  ordinary  Bacillus  subtilis  of 
the  large  intestines,  which  under  certain  circumstances  acquires  the  power  to  accommo- 
date itself  to  the  small  intestines,  to  undergo  a  higher  development  and  to  become  the 
exciting  cause  of  disease. 


260  TYPHOID  FEVER. 

delphia,  the  history  of  which  has  already  been  given  in  detail,  the  second 
case  began  three  weeks  after  the  first,  the  other  six  following  in  rapid 
succession.  In  the  celebrated  epidemic  which  occurred  at  Lausen  in 
Switzerland  in  1872,  and  which  is  referred  to  by  Cay  ley,1  the  first 
ten  patients  were  attacked  within  three  weeks  of  the  time  when 
the  contamination  of  the  spring  which  supplied  the  village  must  have 
taken  place,  and  these  ten  cases  were  followed  in  the  course  of  nine  days 
by  fifty-seven  others.  In  the  town  of  Over  Darwen  1500  persons  were 
seized  with  typhoid  fever  within  three  weeks  after  a  patient  suffering  from 
this  disease  was  brought  to  a  particular  house,  the  sewage  of  which  was 
allowed  to  soak  into  the  ground  through  which  the  water-supply  pipes  of 
the  town  passed,  and  at  a  point  at  which  they  were  leaky,  Lothholz 
observed  in  an  epidemic  which  occurred  in  the  neighborhood  of  Jena  that 
the  average  period  of  incubation  was  three  weeks,  the  shortest  period 
eighteen  days,  the  longest  twenty-eight  days.  Haegler  found  in  three  cases 
produced  by  contaminated  water  a  period  of  at  least  three  weeks.2  There 
are,  however,  epidemics  on  record  in  which  the  period  of  incubation  was 
under  two  weeks,  as,  for  instance,  that  of  Basle,  referred  to  by  Lieber- 
meister,  in  which  a  few  persons  were  attacked  who  had  only  been  in  the 
city  from  seven  to  fourteen  days.  Cayley  also  refers  to  localized  out- 
breaks of  the  disease,  as  those  of  Oalne  and  Nunney,  in  which  persons 
were  attacked  within  fourteen  days  of  their  exposure  to  the  cause.  C. 
J.  C.  Muller  of  Posen3  says  that  the  average  period  of  incubation  of 
the  disease  is  fourteen  days ;  that  it  may  be  not  more  than  ten  days, 
or,  on  the  other  hand,  as  long  as  from  three  to  four  weeks ;  and  that 
he  has  known  a  case  in  -which  it  was  thirty-four  days.  Murchisou 
believed  that  it  was  most  commonly  about  two  weeks,  and  William 
Budcl  arrived  at  the  conclusion,  from  the  observation  of  a  large  number 
of  cases,  that  it  varied  from  ten  to  fourteen  days. 

From  this  review  of  the  opinions  of  various  authors  the  conclusion 
would  seem  to  be  justifiable  that  the  period  of  incubation  in  typhoid  fever 
is  usually  between  two  and  three  weeks,  but  that  in  many  cases  it  does 
not  exceed  ten  days,  and  in  rare  instances  has  unquestionably  been  very 
much  less.  On  the  other  hand,  there  are  authentic  cases  on  record  in 
which  it  is  said  to  have  reached,  or  even  exceeded,  twenty-eight  days. 
Unfortunately,  we  do  not  possess  any  reliable  data  with  which  to  decide 
the  question  whether  it  is  shorter  or  longer  when  the  poison  is  imbibed 
with  the  ingesta  than  when  it  is  inhaled.  It  would  seem,  however,  that 
there  is  a  difference  in  the  susceptibility  of  different  individuals  to  the 
poison  of  this  disease,  in  many  persons  a  single  exposure  to  the  cause  being 
sufficient  to  induce  an  attack,  while  in  others  the  disease  is  contracted  only 
after  repeated  exposure. 

MORBID  ANATOMY. — As  a  thorough  knowledge  of  the  morbid  anatomy 
of  typhoid  fever  is  absolutely  necessary  to  a  correct  understanding  of  its 
pathology,  it  seems  to  me  better  to  deviate  from  the  order  usually  observed 
in  systematic  treatises  and  to  proceed  at  once  to  a  description  of  the  former, 
rather  than  to  defer  it,  as  it  is  usual  to  do,  until  after  the  symptomatology 
of  the  disease  has  been  discussed. 

Rigor  mortis  is  generally  more  marked  and  more  prolonged  than  after 

1  Brit.  Med.  Jour.,  Mar.  15,  1880.  *  Ziemssen's  Cyclopaedia,  vol.  i. 

*  Neue  Beitragezur  Aetologie  des  Unlerleibs- Typhus,  Posen,  1878. 


MORBID  ANATOMY.  261 

typhus.  Emaciation  is  often  extreme  in  cases  in  which  death  has  taken 
place  after  the  third  week,  especially  if  they  have  been  attended  by  much 
diarrhoea  and  fever.  No  traces  of  the  characteristic  rose-colored  eruption 
are  found  after  death,  no  matter  how  profuse  it  may  have  been  during 
life.  Sudamina,  on  the  other  hand,  persist,  and  discolorations  of  the 
dependent  portions  from  settling  of  blood  are  always  present  in  the  dead 
body. 

The  lesions  of  typhoid  fever  may  be  divided  into  two  classes.  The 
first  class  includes  certain  changes  in  the  glands  of  Peyer,  the  solitary 
glands  of  the  intestines,  the  spleen,  and  other  lymphatic  structures  of  the 
body.  These  changes,  which  consist  essentially  in  a  medullary  infiltra- 
tion of  these  glands,  will  be  minutely  described  presently.  They  are 
peculiar  to  the  disease,  and  are  just  as  characteristic  of  it  as  the  condition 
of  the  lungs  and  their  membranes  found  in  pneumonia  and  pleurisy  are 
characteristic  of  those  diseases.  They  are  usually  most  developed  in 
grave  cases,  but  occasionally  they  are  slight  and  but  little  marked  in  cases 
in  which  the  general  symptoms  were  severe.  They  therefore  cannot  be 
regarded  as  the  sole  cause  of  the  latter.  It  is  more  probable  that  they 
are  themselves  the  results  of  the  local  action  of  the  typhoid  poison,  and 
bear  somewhat  of  the  same  relation  to  typhoid  fever  that  the  eruption  in 
small-pox  does  to  that  disease.  The  second  class  is  made  up  of  lesions 
which  are  met  with  not  only  in  this  disease,  but  in  other  diseases  accom- 
panied by  high  fever,  and  are  therefore  unquestionably  the  result  of  the 
general  process.  They  consist  essentially  of  parenchymatous  degenera- 
tions of  various  organs  and  tissues,  and  are  generally  more  marked  in 
typhoid  fever  because  the  pyrexia  is  not  only  of  high  grade,  but  also  of 
longer  duration  than  in  other  diseases. 

We  shall  first  consider  the  lesions  peculiar  to  typhoid  fever.  Among 
the  most  important  of  these  are  the  changes  which  occur  in  the  agminated 
and  solitary  glands  of  the  intestines.  These  have  been  usually  described 
as  passing  through  four  stages,  as  follows :  (1)  the  stage  of  medullary 
infiltration;  (2)  the  stage  of  softening  or  sloughing;  (3)  the  stage  of 
ulceration ;  (4)  the  stage  of  cicatrization.  These  stages  are  said  to  last 
almost  a  week,  and  correspond  to  certain  definite  periods  of  the  disease, 
but  it  is  not  uncommon  to  find  in  the  same  intestine  glands  in  two  or 
more  of  these  stages.  Indeed,  the  same  gland  may  sometimes  be  found 
ulcerating  at  one  side  while  cicatrization  is  going  on  at  the  other. 

In  the  first  stage  the  agminated  glands  are  enlarged,  each  patch  pre- 
serving its  oblong  shape,  and  being  flattened  on  the  surface  and  elevated 
from  half  a  line  to  two  lines  above  the  surrounding  mucous  membrane, 
from  which  it  is  separated  by  an  abrupt  border,  and  which  it  may  in  a 
few  cases  overhang  like  a  fungous  growth.  The  solitary  follicles  are  also 
swollen,  and  may  vary  in  size  from  a  hempseed  to  a  split  pea.  In  very 
severe  cases  all  the  glands  may  be  more  or  less  involved,  but  in  mild 
cases  the  changes  may  be  limited  to  three  or  four  of  the  patches 
of  Peyer,  although  the  solitary  glands  rarely  wholly  escape.  It  is 
uncommon  also  for  the  latter  to  be  alone  affected,  but  a  few  such  cases 
have  been  reported.  In  these  the  mucous  membrane  appears  to  be 
studded  with  pustules,  and  hence  Cruveilhier  designated  this  variety  as 
the  forme  pustuleuse.  The  mucous  membrane  covering  the  affected 
glands  is  reddish-green  in  color,  and  that  in  their  immediate  vicinity  is 


262  TYPHOID  FEVER. 

often  injected.  The  changes  above  described  occur  early  in  the  disease — 
Murchison  has  seen  them  in  two  cases  in  which  death  took  place  at  the 
end  of  the  first  day — and  they  are  often  well  marked  at  the  end  of  the 
third  or  fourth  day.  They  are  usually  limited  to  the  glands  in  the  lower 
part  of  the  ileum,  the  agminated  glands  being  often  found  perfectly 
healthy  four  feet  above  the  ileo-csecal  valve.  In  mild  cases,  indeed,  the 
lesions  may  be  confined  to  those  nearest  to  this  valve.  So,  too,  the 
changes  in  the  solitary  glands  may  be  confined  to  the  last  twelve  inches 
of  the  smaller  intestine,  but  this  is  by  no  means  universally  the  case,  for 
these  glands  are  not  only  often  found  enlarged  higher  up  in  the  small 
intestine,  but  also  occasionally  in  the  caecum.  The  agminated  glands  are 
sometimes  found  enlarged  in  the  bodies  of  those  who  have  died  of  measles 
and  of  some  other  diseases,  but  the  degree  of  enlargement  is  rarely  as  great 
as  in  typhoid  fever,  and  the  further  changes  presently  to  be  described  are 
never  found  except  in  the  latter  disease. 

Under  the  microscope  the  medullary  infiltration  upon  which  the  en- 
largement of  the  glands  depends  is  found  to  be  due  to  proliferation  of 
the  cellular  elements.  In  the  case  of  the  agminated  glands  this  prolif- 
eration may  be  limited  to  the  follicles  or  it  may  extend  to  the  inter- 
cellular tissue,  and  even  to  the  adjacent  mucous  membrane.  In  the 
former  case  the  patches  have  a  reticulated  aspect ;  they  are  soft  and  but 
little  elevated.  These  are  the  plaques  molles  of  Louis  and  the  plaques 
reticulees  of  Chomel.  In  the  latter  they  are  harder,  smoother,  and 
more  elevated.  To  this  variety  Louis  has  given  the  name  of  plaques 
dures,  Chomel  that  of  plaques  gauffr^es.  The  morbid  process  is  also 
very  apt  to  extend  from  the  solitary  follicles  to  the  surrounding  mucous 
membrane. 

In  a  large  number  of  the  glands  in  many  cases,  and  probably  in  all 
of  them  in  the  abortive  form  of  the  disease,  the  changes  never  advance 
beyond  the  first  stage,  a  restoration  to  their  normal  condition  taking 
place  by  colliquative  softening.1  The  morbid  material  upon  which  their 
enlargement  depends  breaks  down  into  an  oily  debris  which  is  gradually 
absorbed.  This  retrograde  process  takes  place  faster  in  the  follicles  than 
in  the  interfollicular  tissue,  and,  as  pigment  is  very  apt  to  be  deposited 
in  the  depressions  thus  formed,  the  patches  acquire  an  appearance  which 
has  been  compared  to  that  of  a  recently  shaven  beard.  This  appearance 
is  met  with,  however,  in  other  diseases,  and  is  therefore  not  peculiar  to 
typhoid  fever. 

The  description  of  the  changes  in  these  glands  in  the  subsequent  stages 
of  the  disease  which  follows  is  taken  mainly  from  Rindfleisch's  work  on 
Pathological  Histology. 

In  the  stage  of  necrosis  small  portions  of  single  Peyerian  patches, 
varying  in  size  from  that  of  a  lentil  to  from  three-quarters  of  an  inch  to 
an  inch  and  a  quarter  in  diameter,  assume  a  yellowish-white,  opaque  tint 
instead  of  their  former  reddish  and  translucent  aspect,  gradually  become 
separated  from  the  surrounding  tissue  by  a  sharp  line  of  demarcation, 
and  then  pass  into  a  state  of  cheesy  necrosis.  Here  and  there  the  same 
changes  are  observed  to  have  taken  place  in  the  solitary  glands.  When 
once  this  has  occurred,  recovery  can  only  take  place  by  expulsion  of  the 
necrosed  parts  and  consequent  ulceration.  Necrosis  of  the  glands  prob- 

1  Kindfleisch,  Pathological  Histology,  Sydenham  Society  Translation,  vol.  i.  p.  441. 


MORBID  ANATOMY.  263 

ably  rarely  occurs  before  the  beginning  of  the  second  week,  but  it  has 
occasionally  been  observed  much  earlier.  Murchison  reports  cases  in 
which  he  saw  it  as  early  as  the  first  and  second  days.  The  process 
usually  involves  the  mucous  membrane  only,  but  it  may  extend  to  the 
muscular  and  even  to  the  peritoneal  coats. 

In  the  third  stage  the  dead  parts  are  gradually  thrown  off,  the  pro- 
cess of  separation  usually  occupying  several  days.  At  first  an  increased 
degree  of  congestion,  followed  by  suppuration,  is  observed  at  the  edges 
of  the  sloughs,  which  before  their  complete  detachment  may  often  acquire 
a  yellow,  green,  or  brown  color  from  the  imbibition  of  bile.  The  ulcers 
which  result  correspond  in  size  and  form  with  the  sloughs.  They  are, 
therefore,  in  the  case  of  the  agminated  glands  elliptical  in  shape,  with 
their  long  diameter  corresponding  to  the  axis  of  the  intestine.  Their 
edges  are  swollen  and  overhanging,  and  their  floor  is  generally  formed 
by  the  deepest  layer  of  the  submucous  connective  tissue.  They  some- 
times penetrate  much  more  deeply,  and  may  even  extend  to  the  peritoneal 
coat,  and  thus  give  rise  to  perforation  of  the  bowel.  The  ulcers  which 
result  from  sloughing  of  the  solitary  glands  are,  as  a  rule,  small  and 
round.  Murchison  says  that  ulceration  may  also  be  produced  in  the 
following  way :  The  mucous  membrane  becomes  softened,  and  one  or 
more  superficial  abrasions  appear  on  the  surface  of  the  diseased  patch, 
which  extend  and  unite  into  one  large  ulcer,  and  this  ulcer  proceeds  to 
various  depths  through  the  coats  of  the  bowel,  and  even  to  completed 
perforation,  but  Kindfleisch  and  other  recent  German  writers  do  not 
allude  to  this  process. 

The  fourth  stage,  or  that  of  cicatrization,  usually  commences  with  the 
beginning  of  the  fourth  week.  The  swelling  of  the  edges  of  the  ulcers 
gradually  diminishes,  and  they  become  adherent  to  the  tissues  beneath. 
The  floor  of  the  ulcers  covers  itself  with  delicate  granulations,  which  in 
course  of  time  are  converted  into  connective  tissue.  This  is  ultimately 
coated  with  epithelium,  but  neither  the  villi  nor  the  glands  of  the  mucous 
membrane  are  ever  reproduced.  The  resulting  cicatrices  may  be  recog- 
nized by  the  affected  parts  of  the  bowel  being  thin  and  more  translucent 
than  in  health,  and  may  retain  these  characters  after  the  lapse  of 
several  years.  They  never  give  rise  to  contraction  of  the  bowel.  The 
time  occupied  in  the  cicatrization  of  each  ulcer  is  said  to  be  about  two 
weeks.  It  occasionally  happens  that  while  cicatrization  is  taking  place 
at  one  end  of  the  ulcer  the  processs  of  necrosis  and  ulceration  is  still 
going  on  at  the  other,  so  that  two  or  more  ulcers  may  occasionally  run 
together.  This  form  of  ulcer  may  often  retard  recovery,  and  may  some- 
times end  in  perforation  of  the  bowel,  even  after  convalescence  seems  to 
have  been  established. 

The  color  and  consistence  of  the  mucous  membrane  of  the  caecum 
and  colon  are  in  a  large  proportion  of  cases  normal.  In  a  few  the 
membrane  is  paler  than  in  health,  and  in  others  it  is  of  an  ash-gray 
color.  It  is  also  sometimes  injected  and  softened.  The  solitary  glands 
are  frequently  enlarged  and  ulcerated,  like  those  of  the  ileum.  In 
the  former  case  the  mucous  membranes  of  the  large  intestine  through- 
out its  whole  extent,  but  especially  that  of  the  csecum  and  of  the  part  of 
the  colon  adjacent  to  it,  is  studded  with  minute  elevations  about  a  line  in 
diameter.  When  ulceration  has  occurred  the  ulcers  are  generally  round 


264  TYPHOID  FEVER. 

and  small,  but  they  may  occasionally  be  oval  and  of  considerable  size. 
In  the  latter  case  their  long  diameter  will  correspond  in  direction  with 
that  of  the  circular  fibres  of  the  intestine.  Murchison  has  known 
them  to  measure  fully  an  inch  and  a  half  in  length.  The  colon  is  gen- 
erally found  much  distended  with  flatus. 

Enlargement  of  the  mesenteric  glands  from  cellular  hyperplasia  and 
hypertrophy  of  the  connective  tissue  is  constantly  associated  with  the 
morbid  changes  of  the  intestines  just  described.  This  enlargement 
varies  in  diiferent  cases.  In  some  the  glands  are  not  larger  than  a 
pea  or  bean ;  in  others  they  are  said  to  have  reached  the  size  of  a  hen's 
egg.  It  is  always  more  marked  in  the  glands  which  lie  in  the  angle 
between  the  lower  end  of  the  ileum  and  the  caecum,  and  usually  bears 
some  proportion  to  the  intensity  of  the  local  disease ;  but  it  is  not  to  be 
regarded  merely  as  a  result  of  the  local  irritation,  as  it  has  been  observed 
in  parts  of  the  mesentery  corresponding  to  perfectly  healthy  portions  of 
the  intestine,  and  as  the  meso-colic  glands  have  been  involved  in  cases  in 
which  the  colon  was  free  from  disease.  It  has,  moreover,  been  observed 
in  cases  in  which  death  has  occurred  very  early  in  the  disease,  and  there 
can  therefore  be  little  doubt  that  it  is  as  much  the  result  of  the  infective 
process  as  the  infiltration  of  Peyer's  patches.  In  addition  to  being 
enlarged,  if  death  has  taken  place  before  the  end  of  the  second  week 
the  glands  are  hyperaemic  and  of  a  purplish  color.  Later  than  this, 
when  the  sloughs  become  detached  from  Peyer's  patches,  the  swelling  of 
the  glands  diminishes ;  they  lose  their  color  and  become  pale,  and  if 
convalescence  ensues  they  return  finally  to  their  former  healthy  condition. 
Still,  Murchison  has  seen  them  shrivelled  and  pale  or  bluish  for  some 
time  after  convalescence.  In  other  cases  the  substance  of  the  glands 
softens,  with  the  formation  of  a  puriform  liquid.  If  the  softening  only 
involves  a  small  part  of  the  glandular  structure,  restoration  to  health  may 
take  place  through  the  absorption  of  this  liquid.  If  it  is  more  extensive, 
the  whole  of  the  glands  may  break  down  into  this  puriform  liquid,  which, 
when  the  patient  recovers,  undergoes  caseous  and  finally  calcareous  degen- 
eration. Occasionally,  a  gland  in  this  condition  is  the  cause  of  death 
from  rupture  and  extravasation  of  its  contents  into  the  cavity  of  the 
peritoneum. 

The  glands  in  the  fissure  of  the  liver,  the  gastric,  lumbar,  inguinal 
glands,  and  indeed  all  the  lymphatic  glands  in  the  body,  have  occasionally 
been  found  swollen  and  congested,  but  their  enlargement  cannot  be  classed 
among  the  specific  lesions  of  the  disease,  but  is  merely  the  result  of  a 
local  irritation.  Thus,  Jenner  says  that  in  the  case  of  extensive  ulcera- 
tion  of  the  oasophagus  which  came  under  his  observation  there  was  marked 
enlargement  of  the  oesophageal  glands.  Liebermeister  says  that  the  lym- 
phatic follicles  which  surround  the  glands  at  the  root  of  the  tongue  and  in 
the  tonsils  arc  often  affected  in  the  same  way  as  the  glands.  In  most 
cases  after  a  time  the  swelling  disappears,  but  sometimes  softening  and 
rupture  take  place. 

The  spleen  is  almost  invariably  found  to  be  increased  in  volume  and  to 
have  undergone  changes  in  consistence  and  color.  The  degree  of  enlarge- 
ment and  the  other  changes  vary  of  course  with  the  stage  of  the  disease 
at  which  death  has  occurred.  The  enlargement  occurs  with  less  fre- 
quency in  elderly  than  in  young  people,  and  is  most  marked  at  the  height 


LESIONS  NOT  PECULIAR  TO  TYPHOID  FEVER.  265 

of  the  disease,  the  organ  being  then  often  twice  or  three  times  it  normal 
size,  and  in  some  cases,  it  is  said,  even  larger.  Later,  and  especially 
during  convalescence,  the  enlargement  has  generally  very  much  dimin- 
ished. During  the  first  ten  days  of  the  disease  the  spleen  is  generally 
tense  and  firm,  engorged  with  blood,  and  dark  red  in  color.  Between  the 
tenth  and  thirtieth  days  its  appearance  remains  the  same,  but  the  organ 
is  found  to  be  soft  and  friable.  During  convalescence  it  becomes  paler 
and  firmer  again,  and  is  often  so  shrunken  in  size  that  its  capsule  is 
relaxed  and  wrinkled.  Hemorrhagic  infarctions  are  often  met  with. 
These  sometimes  soften  and  break  down  into  a  puriform  liquid,  which 
may  sometimes  cause  peritonitis  by  rupture  into  the  peritoneal  cavity. 
Rupture  of  the  spleen  is  also  said  to  have  occurred  from  mechanical  vio- 
lence. These  changes  are  due  in  part  to  variations  in  the  amount  of 
blood,  and  in  part  to  a  medullary  infiltration  of  Malpighian  corpuscles 
similar  to  that  which  takes  place  in  Fever's  patches  and  the  glands  of  the 
mesentery. 

LESIONS  WHICH  ARE  NOT  PECULIAR  TO  TYPHOID  FEVER,  BUT  ARE 
OF  MORE  OR  LESS  FREQUENT  OCCURRENCE. — The  mucous  membrane  of 
the  pharynx  and  oesophagus  may  present  a  perfectly  healthy  appearance, 
but  occasionally  it  is  congested  and  the  seat  of  ulcerations  which  are  for  the 
most  part  superficial.  Sometimes,  however,  they  have  been  found  to 
extend  to  the  muscular  coat,  but  they  have  never  been  known  to  pene- 
trate all  the  coats  of  these  organs.  Jenner  refers  to  one  case  in  which 
there  was  extensive  ulceration  of  the  oesophagus,  but  usually  the  number 
of  ulcers  is  not  large.  In  a  few  cases  the  mucous  membrane  of  the 
pharynx  is  coated  with  diphtheritic  false  membrane,  and  the  submucous 
tissues  is  infiltrated  with  serum  and  pus  (Murchison). 

Thfc  stomach  and  the  upper  part  of  the  intestinal  tract  present  no 
lesions  which  are  at  all  peculiar  to  typhoid  fever.  In  a  certain  number 
of  cases  congestion,  softening,  and  even  superficial  ulceration,  of  the 
mucous  membrane  of  the  stomach,  and  less  frequently  of  that  of  the 
duodenum,  have  been  found.  The  mucous  membrane  of  the  jejunum 
and  of  the  upper  part  of  the  ileum  is  not  usually  much  reddened,  and 
may  be  even  paler  than  in  health.  In  cases  which  have  been  protracted 
it  may  be  of  an  ashy-gray  or  slate  color.  The  contents  of  this  part  of 
the  intestinal  tract,  which  is  rarely  much  distended  by  flatus,  do  not  differ 
materially  in  appearance  or  consistence  from  the  matter  which  generally 
composes  the  typhoid  stool.  The  bowels  may,  of  course,  be  found  filled 
with  blood  in  cases  in  which  a  recent  hemorrhage  has  taken  place.  In- 
vaginations  of  the  small  intestines,  unaccompanied  by  any  evidences  of 
inflammation,  are  occasionally  met  with  in  the  bodies  of  those  who  have 
died  of  typhoid  fever.  They  are  produced,  there  is  good  reason  to  believe, 
during  the  death  agony,  but  are  not  peculiar  to  this  disease,  as  they  occur 
in  many  other  diseases. 

Enlargement  of  the  liver  has  been  found  in  only  a  few  cases  after 
death  from  typhoid  fever.  Softening  is  more  common,  but  even  this  is 
not  a  frequent  result  of  the  disease,  for  it  was  absent  in  41  out  of  73 
cases  examined  with  special  reference  to  this  point  by  Louis,  Jeuner,  and 
Murchison.  The  organ  is  occasionally  hypersemic,  and  darker  in  color 
than  in  health,  but  it  is  oftener  pale  or  normal  in  appearance.  Even, 
However,  where  it  appears  to  be  perfectly  healthy  to  the  unassisted  eye, 


266  TYPHOID  FEVER. 

the  microscope  shows  that  its  cells  are  very  granular  and  filled  with  oil- 
globules  which  often  render  the  nucleus  indistinct  or  completely  conceal 
it.  When  death  has  taken  place  at  an  advanced  stage  of  the  disease 
many  of  the  cells  are  found  to  be  completely  broken  down  into  a  granu- 
lar detritus.  These  changes  are  usually  proportional  to  the  degree  of 
pyrexia  which  has  been  present  during  life.  Rarer  lesions  of  the  liver 
are  pyaemic  deposits,  embolism,  abscess,  and  emphysema. 

The  mucous  membrane  of  the  gall-bladder  has  been  found  to  be  the 
seat  of  ulcers  by  Jenuer  and  numerous  other  observers.  It  also  occasion- 
ally presents  the  evidences  of  catarrhal  or  diphtheritic  inflammation.  The 
gall-bladder  usually  contains  a  pale  watery  liquid  of  a  less  density  than 
bile.  When,  however,  inflammation  of  its  lining  membrane  has  existed, 
its  contents  are  mixed  with  pus  and  shreds  of  false  membrane. 

The  mucous  membrane  of  the  larynx  is  sometimes  found  to  have  been 
the  seat  of  catarrhal  or  diphtheritic  inflammation,  and  sometimes  also  of 
ulceration.  Jenner  says  that  in  typhoid  fever  laryngitis  independent  of 
pharyngitis  is  extremely  rare,  but  the  German  writers  express  a  diiferent 
opinion.  Griesinger  estimated  that  laryngeal  ulcers  were  present  in  one- 
fifth  of  the  fatal  cases.  Hoffmann  found  them  twenty-eight  times  in 
two  hundred  and  fifty  autopsies,  and  that  the  ulcers  had  extended  to  and 
involved  the  cartilages  in  twenty-two  out  of  the  twenty-eight  cases. 
They  are  most  commonly  found  in  the  posterior  wrall  of  the  larynx,  and 
may  involve  the  vocal  cords.  These  are  often  discovered  after  death  in 
cases  in  which  their  existence  was  not  suspected  during  life.  They  were 
formerly  supposed  to  be  the  result  of  typhoid  infiltration  of  the  laryngeal 
glands,  but  careful  investigation  has  shown  that  they  are  the  consequence 
of  diphtheritic  inflammation  of  the  mucous  membranes.  Inflammation 
and  ulceration  of  the  trachea  are  comparatively  rare.  Hypostatic/  con- 
gestion and  infarction  of  the  lungs  are  not  uncommonly  found  after  death 
from  typhoid  fever,  and  less  frequently  the  lesions  of  pneumonia.  Evi- 
dences of  recent  pleurisy  are  also  discovered  in  a  few  cases.  Acute  miliary 
tuberculosis  of  the  lungs  is  more  often  met  with  as  a  sequela  than  as  a 
complication. 

The  changes  in  the  brain  and  its  membranes  caused  by  typhoid  fever 
are  few  and  unimportant,  even  in  cases  attended  by  severe  nervous  symp- 
toms. Those  most  frequently  found  are  adhesions  of  the  dura  mater 
to  the  inner  surface  of  the  cranium,  injection  or  oedema  of  the  pia 
mater,  congestive  oadema,  and  sometimes  softening  of  the  brain  and  effu- 
sion at  the  base  of  the  brain.  The  microscopic  changes  do  not  appear  to 
have  been  carefully  studied.  Liebermeister  says  that  the  gray  substance 
of  the  cortical  portion  of  the  brain  and  of  the  interior  is  sometimes  of  a 
rather  yellowish-brown  color,  and  that  he  noticed  besides  diffuse  yellow 
and  blackish-brown  spots  in  different  places,  particularly  in  the  corpus 
striatum  and  thalamus  opticus.  In  such  places,  he  says,  the  microscope 
shows  a  diffuse  yellow  coloration,  a  deposit  of  small  brown  pigment- 
granules,  and  also,  especially  in  the  optic  thalamus  and  corpus  striatum, 
the  ganglion -cells  thickly  crowded  with  brownish  or  blackish  pigment- 
granules  in  such  numbers  as  to  conceal  the  outlines  of  many  of  the  cells. 
These  changes  Hoffmann,1  who  has  specially  studied  them,  is  inclined  to 
place  by  the  side  of  the  parenchymatous  degeneration  of  other  organs. 

1  Quoted  by  Murchison. 


LESIONS  NOT  PECULIAR  TO  TYPHOID  FEVEE.  267 

The  ganglion-cells  of  the  sympathetic  ganglia  are  said  by  Virchow  also 
to  contain  an  unusual  amount  of  pigment. 

The  muscles  are  frequently  the  seat  of  marked  changes  in  typhoid  fever. 
Their  macroscopic  appearances  vary  with  the  stage  of  the  disease  at  which 
they  are  examined.  When  death  takes  place  in  the  first  or  second  week 
they  are  usually  dark  red  or  reddish-brown  in  color,  and  very  dry.  If  it 
is  delayed  until  later,  they  "  present  a  peculiar  fawn  or  yellow  tint  per- 
meating the  ordinary  red  in  patches  and  veins  not  unlike  the  appearance 
of  veined  marble."  Their  consistence  is  also  so  much  diminished  that 
the  finger  may  be  readily  passed  through  them.  Occasionally,  pseudo- 
abscesses  and  hemorrhages  into  the  muscular  sheath  are  found,  and 
Dauve  and  B.  Ball l  report  cases  in  which,  in  addition  to  these  changes, 
rupture  of  muscles  had  occurred.  Zenker,  who  was  the  first  to  call  atten- 
tion to  them,  ranged  the  changes  seen  under  the  microscope  under  two 
heads :  (1)  granular  or  fatty  degeneration ;  (2)  waxy  degeneration.  In 
the  first  variety  the  transverse  striae  disappear  and  the  sarcolemma  appears 
filled  with  finely  granular  matter.  In  the  second  variety  the  striated 
muscles  become,  as  it  were,  pervaded  by  a  coagulating  material  which 
sets,  and  in  contracting  breaks  up  the  fibres  into  great  numbers  of  short 
waxy-looking  lumps,  not  unlike  a  certain  variety  of  casts  of  the  tubuli 
recti  of  the  kidneys.  When  recovery  takes  place  the  affected  fibre  is 
believed  to  be  regenerated  by  a  cell-growth  within  the  sarcolemma.  These 
changes  occur  in  most  fevers,  as  typhus,  small-pox,  scarlet  fever,  and  are 
attributed  by  authors  generally  to  the  hyperpyrexia  which  is  a  frequent 
accompaniment  of  these  diseases.  Hayem,  however,  asserts  that  he  has 
found  them  well  marked  in  cases  not  characterized  by  a  high  tempera- 
ture, and  that,  on  the  other  hand,  they  are  sometimes  absent  in  cases 
where  this  has  been  present.  The  waxy  form  of  degeneration  may  affect 
all  the  striped  muscles,  but  is  oftenest  seen  in  the  muscles  of  the  abdom- 
inal walls,  the  adductors  of  the  thigh,  the  muscles  of  the  diaphragm,  and 
tongue. 

The  heart,  in  common  with  the  other  muscles  of  the  body,  suffers  from 
both  the  forms  of  degeneration  above  described,  but  the  granular  form 
appears  to  be  more  common  than  the  waxy.  In  protracted  cases  it  is 
usually  much  softened,  and  when  thrown  upon  a  plate  no  longer  retains 
its  form.  It  has  usually  lost  its  normal  color  and  acquired  the^  tint 
described  by  the  French  as  feuille  morte  (faded  leaf).  ^  Upon  minute 
examination  the  degeneration  is  found  to  have  taken  place  in  patches,  the 
diseased  fibres  being  found  alongside  of  others  which  have  scarcely  under- 
gone any  alteration.  These  patches  are  especially  common  in  the  papil- 
lary muscles  of  the  mitral  valve — a  fact  which  explains  the  occasional 
presence  of  systolic  murmurs  in  typhoid  fever.  In  addition  to  the 
microscopic  appearances  of  the  muscles  already  described,  Hayem2  has 
observed  in  his  examinations  of  the  heart  a  cellular  infiltration  of  the 
connective  tissue  and  a  proliferation  of  the  muscle  nuclei.  These  changes 
are  sufficient  in  his  opinion  to  establish  the  existence  of  myocarditis. 
The  same  observer  thinks  he  has  also  found  evidences  of  the  frequent 
occurrence  of  endoarteritis  in  the  multiplication  of  the  cellular  elements 

1  L'  Union  Medicale,  1866,  quoted  by  Biennial  Retrospect  of  Medicine  and  Suryery  and 
their  Allied  Sciences,  for  1865-66.  _  . 

2  Lemons  cliniques  sur  les  Manifestations  cardiaques  de  la  Fievre  typhoide,  Pans,  1875. 


268  TYPHOID  FEVEE, 

of  the  internal  coat  of  the  small  arteries,  which  he  has  discovered  under 
the  microscope. 

Some  discrepancy  of  opinion  exists  in  regard  to  the  condition  of  the 
blood  in  typhoid  fever.  Trousseau,  for  instance,  speaks  of  it  as  being 
profoundly  altered  and  in  a  state  of  dissolution  ;  Liebermeister  says  that 
at  the  height  of  the  disease  the  blood  is  very  dark-colored,  and  that  after 
coagulation  it  presents  a  small  and  soft  clot ;  and  Murchison,  that  a  dark, 
liquid  condition  of  the  blood  is  rarer  than  in  typhus,  and  that  fine  white 
coagula  are  more  common.  Harley  too  has  frequently  found  firm  color- 
less clots  of  fibrin  in  the  heart  and  roots  of  the  great  vessels  in  subjects 
dead  in  the  third  week  of  the  disease.  Forget  concludes  from  an 
examination  "of  one  hundred  and  twenty-three  specimens  of  blood 
derived  from  patients  in  all  stages  of  the  disease  that  an  appreciable 
alteration  of  the  blood  in  the  several  periods  of  enteric  fever  cannot  be 
accepted  as  a  general  fact ;  that  the  blood  is  rarely  altered  in  the  first 
period ;  that  the  alteration  is  more  marked  in  proportion  as  the  disease  is 
more  advanced  ;  that  the  alteration  is  not  always  in  proportion  to  the 
gravity  of  the  disease."  x  I  have  myself  seen  the  disorganization  of  the 
blood  as  complete  in  severe  cases  of  typhoid  fever  which  have  rapidly 
proved  fatal  as  in  cases  of  diphtheria  or  of  other  malignant  diseases. 
On  the  other  hand,  in  protracted  cases  and  during  convalescence  the  blood 
is  often  thin  and  watery. 

The  kidneys  are  sometimes  engorged  with  blood,  sometimes  pale  and 
flabby.  Under  the  microscope  the  appearances  are  similar  to  those  jiist 
described  as  occurring  in  the  liver,  and  it  is  therefore  unnecessary  to  refer 
to  them  more  fully  here.  As  a  rule,  the  epithelium  becomes  granular 
earlier  and  to  a  marked  degree  in  the  cortical  than  in  the  tubular  portion. 
The  absence  of  albuminuria  must  not  always  be  accepted  as  proof  of 
a  healthy  condition  of  the  kidneys,  as  this  symptom  has  been  wholly 
wanting  in  cases  in  which  the  organs  have  been  extensively  diseased. 

Analogous  changes  have  also  been  observed  in  the  salivary  glands 
and  pancreas,  except  that,  according  to  Hoffmann,  a  cellular  proliferation 
precedes  the  degenerative  process. 

CLINICAL  DESCRIPTION. — The  invasion  of  the  disease  is  usually  so 
gradual  that  it  is  often  impossible  to  obtain  from  patients  exact  informa- 
tion as  to  the  time  of  the  beginning  of  their  illness.  Among  those  who 
present  themselves  for  treatment  at  the  Pennsylvania  Hospital  it  is  not 
uncommon  to  find  that  many  have  suffered  for  several  days,  it  may  be  as 
long  as  a  week,  or  even  longer,  before  taking  to  their  beds,  from  vague  feel- 
ings of  discomfort,  from  headache  more  or  less  intense,  aching  pains  in 
the  back  or  limbs,  or  from  sensations  of  chilliness  alternating  with  flashes 
of  heat.  In  other  cases  derangements  of  the  digestive  system  are  more 
prominent,  such  as  nausea,  or  even  vomiting,  diarrhoea,  or  irritability  of 
the  bowels.  Notwithstanding  these  symptoms,  and  the  indisposition  to 
exertion  engendered  by  them,  they  have  frequently  continued  to  follow 
their  usual  avocations  up  to  the  time  of  their  application  at  the  hospital 
for  admission.  There  is  generally,  however,  no  difficulty  in  recognizing  at 
once  the  nature  of  their  disease.  Upon  examination  the  pulse  is  found  to 
be  frequent,  the  respiration  accelerated,  the  tongue  furred,  the  skin  hot  and 
dry,  and  the  abdomen  tympanitic. 

1  Quoted  by  Harley,  Reynolds' s  System  of  Medicine,  vol.  i. 


CLINICAL  DESCRIPTION.  269 

Among  patients  whose  position  in  life  enables  them  to  pay  greater 
attention  to  trifling  symptoms  than  those  who  are  compelled  to  seek  hos- 
pital relief,  opportunity  is  frequently  aiforded  to  the  physician  to  study  the 
disease  at  a  period  less  remote  from  its  commencement.  The  symptoms 
it  presents  when  seen  as  early  as  the  second  day  are  generally  of  a  very 
indefinite  character.  There  may  be  a  feeling  of  malaise,  headache  with  a 
tendency  to  giddiness,  pain  in  the  back  and  limbs,  a  slightly  coated  tongue, 
thirst,  and  anorexia.  The  patient  may  complain  of  chilly  sensations 
alternating  with  flashes  of  heat,  but  it  will  rarely  be  found  that  the  attack 
has  commenced  with  a  decided  chill.  Diarrhoea  may  also  be  present  at 
this  time,  or  may  not  supervene  until  later.  Even  in  cases  in  which 
it  is  absent  the  bowels  will  generally  act  inordinately  after  the  adminis- 
tration of  a  gentle  purgative.  Occasionally,  the  attack  begins  with  vom- 
iting, but  this  is  not,  in  my  experience,  a  frequent  mode  of  commence- 
ment. If  the  visit  be  made  in  the  morning,  the  febrile  symptoms  will 
be  little  marked,  the  pulse  being  only  slightly  accelerated  and  the  temper- 
ature being  rarely  more  than  from  a  half  to  a  degree  above  the  normal.  In 
the  evening,  however,  the  thermometer  usually  indicates  a  greater  elevation 
of  temperature. 

At  subsequent  visits  the  same  symptoms  are  presented.  It  will  be 
observed,  however,  that  the  fever  is  decidedly  remittent  in  character,  the 
evening  temperature  being  always  from  a  degree  to  a  degree  and  a  half 
higher  than  that  of  the  morning,  while  the  temperature  of  each  succeed- 
ing day  is  a  little  higher  than  that  of  the  day  which  preceded  it.  The 
patient  is  restless  and  wakeful  at  night,  or  sleep,  when  obtained,  is  unre- 
freshing  and  disturbed  by  dreams.  He  grows  dull  and  slightly  deaf,  and 
although  able  to  answer  questions  intelligently  when  roused,  does  so 
with  an  effort,  and  soon  after  lapses  into  his  former  condition.  Although 
obviously  growing  weaker  every  day,  it  is  sometimes  difficult  to  get  him 
to  take  to  his  bed.  The  diarrhoea  continues  and  increases  in  severity ; 
the  stools  become  watery  in  character  and  ochrey-yellow  in  color ;  they 
may  exceed  six,  or  even  twelve,  in  the  twenty-four  hours.  Epistaxis 
either  consisting  of  a  few  drops  of  blood  only,  or  so  profuse  as  to  endanger 
life,  may  also  occur  during  the  first  week.  Examination  of  the  abdomen 
toward  the  middle  or  close  of  the  first  week  will  almost  always  reveal 
the  existence  of  tympany  and  of  tenderness  and  gurgling  in  the  right 
iliac  fossa,  and  very  frequently  also  of  slight  enlargement  of  the  spleen. 
The  urine  at  this  stage  of  the  disease  is  dense,  scanty,  and  of  high  color. 
The  tongue  too  will  be  observed  to  be  more  heavily  coated  than  at  first, 
and  to  be  dryish,  the  fur  being  disposed  on  the  middle  of  the  dorsum  of 
the  organ,  while  the  tip  and  edges  are  free  from  it  and  abnormally  red  in 
color.  Usually,  toward  the  close  of  the  first  week,  the  pulse  will  be 
found  to  be  between  100  and  120  in  frequency.  It  often,  however,  does 
not  attain  this  frequency,  and  in  some  cases  does  not  exceed  50  throughout 
the  whole  of  the  attack.  At  the  same  time,  the  thermometer  generally 
indicates  a  temperature  of  from  102°  to  104°,  and  in  bad  cases  even  one 
much  higher  than  the  latter. 

These  symptoms  are  not  pathognomonic,  but  Murchison  regards  their 
existence  in  a  young  person  as  warranting  the  suspicion  that  he  is  suffer- 
ing from  this  disease.  About  this  time,  however,  or,  to  speak  more  accu- 
rately, usually  from  the  seventh  to  the  twelfth  day,  a  new  symptom  occurs 


270  TYPHOID  FEVER. 

which  is  more  characteristic.  This  is  an  eruption  of  isolated  rose-colored 
spots,  the  taches  roses  lenticulaires  of  Louis,  occurring  principally  upon 
the  surface  of  the  abdomen,  but  not  infrequently  seen  also  upon  the  chest, 
back,  limbs,  and  even,  according  to  some  authors,  upon  the  face.  They 
are  round  in  shape,  with  a  well-defined  margin,  usually  about  a  line  in 
diameter,  but  sometimes  considerably  larger,  slightly  elevated  above  the 
surface,  and  disappearing  upon  pressure,  but  returning  when  the  pressure 
is  removed.  They  can  almost  always  be  found  at  this  stage  of  the  disease 
if  diligently  sought  for. 

If  the  disease  tends  to  run  a  severe  course,  all  the  symptoms  become 
aggravated  toward  the  end  of  the  second  week.  The  tongue  grows  dry 
and  brown,  the  pulse  more  frequent,  feeble,  and  markedly  reduplicated  in 
character,  the  diarrhoea  still  more  severe,  and  the  fever  higher  than  before, 
with  little  or  no  tendency  to  remit  in  the  morning.  The  nervous  symp- 
toms also  come  into  prominence.  The  headache  may  grow  more  violent 
or  may  be  replaced  by  increased  dulness,  which  may  sometimes  be  so 
decided  as  to  render  it  difficult  to  fully  rouse  the  patient.  At  other  times 
delirium  is  a  prominent  symptom.  This  may  only  occur  at  night,  but 
not  infrequently  is  observed  during  the  daytime  as  well.  It  is  usually 
more  active  in  character  than  that  which  accompanies  typhus.  Trembling 
of  the  tongue  and  of  the  limbs  is  not  uncommon  at  this  time.  The  urine 
becomes  more  abundant,  paler,  and  less  dense  than  before.  Even  in  cases 
characterized  by  symptoms  as  severe  as  those  above  detailed  some  improve- 
ment is,  however,  often  observed  to  take  place  between  the  fourteenth  and 
twenty-first  days.  The  morning  remission  becomes  more  decided,  the 
evening  temperature  less  high  than  that  of  the  preceding  day ;  the  stools 
lessen  in  number,  and  gradually  assume  a  more  healthy  appearance ; 
the  pulse  diminishes  in  frequency  and  gains  in  force;  the  tongue  becomes 
moist,  and  shows  a  tendency  to  throw  off  its  fur ;  the  trembling  grows 
less  marked ;  the  dulness  and  delirium  lessen ;  and  the  patient  falls  into 
a  refreshing  sleep.  In  other  cases,  in  many  of  which  recovery  eventually 
takes  place,  there  is  at  this  time,  instead  of  an  improvement,  a  still 
further  aggravation  of  the  symptoms.  The  pulse  becomes  more  feeble 
and  frequent ;  the  tongue  is  not  only  excessively  dry  and  brown,  but 
shrivelled  and  fissured ;  the  lips  and  teeth  are  encrusted  with  sordes ;  the 
stools  contain  shreds  of  membrane,  and  often  blood ;  the  subsultus  ten- 
dinum  increases ;  carphololgia,  or  picking  at  the  bed-clothes,  occurs.  The 
prostration  becomes  so  extreme  that  the  patient  frequently  slips  down  in 
bed  from  sheer  weakness.  The  active  delirium  of  the  previous  stage  is 
replaced  by  the  low  muttering  form,  or  the  patient  lies  upon  his  back 
with  his  eyes  half  closed  in  a  semi-unconscious  condition,  from  which  he 
is  with  difficulty  aroused,  and  which  may  deepen  into  coma.  Occasionally, 
however,  the  active  delirium  continues,  and  is  associated  with  an  obstinate 
wakefulness ;  the  urine  and  feces  are  passed  involuntarily,  or,  with  an 
apparent  incontinence  of  the  former,  there  may  be  retention,  which  is 
very  apt  to  be  overlooked.  If  these  symptoms  continue  for  any  length 
of  time,  bed-sores  may  form  not  only  over  the  sacrum,  but  on  other  parts 
subject  to  pressure,  and  the  patient,  worn  out  by  long-continued  suffering, 
dies  from  exhaustion. 

Occasionally,  in  the  midst  of  these  symptoms,  and  sometimes  even  in 
cases  in  which  the  condition  is  not  so  alarming,  prostration  approaching 


CLINICAL  DESCRIPTION.  271 

collapse,  without  obvious  cause,  suddenly  supervenes.  The  pulse  becomes 
a  mere  thread,  the  surface  is  bathed  in  a  clammy  sweat,  and  the  tempera- 
ture is  found  to  have  fallen  from  four  to  seven  degrees,  and  in  some  cases 
even  more.  These  symptoms  almost  always  indicate  that  intestinal 
hemorrhage  has  taken  place,  and  are  followed  by  the  discharge  of  blood 
either  in  the  course  of  a  few  hours  or  not  until  a  day  or  two  subsequently. 
If  the  hemorrhage  be  moderate  in  amount,  and  does  not  recur,  reaction 
usually  takes  place  in  a  short  time ;  but  if,  on  the  other  hand,  it  is  pro- 
fuse or  frequently  repeated,  death  may  occur,  either  immediately  or  later, 
as  the  result  of  the  exhaustion  it  has  induced.  Very  much  the  same  set 
of  symptoms  attend  the  occurrence  of  perforation  of  the  bowel,  an  acci- 
dent which  is  also  liable  to  happen  in  the  course  of  typhoid  fever,  but 
which  may  generally  be  distinguished  from  intestinal  hemorrhage  by  its 
being  accompanied  by  a  sharp  pain  in  the  abdomen,  which  is  frequently 
so  severe  as  to  cause  the  patient  to  cry  out,  by  its  not  being  attended  with 
the  same  reduction  of  temperature,  and  by  the  absence  of  blood  in  the 
discharges.  In  a  day  or  two  all  doubt  will  be  set  at  rest,  if  the  case  be 
one  of  perforation,  by  the  occurrence  of  general  peritonitis. 

A  fatal  termination  is  by  no  means  the  usual  result,  even  in  cases  in 
which  the  disease  has  assumed  its  worst  features.  Indeed,  it  may  be  said 
that  there  is  no  condition  in  typhoid  fever  so  grave  that  recovery  from  it 
is  impossible.  Many  authors  would  make  perforation  of  the  bowel  an 
exception  to  this  general  rule,  but  there  are  observations  on  record  which 
would  seem  to  show  that  this  accident  is  not  invariably  fatal.  Even  in 
cases  in  which  the  patient  has  lain  helplessly  on  his  back  in  a  semi-uncon- 
scious or  comatose  condition,  passing  his  discharges  under  him,  the  physi- 
cian will  often  be  gratified  to  find  at  one  of  his  visits  some  evidence  of 
improvement,  trifling  as  it  will  probably  be.  It  may  be  only  a  slight 
change  of  position,  an  inconsiderable  fall  of  temperature,  or  a  scarcely 
appreciable  moistening  of  the  tongue ;  but  these  changes,  insignificant  as 
they  apparently  are,  are  sufficient  to  indicate  to  the  practised  eye  of  the 
observant  physician  the  approach  of  convalescence.  Next  day  there  will 
be  a  still  further  reduction  of  temperature,  a  more  decided  moistening  of 
the  tongue,  a  sensible  diminution  of  the  nervous  symptoms,  and  a  reduc- 
tion in  the  frequency  of  pulse.  In  this  condition,  however,  as  may  be 
readily  imagined,  convalescence  may  be  retarded  by  numerous  accidents, 
and  life  may  hang  trembling  in  the  balance  for  several  days,  or  even 
weeks,  before  it  is  fully  established.  It  is  not  necessary  to  recount  here 
the  various  steps  by  which  a  return  to  health  is  reached,  as  they  are  essen- 
tially the  same  as  those  which  mark  the  convalescence  of  the  less  severe 
variety  of  the  disease,  and  have  already  been  fully  referred  to  in  the 
description  of  that  form. 

But  even  after  the  establishment  of  convalescence,  and  after  the  patient 
has  been  free  from  fever  for  several  days,  febrile  attacks  lasting  for  a  day 
or  two,  or  even  longer,  may  occur  as  the  consequence  of  very  slight  causes, 
such  as  undue  excitement,  or  fatigue  of  any  kind,  or  the  immoderate 
indulgence  of  the  appetite,  which  in  this  condition  frequently  needs  to  be 
restrained.  These  attacks  are  usually  spoken  of  as  recrudescences  of 
fever,  and  do  not  differ  materially  from  attacks  of  irritative  fever  occur- 
ring under  other  circumstances.  They  usually  subside  under  appropriate 
treatment  with  the  removal  of  their  cause,  but  leave  the  patient  somewhat 


272  TYPHOID  FEVER. 

weaker  than  they  found  him.  In  other  cases,  it  may  be  a  week  or  ten 
days  after  the  fall  of  the  temperature  to  the  normal,  and  frequently  at  a 
time  when  all  danger  seems  to  have  been  passed,  a  true  relapse  of  the  dis- 
ease occurs.  In  this,  of  course,  all  the  symptoms  of  the  primary  attack 
are  reproduced,  including  even  the  eruption  of  rose-colored  spots.  The 
temperature  usually,  however,  attains  the  maximum  more  rapidly,  and  the 
duration  of  the  fever  is  generally  shorter,  than  that  of  the  original  attack. 
A  second  relapse  is  also  not  very  uncommon,  and  even  a  third  may  occur. 
Various  complications  and  sequelae  also  occur  in  the  course  of  typhoid 
fever,  which  will  be  referred  to  fully  hereafter. 

Another  form  of  the  disease,  which  it  may  be  well  to  allude  to  briefly 
here  before  closing  the  general  description  of  the  disease,  is  the  abortive 
form.  In  this  variety  the  attack  begins  and  runs  its  course  up  to  a  cer- 
tain point,  including  often  even  the  occurrence  of  the  eruption,  as  it  does 
in  the  majority  of  cases  ;  but  at  a  period  which  varies  between  the  seventh 
and  fourteenth  day  the  symptoms  suddenly  subside  and  the  patient  rapidly 
convalesces.  In  some  cases  it  may  be  difficult  to  distinguish  this  form 
from  an  attack  of  simple  continued  fever,  and,  in  fact,  in  cases  in  which 
the  eruption  is  absent  it  will  be  impossible,  unless  other  cases  of  typhoid 
fever  have  occurred  in  the  same  house  or  family,  or  unless  the  patient  has 
been  unmistakably  exposed  to  the  influences  under  which  the  disease 
arises. 

In  a  few  cases  the  disease  begins  abruptly  with  a  chill,  intense  head- 
ache, or  with  gastro-mtestinal  symptoms,  \vhich  have  in  rare  instances 
been  so  violent  as  to  have  suggested  to  the  mind  of  the  attending  physi- 
cian the  possibility  of  corrosive  poisoning.  This,  according  to  Chomel,  is 
the  most  frequent  mode  of  commencement,  but  his  experience  on  this 
point  is  opposed  to  that  of  the  great  majority  of  observers. 

I  shall  now  proceed  to  describe  in  detail  some  of  the  most  important 
of  the  symptoms  presented  by  the  disease. 

Even  in  the  beginning  of  an  attack  of  typhoid  fever  the  face  has  a  list- 
less and  languid  expression,  although  the  eyes  are  usually  bright  and  the 
pupils  dilated.  In  mild  cases  no  further  alteration  of  the  physiognomy 
than  this  may  be  noticeable  throughout  the  whole  course  of  the  disease, 
but  in  bad  cases,  when  the  typhoid  condition  is  fully  developed,  the 
expression  becomes  dull  and  heavy.  There  is,  however,  never  the  general 
suffusion  of  the  face  seen  in  typhus.  On  the  contrary,  the  face  is  often 
pallid,  or  there  is  at  most  a  circumscribed  flush  on  one  or  both  cheeks, 
which  is  most  marked  during  the  exacerbations  of  fever  or  after  the 
administration  of  food  and  stimulants.  During  convalescence  the  effects 
of  the  long  illness  are  fully  visible  in  the  face. 

Prostration,  or  loss  of  muscular  strength,  is  present  from  the  beginning 
in  a  large  number  of  cases  of  typhoid  fever,  but  is  generally  not  so 
marked  in  the  early  stages  as  in  typhus  fever.  It  is  usually  most  intense  in 
grave  cases,  but  to  this  rule  there  are  numerous  exceptions.  It  is  not  rare 
to  find  patients,  in  whom  the  other  symptoms  are  severe,  able  to  sit  up  in 
bed,  and  even  to  rise  to  stool,  throughout  the  attack.  Bartlett  records  a 
case  in  which  the  patient  did  not  confine  herself  to  bed  until  the  occur- 
rence of  perforation,  and  I  have  had  under  my  care  a  man  who,  suppos- 
ing he  was  suffering  only  from  a  slight  diarrhoea,  performed  the  duties 


CLINICAL  DESCRIPTION.  273 

of  a  nurse  in  a  military  hospital  until  two  days  before  his  death,  although 
the  autopsy  showed  very  extensive  ulceration  of  the  intestine.  Several 
cases  have  come  under  my  care  in  the  second  week  in  which  patients 
have  walked  a  considerable  distance  to  make  application  for  admission  to 
a  hospital.  Generally,  however,  the  prostration  becomes  extreme  in  the 
third  and  fourth  weeks  of  bad  cases,  the  patient  lying  helplessly  on  his 
back,  and  frequently  slipping  down  in  bed  from  sheer  weakness. 

Epistaxis  may  occur  at  any  stage  of  typhoid  fever,  but  is  most  common 
in  the  forming  stage.  Observers  diifer  in  opinion  in  regard  to  its  fre- 
quency. Murchison  noted  it  in  only  15  of  58  cases,  and  gives  it  as  his 
belief  that  it  is  more  common  in  France  than  in  England  or  this  country. 
Flint  found  that  it  had  occurred  in  21  only  of  73  cases,  and  Jenner  in  5 
of  15  fatal  cases.  On  the  other  hand,  Bartlett  says  that  it  is  quite  a 
common  symptom,  and  Wood  and  Gerhard,  from  the  frequency  with 
which  they  had  met  with  it  in  the  beginning  of  the  disease,  were  accus- 
tomed to  regard  its  presence  as  of  importance  in  a  diagnostic  point  of 
view.  Part  of  this  divergence  of  opinion  is  probably  due  to  the  fact 
that  it  is  usually  small  in  amount,  and  therefore  very  apt  to  be  overlooked. 
I  have  in  many  cases,  after  having  been  told  there  had  been  no  epistaxis, 
found  the  evidence  of  it  upon  the  fingers  or  bed-clothes  of  the  patient. 
It  may,  however,  be  so  profuse  as  to  endanger  life  and  render  necessary 
the  use  of  the  tampon.  Except  in  the  latter  case  it  is  without  influence 
upon  the  course  of  the  disease. 

The  skin  may  be  almost  constantly  dry  as  well  as  warm  throughout 
the  whole  course  of  the  fever  in  a  small  proportion  of  severe  cases.  But, 
on  the  whole,  perspiration  occurs  with  greater  frequency  in  typhoid  fever 
than  in  any  other  acute  disease,  unless  it  be  rheumatism.  It  takes  place 
most  commonly  at  night  after  the  evening  exacerbation,  or  in  the  morning 
when  the  patient  awakes  from  sleep,  but  it  is  not  very  rare  to  find  the 
skin  clammy  at  other  times.  The  sweating  is  usually  general,  but  in  a 
few  cases  it  is  local  only.  When  colliquative,  it  is  frequently  exhaust- 
ing, and  is  then  a  grave  symptom.  It  is  sometimes  prolonged  into 
convalescence,  when  it  is  not  only  annoying,  but  in  consequence  of  the 
prostration  it  induces  may  sometimes  retard  the  restoration  to  health. 

I  have  never  been  able  to  satisfy  myself  that  any  peculiar  odor  is  given 
off  by  the  skin  in  typhoid  fever,  and  most  observers  make  a  similar  state- 
ment. Chomel,  however,  asserted  that  the  perspiration  has  a  strong  acid 
odor,  and  Bartlett  agreed  with  Nathan  Smith  in  thinking  that  typhoid 
fever  patients  exhale  a  peculiar  odor,  not  pungent  and  ammoniacal,  like 
that  of  typhus,  but  "  of  a  semi-cadaverous  and  musty  character,"  which 
is  especially  noticeable  during  the  later  stages  of  severe  and  fatal  cases. 

The  eruption  is  one  of  the  most  characteristic  symptoms  of  the  disease. 
Indeed,  in  many  cases,  without  it  the  diagnosis  would  be  impossible.  It 
is  rarely  absent  in  a  well-developed  case.  Murchison  says  that  it  was 
noted  in  4606  cases  only  out  of  5988  admitted  into  the  London  Fever 
Hospital  in  twenty-three  years,  but  admits  that  it  would  probably  have 
been  found  in  some  of  the  others  if  it  had  been  properly  looked  for. 
Wood  says  that  he  has  seldom  met  with  cases  in  which  it  was  absent. 
It  is  oftener  absent  in  children  than  adults — a  circumstance  which  makes 
the  diagnosis  of  the  disease  in  the  former  often  a  matter  of  great  diffi- 
culty. It  consists  of  isolated  rose-colored  spots,  slightly  elevated  above 

VOL.  I.— 18 


274  TYPHOID  FEVER. 

the  surface,  circular  in  form  or  nearly  so,  having  well-defined  margins, 
usually  about  a  line  in  diameter,  but  sometimes  varying  from  half  a  line 
to  two  and  even  three  lines  in  diameter,  and  disappearing  on  pressure,  to 
return  when  the  pressure  is  removed.     They  are  generally  first  observed 
some  time  between  the  seventh  and  fourteenth  days,  but  cases  are  on 
record,  especially  in  children,  in  which  they  are  said  to  "have  appeared 
much  earlier,  and  others  in  which  they  could  not  be  discovered  until  the 
twentieth  day.     In  the  latter  cases,  however,  it  is  not  improbable  they 
had  really  been  present  at  an  earlier  period,  but  had  escaped  detection. 
The  eruption  occurs  in  crops  at  intervals  of  three  or  four  days,  each  spot 
lasting  from  three  to  five  days,  and  the  whole  duration  of  the  eruption 
being   usually  from  ten  to  twenty,   and   varying   of  course  with  the 
severity  of  the  attack.     It  may  continue  to  appear  as  late  as  the  twen- 
tieth day,  and  in  cases  of  relapses  very  much  later.     Spots  are  sometimes 
seen  on  the  abdomen  or  elsewhere  after  the  subsidence  of  fever,  and 
whenever  seen  indicate  that  the  diseased  'process  is  not  at  an  end.     They 
are  usually  scattered  over  the  lower  part  of  the  front  of  the  chest  and 
the  abdomen,  but  are  also  not  infrequently  met  with  upon  the  back,  and 
if  they  are  not  found  upon  the  abdomen,  the  patient  should  be  gently 
turned  npon  his  side   and   this  part  of   his  body  carefully  examined. 
When  very  abundant  they  are  often  also  seen  upon  the  extremities,  and 
occasionally  even  upon  the  face.     Wood  has  seen  them  abundant  on  the 
upper  and  inner  part  of  the  thigh,  and  confined  to  that  place.     When 
tardy  in  making  their  appearance,  they  may  often  be  brought  out  by 
application  of  a  mustard  plaster  or  by  that  of  heat  in  any  form ;  and 
it  is  probably,  therefore,  owing  in  large  measure  to  the  warmth  of  the  bed 
that  they  are  often  so  fully  developed  upon  the  back.     In  number  they 
may  vary  from  two  or  three  to  several  hundred.     In  one  case  Murchison 
counted  one  thousand,  and  in  three  cases  which  came  under  my  care  in 
the  winter  of  1881—82  the  body  was  so  thickly  covered  by  spots  of  an 
unusually  large  size  that  when  I  first  saw  the  patients  I  directed  them 
to  be  isolated  under  the  fear  that  the  disease  would  prove  to  be  typhus 
fever.     When  very  numerous  the  edges  of  two  or  three  of  the  spots  may 
run  together,  giving  the  eruption  an  irregular  character.     No  relation 
between  the  copiousness  of  the  eruption  and  the  severity  of  the  disease 
has  ever  been  proved  to  exist.     While  the  prevailing  impression,  there- 
fore, that  cases  in  which  the  eruption  is  freely  developed  are  apt  to  be  of 
a  mild  character,  is  true  in  many  instances,  it  is  by  no  means  so  in  all. 
The  three  cases  above  referred  to  all  ran  a  severe  course,  and  one  of  them 
proved  fatal.     The  spots  disappear  after  death,  and  are  rarely  converted 
into  petechiae,  but  in  bad  cases  I  have  seen  purpura  spots,  and  even 
vibices,  developed  independently  of  them.     Sometimes  the  appearance 
of  the  eruption  is  preceded  for  a  day  or  two  by.  a  delicate  scarlet  rash, 
which  Tweedie  says  resembles  roseola  and  has  been  mistaken  for  scarlet 
fever. 

Sudamina,  so  called  from  their  resemblance  to  sweat-drops,  also  occur 
not  infrequently  in  this  disease.  They  are  minute  vesicles,  often  not 
larger  than  a  pin's  head,  but  sometimes  two  lines  in  diameter,  and  occa- 
sionally, in  cases  in  which  two  or  three  have  coalesced,  much  larger. 
They  usually  contain  at  first  a  clear  serum,  which  may,  however,  subse- 
quently become  turbid,  and  when  very  minute  must,  in  consequence  of 


CLINICAL  DESCRIPTION.  275 

their  transparency,  be  viewed  obliquely  to  be  seen.  Frequently,  when 
they  cannot  be  distinguished  by  the  eye,  they  are  readily  detected  by  the 
touch.  They  rarely  occur  before  the  twelfth  day,  and  often  not  before 
the  close  of  the  third  week.  Their  most  usual  seat  is  the  neck,  the  folds 
of  the  axillae,  and  the  groin,  but  there  is  no  part  of  the  body  except  the 
face  in  which  they  may  not  occur.  They  are  most  frequently  seen  in 
those  cases  attended  by  profuse  sweating,  and  are  by  no  means  peculiar  to 
typhoid  fever,  but  are  met  with  in  other  diseases — as,  for  instance,  acute 
rheumatism — which  are  attended  by  this  symptom.  They  are  generally 
followed  by  branny  desquamation  of  the  cuticle  in  the  position  they  have 
occupied. 

Spots  of  a  delicate  blue  tint — the  "  taches  bleuatres  "  of  French  writers 
— are  sometimes  observed  on  the  skin  in  cases  of  enteric  fever.  They 
must  be  of  infrequent  occurrence  in  this  country,  for,  although  I  have 
looked  carefully  for  them  in  every  case  that  has  come  under  my  care,  I  have 
rarely  been  able  to  detect  them.  According  to  Murchison,  "  they  are  of 
an  irregularly  rounded  form  and  from  three  to  eight  lines  in  diameter. 
They  are  not  in  the  least  elevated  above  the  skin,  nor  affected  by  pressure, 
even  at  their  first  appearance.  They  have  a  uniform  tint  throughout  their 
extent,  and  they  never  pass  through  the  successive  stages  observed  in  the 
spots  of  typhus.  Two  or  three  of  them  are  sometimes  confluent.  They 
are  most  common  on  the  abdomen,  back,  and  thighs."  They  are  said  in 
some  cases  to  be  distributed  along  the  course  of  the  small  cutaneous  veins, 
and  to  occur  most  frequently  in  cases  which  are  mild.  They  are  met 
with  in  other  diseases,  and  usually  precede  in  appearance  the  character- 
istic eruption  of  typhoid  fever. 

The  hair  is  very  apt  to  fall  out  after  an  attack  of  typhoid  fever.  The 
nails  suffer  in  their  nutrition  in  common  with  other  parts  of  the  body — 
a  fact  which  may  be  recognized  by  the  peculiar  markings  which  are  found 
upon  them  after  recovery,  and  to  which  attention  has  been  particularly 
drawn  by  Morris  Longstreth  in  a  paper  in  the  Transactions  of  the  Col- 
lege of  Physicians  of  Philadelphia,  vol.  iii.,  3d  Series. 

The  circulation  is  usually  accelerated  from  the  beginning  of  an  attack 
of  typhoid  fever.  The  degree  of  acceleration  is  commonly  proportioned 
to  the  severity  of  the  other  symptoms,  and  especially  to  the  elevation  of 
the  temperature,  and  is  generally  more  marked  in  the  evening  than  in  the 
morning.  It  is  subject,  however,  to  numerous  variations,  not  only  in 
different  cases,  but  even  in  the  same  case  from  day  to  day,  and  even  from 
hour  to  hour.  Murchison  refers  to  a  case  in  which  the  pulse  sank  to  37, 
and  never  exceeded  56  during  the  fever,  although  it  rose  to  66  during 
the  convalescence.  I  have  never  had  the  opportunity  myself  of  observ- 
ing such  an  infrequent  pulse  in  the  febrile  period  of  the  disease,  but 
have  had  cases  under  my  care  in  which  the  pulse  often  fell  below  60,  and 
in  which  it  never  exceeded  80  until  after  the  commencement  of  conva- 
lescence. A  comparatively  infrequent  pulse  may  coexist  with  a  high 
temperature.  Thus,  for  example,  a  pulse  of  80  was  noted  in  one  of  my 
cases  at  the  same  time  that  the  thermometer  showed  that  the  temperature 
was  105°,  and  on  another  occasion  in  the  same  case  the  pulse  was  82  and 
the  temperature  104 J°.  As  a  rule,  the  pulse  is  more  frequent  in  cases 
which  terminate  fatally  than  in  those  which  end  in  recovery ;  but  to  this 
rule  there  are  numerous  exceptions.  In  eight  of  Louis's  cases  it  never 


276  TYPHOID  FEVER. 

went  above  90,  and  in  some  of  my  own  it  did  not  reach  100  on  more 
than  one  or  two  occasions.  On  the  other  hand,  in  mild  cases  the  pulse 
may  be  exceedingly  frequent,  reaching,  and  even  exceeding  in  many 
cases,  120.  When  the  disease  is  prolonged  and  the  prostration  is 
extreme,  a  pulse  of  from  140  to  150  is  not  uncommon.  In  the  majority 
of  cases  which  have  come  under  my  care  the  pulse  has  varied  in  fre- 
quency from  80  to  120.  In  some  cases  the  range  has  been  between  these 
two  figures,  in  others  it  has  been  very  much  less. 

During  convalescence  the  pulse  usually  gradually  diminishes  in  fre- 
quency, and  may  sometimes  fall  below  the  normal  standard.  I  have 
known  it  in  a  few  instances  to  fall  to  38,  and  have  often  met  with  pulses 
ranging  between  40  and  60  at  this  period.  In  other  cases,  on  the  con- 
trary, the  pulse  continues  frequent  during  convalescence,  or  readily 
becomes  so  after  a  slight  exertion  or  excitement  of  any  kind.  A  slow 
pulse  during  convalescence  has  been  in  my  experience  most  frequent 
in  men  whose  health  previous  to  the  attack  was  good,  and  a  frequent 
pulse  in  women  and  delicate  men.  If  the  convalescence  is  retarded 
by  a  complication,  the  pulse  will  maintain  its  frequency  until  this  is 
removed. 

The  pulse  will  of  course  present  other  changes  than  those  above 
referred  to.  It  is  in  the  beginning  firm  and  full,  but  after  the  first 
week  becomes  small  and  compressible,  and  acquires  the  peculiarity 
known  as  reduplication.  Sometimes,  when  this  is  not  well  developed, 
it  will  be  rendered  quite  distinct  by  elevating  the  patient's  arm. 
Irregularity  or  intermission  of  the  pulse,  although  not  commonly  ob- 
served in  this  disease,  occasionally  occurs.  The  heart's  action  will  also 
be  observed  to  grow  feeble  in  the  course  of  severe  cases,  and  its  first 
sound  indistinct,  but  neither  of  these  changes  is  as  marked  in  typhoid 
as  in  typhus  fever.  Hay  em  asserts  that  in  a  certain  number  of  cases  a 
systolic  bellows  murmur,  with  its  point  of  greatest  intensity  at  the  apex, 
is  heard  during  the  course  or  at  the  close  of  the  second  week.  This  mur- 
mur is  sometimes  soft  in  the  beginning,  but  becomes  harsh  and  intense 
later,  or  may  have  these  characters  from  the  start  to  such  a  degree  as  to 
give  the  impression  that  endocarditis  exists.  During  convalescence  an 
ansemic  murmur  is  not  infrequently  present. 

The  respiratory  movements  are  accelerated  in  typhoid  fever,  as  they 
are  in  all  febrile  conditions,  independently  of  any  disease  of  the  lungs, 
and  their  frequency  is  generally  proportional  to  that  of  the  pulse.  In 
looking  over  my  records  of  cases  I  find  that  the  former  are  less  liable 
to  fluctuate  from  day  to  day  than  the  pulse,  and  that  when  the  latter 
becomes  abnormally  infrequent  they  do  not  sink  below  the  standard  of 
health.  In  several  cases  of  which  I  have  notes  the  respiration  was  from 
20  to  28,  while  the  pulse  was  below  60,  and  in  a  case  referred  to  by 
Murchison  the  pulse  was  42  at  the  same  time  that  the  respirations, 
although  no  pulmonary  lesion  could  be  discovered,  were  48.  The  res- 
piration is  often,  as  in  the  case  just  alluded  to,  very  much  accelerated 
when  the  most  careful  examination  of  the  chest  will  not  lead  to  the 
detection  of  any  disease  there.  This  is  sometimes  the  consequence  of 
very  great  tympanites,  which,  by  interfering  with  the  descent  of  the  dia- 
phragm, gives  rise  to  dyspnoea,  but  it  may  also  occur  as  a  purely  nervous 
phenomenon.  The  air  expired  by  patients  has  been  examined,  and  has 


CLINICAL  DESCRIPTION.  277 

been   found   sometimes,  in  the   later  stages  of  the  disease,  to  contain 
ammonia. 

Bronchitis  is  so  common  an  accompaniment  of  typhoid  fever  that 
auscultation  rarely  fails  to  reveal  its  presence  in  some  form  or  other.  In 
some  cases  there  may  be  only  slight  harshness  of  the  respiratory  murmur 
at  the  base  of  the  chest,  but  in  a  large  number  of  cases  the  auscultatory 
signs  will  be  sonorous,  sibilant,  and  mucous  rales.  The  last  named  may 
be  so  numerous  that  I  have  known  the  disease  in  the  beginning  mistaken 
for  acute  bronchitis,  and  even  acute  phthisis,  by  accomplished  diagnos- 
ticians. 

Headache  is  one  of  the  most  constant  symptoms  of  typhoid  fever. 
Bartlett  says  that  it  is  rarely  absent,  Louis  found  it  in  all  but  7  of  133 
cases,  and  Jackson  noted  it  in  nearly  all  his  cases.  It  is  often  the  first 
symptom  of  which  the  patient  complains,  and,  when  not  present  at  the 
beginning  of  the  attack,  makes  its  appearance  soon  after.  It  is  almost 
as  common,  although  less  severe,  in  mild  cases  as  in  grave  ones.  It  some- 
times persists  throughout  the  attack,  but  oftener  subsides  at  the  close  of  the 
first  week  or  toward  the  •  middle  of  the  second,  or  the  patient  may  cease 
to  complain  of  it  in  consequence  of  the  dulness  which  is  very  apt  to 
supervene.  It  is  usually  referred  to  the  forehead  and  temples,  but  may 
extend  over  the  whole  head.  It  is  usually  dull  and  heavy,  but  in  a  few 
cases  is  throbbing.  It  is  said  by  authors  rarely  to  be  severe,  but  I  have 
known  it  so  intense  and  acute  as  to  cause  the  disease  at  its  commencement 
to  be  mistaken  for  meningitis,  and  Jackson  asserted  that  it  is  sometimes 
so  severe  that  local  bloodletting,  and  even  venesection,  had  to  be  employed 
for  its  relief.  It  would  appear  to  be  as  common  in  children  as  adults. 

The  headache  is  sometimes  accompanied  by  vertigo  and  dizziness,  and 
even  by  retraction  of  the  head.  Distressing  pains  in  the  back  and  limbs 
may  also  occur,  and  in  rare  cases  even  contraction  of  the  hands  and  feet. 

In  the  beginning  of  an  attack  of  typhoid  fever  the  patient  usually 
suffers  from  wakefulness  and  restlessness  at  night,  and  it  occasionally 
happens  that  the  wakefulness  becomes  a  distressing  symptom.  But  in  a 
great  many  cases,  sooner  or  later  in  the  course  of  the  "disease,  drowsiness 
supervenes.  In  mild  cases  this  symptom  is  late  in  making  its  appear- 
ance, and  is  generally  slight  and  evanescent,  but  in  grave  cases  it  may 
come  on  as  early  as  the  eighth  day,  and  when  once  present  may  gradually 
become  more  profound  until  it  deepens  at  last  into  unconsciousness.  It 
usually  persists  until  the  occurrence  of  death  or  of  convalescence,  but 
may  alternate  with  periods  of  delirium,  the  delirium  being  more  frequent 
at  night  and  the  somnolence  by  day.  It  is  as  frequent  in  children  as 
in  adults.  Occasionally,  the  wakefulness  of  the  earlier  stage  may  reap- 
pear at  the  beginning  of  the  third  week,  and  coexist  with  muttering  delir- 
ium, or  occasionally  with  delirium  of  a  more  violent  character.  It  then 
constitutes  a  most  unfavorable  symptom,  the  patient  frequently  passing 
several  days  and  nights  in  incessant  agitation,  and  sinking  finally  from 
exhaustion  due  to  want  of  sleep. 

Some  degree  of  mental  hebetude  is  rarely  absent,  even  in  the  mildest 
cases  of  typhoid  fever,  and  is  usually  among  its  earliest  symptoms.  It 
may,  however,  be  absent  occasionally  in  cases  which  run  a  severe  course. 
It  exhibits  itself  in  the  beginning  in  an  indisposition  to  be  disturbed.,  a 
slight  inability  to  fix  the  thoughts,  or  a  loss  of  memory.  Generally,  the 


278  TYPHOID  FEVER. 

patient  will  be  able  at  first,  by  an  effort,  to  rouse  himself  from  this 
apathy,  but  the  moment  he  relaxes  this  effort  will  lapse  into  his  former 
condition.  As  the  disease  progresses  the  hebetude  becomes  more  profound 
and  is  overcome  with  greater  difficulty.  In  mild  cases  it  may  continue 
until  the  occurrence  of  convalescence,  but  in  grave  cases  it  is  soon  lost  in 
delirium.  This  is  one  of  the  commonest  symptoms  of  the  disease.  If  I 
should  rely  solely  upon  my  own  experience,  I  should  say  that  it  was  rare 
for  any  but  the  mildest  cases  to  run  their  course  without  its  occurring  at 
some  time  or  other.  Louis  found,  however,  that  it  was  absent  in  32 
cases,  8  of  which  were  fatal,  out  of  134  cases,  and  Murchison  in  33  cases, 
3  of  which  ended  in  death,  out  of  100  cases.  In  8  of  these  fatal  cases 
death  was  due  to  perforation — a  fact  which  would  seem  to  show,  as 
suggested  by  James  C.  Wilson,  that  this  symptom  is  not  dependent 
upon  the  intensity  of  the  local  disease  alone.  The  delirium  of  course 
varies  with  the  severity  of  the  other  symptoms,  and  especially  with  the 
intensity  of  the  fever.  In  its  mildest  form  it  consists  of  a  slight  confu- 
sion of  ideas,  which  is  readily  dissipated  by  fixing  the  patient's  attention, 
and  is  most  apt  to  occur  in  the  night  or  when  he  first  wakes  up  from 
sleep.  In  other  cases  it  is  much  more  marked ;  occasionally  it  is  violent 
and  noisy ;  the  patient  may  talk  wildly  and  incoherently,  he  may  break 
out  into  a  paroxysm  of  screaming,  or,  possessed  with  a  sudden  terror,  he 
may  leave  his  bed  and  attempt  to  rush  from  the  room  or  to  jump  from 
the  window.  Later  in  the  course  of  the  disease  the  active  delirium  sub- 
sides, and  low  muttering  delirium  .takes  its  place.  The  latter  may  go  on 
until  convalescence  occurs,  or  the  patient  may  gradually  fall  into  a  coma- 
tose condition,  which  very  often  ends  in  death. 

The  delusions  from  which  the  patient  suffers  are  various.  I  have 
known  in  two  instances  a  perfectly  pure  young  girl  call  loudly  for  her 
baby,  which  she  accused  her  mother  and  sister  of  keeping  from  her. 
Very  frequently  patients  insist  that  they  are  in  a  strange  place,  and 
beg  piteously  to  be  taken  to  their  home  and  friends ;  occasionally,  in 
grave  cases,  the  patient  declares  that  there  is  nothing  the  matter  with 
him.  This  Louis  Vas  accustomed  to  regard  as  a  bad  symptom,  having 
never  known  recovery  to  take  place  after  it.  Delirium  generally  first 
makes  its  appearance  some  time  in  the  course  of  the  second  week,  but 
occasionally  the  invasion  of  the  disease  is  marked  by  maniacal  excitement. 
I  have  known  delirium  to  occur  on  the  second  or  third  day.  Louis 
records  two  cases  in  which  it  was  present  during  the  first  night,  and 
Bristowe1  one  in  which  it  was  noted  on  the  fourth  night.  It  is  some- 
times so  prominent  a  symptom  in  the  beginning  of  an  attack  that  the 
patient  has  at  first  been  supposed  to  be  aifected  with  acute  mania.  M. 
Motet2  indeed  refers  to  a  case  in  which  a  man  was  actually  admitted  into 
an  insane  asylum  before  the  true  nature  of  his  disease  became  known. 
On  the  other  hand,  delirium  may  not  occur  until  much  later  in  the 
disease — sometimes  not  before  the  close  of  the  third  or  even  the  fourth 
week,  when  it  may  suddenly  make  its  appearance  when  least  expected.  I 
have  known  it  to  be  present  in  a  marked  degree  during  a  relapse  when  it 
had  been  wholly  wanting  in  the  primary  attack. 

During  convalescence,  especially  in  cases  in  which  there  has  been  much 

1  Trans.  Path.  Soc.  Lond.,  vol.  xiii. 

*  Archiv.  gen.  de  Med.,  1868,  quoted  by  Murchison. 


CLINICAL  DESCRIPTION.  279 

mental  disturbance  during  the  febrile  period,  the  intellect  may  be  weak, 
and  continues  so  in  some  cases  even  after  recovery  in  other  respects  is 
complete ;  but  it  is  rarely  permanently  impaired.  Insanity  may  also  occur 
during  the  convalescence  or  after  recovery,  but  it  is  usually  under  these 
circumstances  amenable  to  treatment.  In  some  cases  the  moral  sense 
appears  to  be  weakened  after  an  attack,  as  in  the  case  reported  by 
Nathan  Smith,  in  which  a  young  man  of  previously  good  habits  devel- 
oped thieving  propensities  after  his  recovery. 

Hypereesthesia  of  the  skin  exists,  according  to  Murchison,  in  about  5 
per  cent,  of  the  cases,  and  may  occur  at  any  stage  of  the  disease.  It  is 
chiefly  observed  in  the  abdomen  and  lower  extremities,  and  is  more  fre- 
quently met  with  in  women  and  children  than  in  adult  males.  In  a  case 
which  was  partially  under  my  care  during  the  past  summer  the  slightest 
touch  made  the  patient,  a  boy  of  fifteen  years,  cry  out  with  pain,  and  the 
administration  of  an  enema  gave  him  excruciating  agony.  Occasionally, 
the  tenderness  over  the  abdomen  is  so  great  that  it  is  sometimes  difficult 
to  distinguish  it  from  that  due  to  peritonitis,  except  by  the  coexistence  of 
hypersesthesia  in  other  parts  of  the  body.  It  is  very  often  associated 
with  spinal  tenderness,  and  sometimes  with  other  spinal  symptoms. 
Murchison  does  not  regard  it  as  a  formidable  symptom. 

Cutaneous  ansesthesia  may  also  occur,  but  it  is  certainly  less  common 
in  the  earlier  stages  than  hyperaesthesia.  Billiet  and  Barthez  look  upon 
it  as  of  grave  diagnostic  import  when  it  occurs  in  children. 

Muscular  tremor  is  also  a  common  symptom  of  typhoid  fever.  A 
little  tremulousness  of  the  tongue  when  protruded  may  often  be  detected 
before  the  close  of  the  first  week.  A  little  later  the  hands  will  be 
observed  to  tremble  when  held  up,  and  still  later  twitching  of  the 
tendons  at  the  wrist  may  be  appreciable  while  the  pulse  is  being  felt. 
When  muttering  delirium  supervenes  this  subsultus  tendinum  becomes 
constant,  and  extends  to  other  parts  of  the  body.  The  hands  of  the 
patient  are  frequently  then  in  constant  motion,  either  picking  at  the 
bed-clothes — a  very  unfavorable  symptom — or  moving  in  an  objectless 
manner  through  the  air.  This  condition  presents  many  points  of  resem- 
blance to  that  often  seen  in  delirium  tremens,  and  is  said  to  come  on 
earlier  and  to  be  more  marked  in  those  who  are  addicted  to  the  abuse  of 
alcoholic  liquors.  Hiccough  is  occasionally  observed  toward  the  close 
of  grave  cases,  and  is  justly  regarded  as  a  bad  symptom. 

Spasmodic  contraction  of  various  groups  of  muscles  is  occasionally 
observed  in  severe  cases,  but  is  less  frequent  than  muscular  tremor,  and 
in  my  experience  is  generally  met  with  in  the  earliest  period  of  the  dis- 
ease. The  muscles  of  the  extremities,  especially  those  of  the  legs,  are 
oftenest  affected,  but  I  have  known  the  head  as  rigidly  retracted  as  in 
tubercular  meningitis,  and  have  seen  cases  in  which  strabismus  has  been 
an  early  symptom.  Murchison  has  had  patients  under  his  care  who 
have  suffered  from  constriction  of  the  pharynx  to  such  an  extent  that 
they  could  not  swallow.  He  also  reports  cases  in  which  trismus  and 
spasm  of  the  glottis  have  been  present.  General  convulsions  are  not 
common,  but  occasionally  do  occur.  Although  a  very  grave  symptom, 
they  are  not  invariably  fatal.  Recovery  took  place  in  one  of  two  cases 
which  came  under  my  own  observation,  and  in  four  of  the  six  recorded 
by  Murchison.  They  are  not  always  associated  with  an  albuminous  con- 


280  TYPHOID  FEVER. 

clition  of  the  urine.  In  neither  of  my  cases  was  there  albuminuria,  and 
in  only  one  of  the  four  of  Murchison's  cases  in  which  the  urine  was 
examined  was  it  present.  In  one  of  my  cases — the  fatal  one — the  con- 
vulsions seemed  to  have  been  induced  by  giving  the  patient  improper 
food ;  in  the  other  no  cause  could  be  discovered. 

Ringing  or  buzzing  noises  in  the  ears  are  present  in  the  early  stage  of 
the  disease  in  a  large  proportion  of  the  cases,  and  may  sometimes  persist 
until  the  disease  is  well  advanced.  Usually,  however,  after  a  few  days 
they  subside  and  give  place  to  deafness.  This  is  a  very  common  symp- 
tom, and  may  either  affect  both  ears  or  be  limited  to  one.  In  the  former 
case  it  is  probably  generally  due  to  the  blunted  perceptions  of  the  patient, 
although  in  a  few  instances  it  may  be  caused,  as  suggested  by  Trousseau, 
by  inflammation  of  the  Eustachian  tube.  When  only  one  ear  is  affected 
the  deafness  is  of  more  serious  import,  as  it  is  then  dependent  upon  the 
presence  of  local  inflammation,  which  may  possibly  extend  to  the 
meninges.  It  is,  as  a  rule,  most  marked  in  the  severest  cases.  Unless 
there  has  been  a  local  inflammation  it  is  not  followed  by  permanent  im- 
pairment of  the  hearing.  It  has  even  been  regarded  by  some  observers 
as  a  favorable  symptom,  but  this  opinion  does  not  appear  to  rest  upon 
a  more  substantial  basis  than  the  observation  of  Louis,  that  the  most  pro- 
found deafness  adds  nothing  to  the  gravity  of  the  prognosis. 

Imperfect  or  perverted  vision  occasionally  occurs  in  the  course  of 
typhoid  fever.  In  a  case  which  was  recently  under  my  care,  and  which 
has  already  been  referred  to  in  another  connection,  there  was  double 
vision  associated  with  strabismus.  Sometimes  haziness  of  vision,  and 
sometimes  even  visual  illusions,  are  observed.  Bartlett  and  Murchison 
have  often  known  intolerance  of  light  present  in  cases  characterized  by 
active  febrile  excitement.  As  a  general  rule,  the  pupils  are  widely 
dilated  and  the  conjunctiva  pearly  white — a  condition  which  is  in  marked 
contrast  with  what  is  seen  in  typhus  fever.  When,  however,  stupor 
supervenes  in  bad  cases,  the  pupils  are  frequently  as  much  contracted 
and  the  conjunctive  as  much  injected  as  in  the  latter  disease.  In  a  few 
cases  unequal  dilatation  of  the  pupils  has  been  noticed.  Trousseau  was 
accustomed  in  his  clinical  lectures  to  call  attention  to  the  frequency  with 
which  sloughing  of  the  cornea  occurred  in  the  condition  known  as  coma 
vigil,  in  which  the  patient  lies  with  his  eyes  wide  open.  He  attributed 
this  accident  to  the  fact  that  the  eye  in  this  condition  is  not  kept  con- 
stantly moist  by  the  occasional  closure  of  the  eyelids,  and  hence,  as  its 
innervation  is  also  impaired,  is  especially  prone  to  take  on  ulcerative 
inflammation.  In  other  cases  there  is  a  free  secretion  of  viscid  matter, 
which  often  glues  the  eyelids  together. 

The  sense  of  taste  is  often  lost  or  perverted.  This  is  partly  due  to 
impaired  innervation  of  the  tongue  and  palate,  and  partly  to  the  thick 
deposits  which  usually  cover  the  mucous  membrane  of  these  organs. 

Frequent  observations  of  the  temperature  in  typhoid  fever  not  merely 
give  most  important  information  in  a  diagnostic  and  prognostic  point  of 
view,  but  also  often  furnish  valuable  indications  for  treatment.  From  a 
close  study  of  a  large  number  of  cases,  Wunderlich  and  other  physicians 
have  discovered  that  the  pyrexia  has  certain  characters  which  distinguish 
it  from  other  fevers,  and  which,  being  present  in  a  case  in  which  the 
other  symptoms  are  obscure  or  ill  denned,  will  often  enable  us  to  recognize 


CLINICAL  DESCRIPTION.  281 

its  true  nature.  The  pyrexia  may  be  divided  into  three  periods,  each 
having  its  own  peculiarities.  It  is  usually  said  that  each  period  lasts 
about  a  week,  but  in  severe  cases  the  second  and  third  periods  extend  over 
a  longer  time  than  this,  and  the  occurrence  of  a  complication  or  of  any 
other  disturbing  influence  will  have  its  effect  in  producing  either  a  pro- 
longation of  any  one  or  more  of  these  periods,  and  especially  of  the  last 
two,  or  an  unwonted  elevation  or  fall  of  temperature.  During  the  first 
period  there  is  a  progressive  rise  of  temperature,  but  the  rise  is  never  so 
abrupt  as  in  typhus  or  in  many  of  the  phlegmasise.  As  there  are 
morning  remissions,  ranging  from  a  degree  to  two  degrees  in  extent,  cor- 
responding to  the  morning  fall  in  the  daily  variations  of  temperature,  the 
tracing  upon  the  temperature  chart  will  be  a  zigzag  line,  each  evening 
temperature  being  from  a  degree  and  a  half  to  two  degrees  higher  than 
that  of  the  preceding  evening,  while  the  same1  difference  will  be  observed 
in  the  morning  temperature.  The  temperature  ought,  therefore,  never 
in  an  uncomplicated  case  to  be  much  over  100°  on  the  first  evening  or 
102°  on  the  second.  A  temperature  of  104°  at  any  time  during  the  first 
or  second  day  will  consequently  exclude  typhoid  fever  from  the  diagnosis. 
From  six  to  eight  days  are  usually  occupied  before  the  maximum  is 
reached.  I  have  seen  it  attained  as  early  as  the  fourth  day  in  mild  cases, 
and,  on  the  other  hand,  not  until  much  later  in  severe  ones.  It  is  usually 
104°  or  105°,  but  will  of  course  vary  with  the  gravity  of  the  other 
symptoms.  The  temperature  rarely  rises  higher  than  106°  at  this  period. 
On  the  other  hand,  I  have  known  cases  in  which  it  never  exceeded  103° 
during  their  whole  course.  It  would  therefore  be  wrong  to  exclude 
typhoid  fever  from  the  diagnosis,  as  Wunderlich  does,  if  this  temperature 
is  not  reached  by  the  sixth,  or  at  latest  the  eighth,  day. 

In  the  next  period  the  temperature  usually  ceases  to  rise,  but  has  a 
tendency  to  oscillate  about  the  maximum  temperature  of  the  previous 
period  as  a  fixed  point,  occasionally  not  quite  reaching  it,  at  other  times 
rising  a  little  above  it.  The  morning  remissions,  too,  become  less 
decided.  In  other  words,  the  fever  now  becomes  continuous.  This 
period,  although  usually  lasting  about  a  week,  may  extend  over  more 
than  two  weeks,  even  in  the  absence  of  complications,  in  cases  which  run 
a  severe  course,  and  when  it  is  prolonged  from  this  cause  the  temperature 
may  again  show  a  tendency  to  rise,  and  may  even  attain  an  elevation  con- 
siderably above  that  of  the  preceding  period.  The  prognosis  in  all  such 
cases  in  which  the  temperature  rises  after  the  middle  of  the  second  week 
is  grave.  Temperatures  of  108°,  and  even  of  110.3°,  have  been  noted 
at  this  time.  Death  invariably  follows  such  high  temperatures  as  these, 
but  before  death  actually  occurs  a  considerable  fall  of  temperature  very 
often  takes  place.  Wunderlich  has  also  called  attention  to  the  fact  that 
it  is  not  uncommon  for  a  sudden  and  temporary  remission  of  tempera- 
ture to  take  place  at  this  stage,  varying  from  one  degree  to  two  degrees 
and  a  half,  which  may  last  from  ten  to  twelve  hours,  and  which  usually 
has  occurred  in  his  experience  from  the  sixteenth  to  the  eighteenth  day. 
Toward  the  close  of  the  second  period  the  morning  remissions  will  be 
observed  to  be  more  decided,  while  the  evening  temperature  remains  about 
the  same  as  before.  The  beginning  of  the  third  period  is  indicated  by  a 
diminution  of  the  evening  exacerbation,  while  the  morning  remissions 
become  still  more  marked.  The  diminution  is  progressive,  but  slow,  the 


282 


TYPHOID  FEVER. 


temperature  each  evening  falling  short  by  from  half  a  degree  to  a  degree 
of  the  point  it  reached  the  preceding  evening.     The  morning  remissions, 


FIG.  12. 


Chart  of  typical  range  of  temperature  in  typhoid  fever,  after  Wunderlich. 

on  the  other  hand,  each  day  become  greater,  a  fall  of  three  and  a  half 
degrees  being  not  uncommon.  The  lysis,  therefore,  occupies  usually  a 
longer  time  than  was  required  by  the  pyrexia  in  reaching  its  maximum. 
Toward  the  close  of  this  period  the  morning  temperatures  may  be  normal, 
as  even  subnormal,  while  an  elevation  of  temperature  may  continue  to 
take  place  in  the  evening.  Occasionally,  however,  an  abrupt  deferves- 
cence takes  place.  The  duration  of  this  period  will  be  very  much  pro- 
longed if  complications  are  present  or  if  the  intestinal  ulcers  are  slow  in 
healing.  I  have  known  it  to  last  for  more  than  three  weeks.  During 
convalescence  the  temperature  is  frequently  subnormal  even  in  the  even- 
ing, but  the  slightest  cause  is  often  sufficient  to  produce  a  considerable 
though  temporary  elevation  of  temperature.  I  have  known  the  tempera- 
ture in  one  case  to  rise  from  99°  F.  to  105.6°  in  a  few  hours  in  conse- 
quence of  an  indiscretion  in  diet,  and  in  another  from  100°  to  104°  from 
the  suffering  and  excitement  caused  by  a  severe  attack  of  toothache.  In- 
discretions in  diet  are  a  fruitful  source  of  these  recrudesences  of  fever.  The 
fever  of  the  third  period  has  all  the  characters  of  an  irritative  fever,  and 
is  probably  kept  up  by  the  irritation  arising  from  the  intestinal  ulcers. 
On  the  other  hand,  that  of  the  first  two  periods  is  due  to  the  action  of 
the  specific  poison  upon  the  nervous  system  and  the  other  tissues  of  the 
body,  and  corresponds  exactly  with  the  primary  fever  of  the  eruptive  dis- 
eases. 

The  febrile  movement,  however,  rarely  follows  a  perfectly  typical 
course,  and  I  consequently  find,  in  looking  over  the  temperature  sheets 
of  a  large  number  of  cases,  very  few  which  bear,  except  during  the  first 
period,  anything  more  than  a  general  resemblance  to  the  chart  which 


283 


284 


TYPHOID  FEVER. 


Wunderlich  has  prepared  as  typical.  A  very  slight  cause  will  exercise, 
as  has  already  been  said,  a  disturbing  influence  upon  the  course  of  the 
fever,  and  serious  complications  or  accidents  will  of  course  produce  a  still 
more  marked  effect.  An  intestinal  hemorrhage,  for  example,  will  cause 
a  rapid  and  decided  fall  of  temperature.  I  have  often  known  it  to  fall 
from  104°  to  the  normal  temperature,  or  even  below  it.  This  depres- 

FIG.  14. 


Chart  showing  fall  from  intestinal  hemorrhage. 

sion,  unless  the  bleeding  continues  and  the  case  ends  fatally  in  the  course 
of  a  few  hours,  is  only  temporary,  the  temperature  rising  within  twenty- 
four  hours  to  its  former  height,  and  sometimes  even  beyond  it.  A  free 
epistaxis  or  a  copious  diarrhoea  will  in  the  same  way  cause  a  fall  of  the 
temperature,  but  it  is  rarely  so  marked  as  in  the  preceding  case.  The 
same  effect  is  produced  by  the  administration  of  large  doses  of  quinia  or 
by  the  application  of  cold  water  either  in  the  form  of  the  bath,  the 
douche,  or  any  other  form,  to  the  surface  of  the  body.  On  the  other 
hand,  the  occurrence  of  a  complication  will  cause  a  rise  of  temperature, 
often  considerably  above  the  maximum  of  the  first  period. 

The  thermometer  should  be  used  at  least  twice  daily.  In  this  country 
it  is  generally  introduced  into  the  axilla,  and  less  frequently  into  the 
mouth,  for  the  purpose  of  making  an  observation.  In  other  countries  it 
is  not  infrequently  inserted  into  the  rectum,  and  even  into  the  vagina. 
The  best  hours  for  making  the  thermometric  observations  are  eight  in 
the  morning  and  eight  in  the  evening,  since  it  has  been  ascertained  from 


CLINICAL  DESCRIPTION.  285 

frequent  observations  that  the  daily  remissions  are  more  marked  between 
the  hours  of  6  and  8  A.  M.,  and  that  the  temperature  usually  reaches  its 
maximum  some  time  between  those  of  7  and  12  p.  M. 

Loss  of  appetite  is,  except  in  mild  eases,  one  of  the  earliest  symptoms 
of  the  disease,  and  usually  persists  as  long  as  the  fever  lasts.  It  is  some- 
times accompanied  by  positive  loathing  for  food,  but  generally  there  is 
no  great  difficulty  in  persuading  the  patient  to  take  the  necessary  amount 
of  nourishment.  During  convalescence  the  appetite  returns,  and  is  occa- 
sionally immoderate,  so  that  it  is  frequently  necessary  to  curb  it  lest  harm 
should  be  done  by  over  indulgence. 

Thirst,  usually  proportionate  to  the  degree  of  fever,  is  also  present  in 
the  beginning  of  the  fever.  Later,  when  the  patient  sinks  into  a  semi- 
unconscious  condition  and  becomes  insensible  to  the  wants  of  the  system, 
he  will  cease  to  call  for  water,  although  it  is  still  urgently  needed. 

Nausea  and  vomiting  sometimes  occur  at  the  beginning  of  the  disease, 
but  they  have  not  been  such  frequent  symptoms  in  my  experience  as  they 
would  appear  to  have  been  in  that  of  Murchison,  who  says  that  they 
are  of  such  common  occurrence  that  the  patient  is  often  supposed  at  first 
to  be  suffering  merely  from  a  bilious  attack.  He  does  not  regard  them, 
when  occurring  at  this  stage,  as  serious  symptoms.  Indeed,  he  expresses 
the  belief  that  the  subsequent  course  of  the  disease  is  sometimes  favorably 
modified  by  them.  They  may  also  occur  later  in  the  disease,  and  are 
then  of  grave  import,  as  they  are  not  infrequently  the  consequence  .of 
peritonitis.  Louis  regarded  vomiting  as  a  grave  symptom,  but  it  is 
probable  it  occurred  in  the  cases  from  which  he  makes  his  deductions 
late  in  the  course  of  the  disease.  It  may  sometimes  occur  during  con- 
valescence, and  may  then  interfere  very  materially  with  the  proper  nutri- 
tion of  the  patient.  The  matter  vomited  usually  consists  of  a  greenish 
bilious  fluid,  with  the  food  last  taken.  In  some  cases  blood  has  been 
thrown  up. 

The  tongue  at  the  beginning  of  an  attack  of  typhoid  fever  is  usually 
moist  and  coated  with  a  thin  white  fur,  and  in  mild  cases  may  retain 
these  characters  until  the  close.  Even  in  some  cases  which  terminate 
fatally  in  the  course  of  the  second  week,  the  tongue,  with  the  exception 
of  being  less  moist  than  in  health,  may  present  no  marked  deviation 
from  this  appearance.  Generally,  however,  as  the  disease  progresses, 
and  sometimes  as  early  as  the  tenth  day,  it  becomes  dry  and  brownish, 
and  is  protruded  with  a  tremulous  motion.  Still  later  it  tends  to  cover 
itself  with  a  thick  brown  coating.  This  coating  is  disposed  principally 
along  the  middle  of  the  organ,  leaving  uncovered  the  edges  and  tip, 
which  are  very  apt  to  be  unnaturally  red  in  color.  The  bare  portion  at 
the  tip  is  often  rudely  triangular  in  shape — a  point  which  is  regarded 
as  of  some  importance  in  the  diagnosis  of  the  disease  by  Da  Costa. 
In  bad  cases,  during  the  course  of  the  third  week  the  tongue  is  fre- 
quently crossed  by  cracks  and  fissures,  which  are  the  cause  of  much  dis- 
comfort to  the  patient,  and  when  deep  may  bleed  and  leave  behind  them 
scars  which  are  recognizable  during  the  remainder  of  his  life.  In  other 
cases  the  tongue  is  dry,  brown,  and  shrivelled,  or  covered  with  a  tena- 
cious, viscid  secretion  which  renders  it  difficult  to  protrude  it. 

In  favorable  cases,  as  convalescence  approaches  the  tongue  regains  by 
degrees  its  normal  appearance.  At  first  the  only  noticeable  change  may 


286  TYPHOID  FEVER. 

be  thai  the  organ  is  a  little  less  dry  than  before.  In  a  few  days  it  will 
be  observed  to  have  become  moist  and  to  be  gradually  throwing  oif  its 
coating.  The  process  is,  however,  a  slow  one,  and  one,  moreover,  subject 
to  frequent  interruption.  Very  often,  when  it  seems  nearly  completed 
it  will  be  suddenly  arrested,  and  the  tongue  become  dry  and  brown. 
Sometimes,  instead  of  cleaning  itself  gradually,  the  tongue  throws  oif  its 
coating  in  large  flakes,  leaving  the  mucous  membrane  red  and  shining, 
as  if  deprived  of  its  papillary  structure.  Wood  was  accustomed  to  teach 
that  if  the  tongue  when  thus  cleaned  remained  moist  convalescence  might 
be  expected,  but  would  always  be  tedious.  This  is  an  observation  the 
correctness  of  which  I  have  had  abundant  opportunity  to  confirm.  If 
anything  happens,  however,  to  interfere  with  the  progress  of  convales- 
cence, it  not  infrequently  becomes  dry  and  coats  itself  over  again.  When 
the  restoration  to  health  is  retarded  by  the  continuance  of  diarrhoea  or  by 
the  occurrence  of  any  intercurrent  affection,  the  tongue  will  often  become 
pale  and  flabby  and  be  the  seat  of  superficial  ulcerations  or  of  aphthous 
exudations. 

The  mucous  membrane  of  the  posterior  fauces  is  also  often  red  and  dry 
and  covered  with  a  glutinous  secretion,  which  often  materially  interferes 
with  swallowing.  The  lips  and  teeth  are  in  bad  cases  encrusted  with 
sordes,  and  the  former  are  dry  and  cracked,  and  bleed  readily  when 
picked. 

Meteorism  or  tympanites  is  observed  in  the  greater  number  of  cases 
of  typhoid  fever,  having  been  noted  by  Murchison  in  79  out  of  100 
cases,  and  by  Hale  in  130  out  of  179  cases,  and  in  only  43  of  the 
remainder  of  his  cases  is  it  expressly  stated  to  have  been  absent.  My 
own  experience  leads  me  to  believe  that  it  is  present  in  even  a  larger 
proportion  of  cases ;  in  fact,  that  it  is  rarely  absent.  It  is,  as  a  rule, 
later  in  making  its  appearance  than  the  other  abdominal  symptoms, 
showing  itself  usually  about  the  end  of  the  first  or  the  beginning  of  the 
second  week.  It  is  generally  most  marked  in  grave  cases,  especially 
those  attended  by  severe  diarrho3a,  but  I  have  seen  it  highly  developed 
in  cases  in  which  the  symptom  was  not  present  at  all  or  but  little  devel- 
oped. It  may  vary,  moreover,  frequently  in  degree  at  different  times 
in  the  same  case,  but  when  once  present  generally  persists  until  convales- 
cence is  established  or  death  occurs.  When  extreme,  it  may  give  rise  to 
distressing  dyspnoea  by  preventing  the  descent  of  the  diaphragm. 

The  meteorism  is  usually  preceded  and  accompanied  by  gurgling  and 
tenderness  on  pressure  in  the  right  iliac  fossa.  The  former  of  these  symp- 
toms is  most  marked  in  cases  in  which  diarrhoea  exists,  and  is  caused  by 
the  presence  of  liquid  and  gas  in  the  lower  part  of  the  ileum.  The  ten- 
derness is  unquestionably  due  to  the  presence  of  ulcers  in  the  same  part 
of  the  bowel.  There  is  also  occasionally  pain  in  the  region  of  the 
umbilicus,  but  this  is  a  much  less  frequent  symptom. 

Enlargement  of  the  spleen  was  noted  by  Hale  as  being  present  in 
some  of  the  cases  which  he  has  described.  It  is  a  frequent  symptom  of 
the  disease,  and  may  be  generally  demonstrated  by  percussion  in  the 
course  of  the  second  week.  It  has  not,  however,  often  happened  to  me 
to  be  able  to  feel  the  organ  enlarged  through  the  abdominal  walls,  as 
Murchison  asserts  he  has  been  able  to  do.  Indeed,  tympanites  is  usually 
present  in  a  sufficient  degree  to  render  this  difficult.  The  enlargement 


CLINICAL  DESCRIPTION.  287 

occurs  more  frequently  in  persons  under  thirty  years  of  age  than  in  those 
over  it. 

Diarrhosa  is  one  of  the  most  frequent  symptoms  of  the  disease, 
especially  in  severe  cases,  and  there  are  very  few  mild  cases  in  which  it 
does  not  occur  at  some  period  of  their  course.  Louis  noted  it  in  all  but 
three  of  his  fatal  cases,  Murchison  in  93  out  of  100,  and  M.  Barth  in  96 
out  of  101.  It  varies  in  different  cases  in  severity,  in  duration,  and  in 
the  time  at  which  it  appears.  It  may  be  one  of  the  earliest  symptoms, 
presenting  itself  frequently  on  the  first  day,  and  often  being  the  only  one 
which  occasions  uneasiness  to  the  patient  or  his  physician.  At  other 
times  its  appearance  may  be  postponed  until  the  end  of  the  first  week,  or 
even  until  the  patient  is  apparently  entering  on  convalescence.  It  may 
be  mild  in  the  beginning  and  become  more  severe  as  the  disease  pro- 
gresses, or  after  having  been  at  first  acute  may  cease  spontaneously  in  a 
•few  days  to  occasion  any  uneasiness.  In  degree  it  may  vary  from  two 
stools  to  three  or  four,  or  even  twenty,  in  the  course  of  the  twenty-four  hours. 
It  is  absent  in  a  few  cases,  but  in  many  even  of  these  cases  the  bowels 
will  be  found  to  act  inordinately  after  a  very  moderate  dose  of  purgative 
medicine.  I  have  known,  for  instance,  the  administration  of  a  single 
teaspoonful  of  castor  oil  to  be  followed  by  five  or  six  stools  in  an  adult. 
Constipation  does,  however,  actually  exist  in  a  certain  number  of  cases. 
Murchison  has  known  the  bowels  in  cases  in  which  a  relapse  has 
occurred  to  be  constipated  in  the  primary  attack  and  relaxed  in  the 
relapse.  There  is  no  relation  between  the  severity  of  the  diarrhoea  and 
the  extent  of  the  local  lesion.  Although  oftenest  met  with  in  mild  cases, 
constipation  has  existed  in  cases  in  which  perforation  of  the  bowel  or 
intestinal  hemorrhage  has  occurred  during  life,  or  very  extensive  lesions 
been  found  after  death. 

The  stools  are  fetid  and  ammoniacal,  and  are  alkaline  in  reaction, 
instead  of  acid  as  in  health.  They  are  usually  liquid  and  of  the  color  of 
yellow  ochre.  Murchison  says  that  they  separate,  on  standing,  into  two 
layers — a  supernatant  fluid  and  a  flaky  sediment — but  that,  occasionally, 
instead  of  being  watery  they  are  pultaceous,  frothy,  and  fermenting,  and 
so  light  as  to  float  in  water.  I  have  myself  often  seen  the  appearance 
which  Bartlett  compares  to  that  of  new  cider.  They  may  contain  blood, 
and  when  they  do,  occasionally  present  the  appearance  of  coffee-grounds. 
They  are  not  infrequently,  in  grave  cases,  passed  involuntarily. 

Intestinal  hemorrhage  is  fortunately  not  a  frequent  symptom  of  typhoid 
fever.  It  may  occur  as  early  as  the  fifth  or  sixth  day,  but  is  more 
common  after  the  middle  of  the  second  week  or  in  the  third  or  fourth 
week.  In  60  cases  observed  by  Murchison  in  which  the  hemorrhage 
exceeded  six  ounces  it  began  during  the  second  week  (mostly  toward  its 
close)  in  8 ;  during  the  third  week  in  28  ;  during  the  fourth  in  17  ; 
during  the  fifth  in  1 ;  during  the  sixth  in  3 ;  during  the  seventh  in  1 ; 
and  during  the  eighth  week  in  1 ;  while  in  one  case  the  date  of  its  occur- 
rence is  not  noted.  In  the  cases  observed  by  Liebermeister  and  Grie- 
singer,  113  in  all,  the  bleeding  took  place  in  a  much  larger  proportion  of 
cases  at  an  early  period  of  the  disease,  occurring  in  as  many  as  43  in  the 
second  week,  and  in  only  27  during  the  third.  In  7  cases  in  which  I  had 
the  opportunity  of  observing  it  in  patients  under  my  own  care  it  occurred 
on  the  seventeenth  day  in  1 ;  on  the  twenty-third  day  in  1 ;  during  the 


288  TYPHOID  FEVER. 

third  week  in  2  ;  during  the  fifth  week  in  2  ;  and  on  the  fifth  day  of  a 
relapse  in  1.  There  may  be  a  single  hemorrhage,  or  the  bleeding  may  be 
repeated  one  or  more  times.  In  5  of  my  cases  there  was  a  second 
hemorrhage,  and  in  2  of  them  a  third  ;  and  in  several  of  Murchison's 
cases  it  recurred  at  varying  intervals  after  its  first  appearance. 

When  the  bleeding  occurs  early  in  the  disease  it  is  usually  insignificant 
in  amount,  and  is  due  either  to  extreme  congestion  of  the  mucous  mem- 
brane of  the  intestine,  giving  rise  to  rupture  of  the  capillaries,  or  to  dis- 
integration of  the  blood,  allowing  its  ready  passage  through  the  walls  of 
the  vessels.  In  the  latter  case  it  usually  coexists  with  petechiae  or  a 
hemorrhage  from  some  other  part  of  the  body,  as,  for  instance,  epistaxis 
or  hematuria.  After  the  middle  of  the  second  week  the  hemorrhage  is 
generally  the  result  of  the  laying  open  of  a  small  artery,  either  by  the 
detachment  of  a  slough  from  one  of  the  glands  of  Peyer  or  by  the 
involvement  of  its  walls  in  the  ulcerative  process.  It  is  then  often  pro- 
fuse, and  may  even  reach  several  pints  in  quantity.  Murchison  has, 
however,  seen  profuse  hemorrhage  at  such  an  early  stage  of  the  disease 
that  it  was  impossible  that  ulceration  could  have  taken  place.  The  blood 
is  not  always  voided  immediately  after  a  hemorrhage  has  taken  place ; 
it  may  be  retained  for  some  days.  Indeed,  if  the  amount  be  large  the 
patient  may  die  within  a  few  hours  of  its  occurrence  without  any  appear- 
ance of  blood  externally.  This  is,  however,  rare ;  it  is  more  usual  for 
the  hemorrhage  to  be  repeated  before  death  takes  place,  but  the  occur- 
rence of  the  bleeding  may  be  suspected  in  such  cases  by  the  abrupt  fall 
of  temperature,  sometimes  below  the  normal  standard,  and  by  the  extreme 
prostration  and  pallor  which  come  on  suddenly  without  other  assignable 
cause.  The  depression  of  the  temperature  does  not  continue  long.  It 
generally  reaches  its  former  elevation,  or  even  exceeds  it,  in  the  course  of 
twenty-four  hours. 

There  would  appear  to  be  a  slight  difference  in  the  frequency  with 
which  intestinal  hemorrhage  occurs  in  different  times  and  at  different 
places.  Murchison  noted  it  in  58  cases  of  1564,  or  3.77  per  cent.;  Louis 
in  8  cases  of  134,  or  5.9  per  cent.;  Liebermeister  in  127  cases  of  1743,  or 
7.3  per  cent.;  Griesiuger  in  32  cases  of  600,  or  5.3  per  cent.;  and  I  have 
noted  it  7  times  in  81  cases,  or  in  about  8.5  per  cent.  Liebermeister 
makes  it  twice  as  frequent  in  women  as  in  men.  It  seems  to  be  much 
less  common  in  children  than  in  adults,  for  in  252  patients  under  fifteen 
years  of  age  observed  by  Taupin,  Rilliet,  and  Barthez  it  occurred  in  1 
only.  There  is  considerable  diversity  of  opinion  among  observers  in 
regard  to  the  importance  of  this  symptom.  Murchison  lost  32  of  his  60 
cases.  In  11  of  the  32  fatal  cases  the  immediate  cause  of  death  was 
peritonitis ;  in  14 'of  the  remaining  21  cases  the  patients  died  within  three 
days  of  the  bleeding,  and  in  8  of  the  14  within  a  few  hours.  Of  Lieber- 
meister's  127  cases  49,  and  of  Griesinger's  32  cases  10,  terminated  fatally ; 
3  of  my  own  cases  ended  in  death,  but  none  of  them  until  several  days 
had  elapsed  after  the  bleeding.  In  the  face  of  facts  such  as  these  there 
have  not  been  wanting  authors  to  assert  that  the  effect  of  the  hemorrhage 
was  'sometimes  beneficial.  Chief  among  these  are  the  celebrated  Irish 
physician  Graves  and  his  devoted  admirer  Trousseau.  There  may  occa- 
sionally be  a  slight  subsidence  of  the  nervous  symptoms  upon  the  occur- 
rence of  a  hemorrhage,  consequent  upon  the  reduction  of  temperature 


CLINICAL  DESCRIPTION.  289 

which  usually  accompanies  it,  but  this  relief  is  only  temporary,  and  pro- 
cured at  too  great  expense  to  be  really  of  service  to  the  patient. 

The  bleeding  is  most  frequently  observed  in  bad  cases.  All  the  cases 
which  were  under  my  care  in  which  it  occurred  were  of  great  severity 
from  the  very  start.  In  18  of  Murchison's  60  cases  the  antecedent 
symptoms  were  mild.  In  3  of  my  cases  there  was  severe  diarrhoea.  In 
2  of  the  other  cases,  1  of  which  was  fatal,  the  bowels  were  constipated, 
and  in  another  one,  also  fatal,  they  were  slightly  loose.  In  8  of 
Murchison's  cases,  6  of  which  were  fatal,  the  bowels  had  been  consti- 
pated up  to  the  time  of  its  occurrence.  The  blood,  if  voided  immedi- 
ately after  its  escape  into  the  intestines,  is  generally  fluid  and  bright  red  in 
color.  When  retained  for  a  day  or  two  it  is  passed  in  dark  clots,  and  if 
retained  longer  than  this  it  is  usually  mixed  with  fecal  matter  when  dis- 
charged from  the  bowels,  and  gives  the  stools  a  tarry  appearance  and 
consistence,  which  is  not  always  recognized  by  inexperienced  attendants 
as  due  to  blood. 

It  has  been  asserted  that  intestinal  hemorrhage  has  become  more  fre- 
quent since  the  introduction  of  the  cold-water  treatment,  but  Lieber- 
meister  shows  this  to  be  an  error,  for  he  has  found  that  of  861  cases 
treated  before  the  introduction  of  this  treatment,  72,  or  8.4  per  cent.,  had 
intestinal  hemorrhage,  but  that  of  882  cases  treated  since  its  introduction 
hemorrhage  occurred  in  55,  or  in  6.2  per  cent.  Other  methods  of  treat- 
ment have  also  been  charged  with  inducing  a  tendency  to  hemorrhage, 
but  probably  not  upon  more  substantial  grounds  than  the  above. 

The  occurrence  of  perforation  may  be  suspected  when  the  patient  is  sud- 
denly seized  with  acute  pain  in  the  abdomen,  accompanied  by  symptoms  of 
collapse  and  occasionally  by  rigors.  The  fall  of  temperature  is  often  con- 
siderable. Liebermeister  refers  to  one  case  in  which  it  was  as  much  as 
5J°,  or  from  104°  to  98|°.  Very  soon  the  abdomen  becomes  tender  on 
pressure,  and,  if  it  were  not  so  before,  hard  and  tympanitic ;  the  pulse 
grows  frequent,  small,  and  sometimes  almost  imperceptible ;  the  breath- 
ing is  thoracic ;  the  physiognomy  expresses  great  suffering ;  the  features 
are  contracted,  and  the  face  is  bathed  in  profuse  perspiration.  Nausea 
and  vomiting  come  on  soon  after  inflammation  has  commenced,  and 
rapidly  exhaust  the  patient.  The  decubitus  is  dorsal,  and  the  legs  are 
generally  drawn  up  so  as  to  relax  the  abdominal  muscles.  Prostration 
rapidly  increases  until  death  puts  an  end  to  the  patient's  sufferings. 
Occasionally,  the  symptoms  are  more  obscure.  Pain  and  rigors  may 
both  be  wanting,  and  nothing  but  the  extreme  prostration,  the  frequent 
and  feeble  pulse,  and  the  distended  condition  of  the  abdomen  will  indi- 
cate the  gravity  of  the  danger.  This  is  not  infrequently  the  case  in 
delirious  patients.  Death  may  take  place  during  the  collapse,  but  this 
is  rare.  It  more  frequently  takes  place  on  the  second  or  third  day ;  on 
the  other  hand,  it  may  be  postponed  until  much  later.  Liebermeister 
and  Murchison  refer  to  cases  in  which  there  was  an  interval  of  two  or 
three  weeks  between  the  first  symptom  of  perforation  and  the  fatal 
result. 

Perforation  of  the  intestine  was  formerly  regarded  as  an  inevitably 
fatal  accident,  but  this  view  is  no  longer  entertained.  I  have  had  under 
my  observation  cases  in  which  all  the  symptoms  of  this  accident  were 
present,  and  in  which  recovery  took  place.  In  some  of  these  cases  there 

VOL.  I.— 19 


290  TYPHOID  FEVER. 

may  have  been  a  error  of  diagnosis,  but  all  of  them  will  not  admit  of 
this  explanation.  Moreover,  cases  of  a  similar  character  have  been 
reported  by  physicians  whose  skill  in  diagnosis  is  universally  recognized. 
Thus,  Munchison  reports  six  such  cases,  Tweedie  two,  and  Wood  one. 
Liebermeister  and  Bristowe1  also  both  say  that  recovery  is  possible. 
This  view  is  sustained  by  the  results  of  certain  autopsies.  In  one  of 
these,  reported  by  Buhl,2  a  perforation  was  found  completely  closed  by 
adhesions  to  the  mesentery,  and  in  others  reported  by  Murchison  partial 
adhesion  had  taken  place  between  the  edges  of  the  perforation  and  the 
abdominal  walls  or  to  an  adjoining  coil  of  intestine.  Occasionally,  the 
inflammation  excited  by  the  perforation  may  be  circumscribed  and  ter- 
minate in  an  abscess,  which  may  permit  recovery  by  discharging  itself 
into  the  bowel  or  externally.  At  other  times,  however,  it  ruptures  into 
the  peritoneal  cavity,  when  death  speedily  ensues. 

Perforation  is,  fortunately,  not  a  frequent  accident  in  typhoid  fever. 
It  was  the  cause  of  death  in  20  only  of  250  fatal  cases  collected  by  Hoff- 
mann. It  occurred,  according  to  Liebermeister,  in  only  26  cases,  3  of 
\\hich  ended  in  recovery,  in  more  than  2000  cases  observed  at  the  hospital 
at  Basle.  Murchison  observed  it  48  times  in  1580  cases,  Griesiuger  14 
times  in  118  cases,  and  Flint  twice  in  73  cases.  Murchison  found  that 
in  a  total  of  1721  autopsies,  the  details  of  which  were  collected  from 
various  sources,  it  was  the  cause  of  death  in  196,  or  11.38  per  cent.  It 
would  appear  to  be  rather  more  common  on  the  continent  of  Europe  than 
in  England  or  in  this  country.  Perforation  is  much  more  frequently  met 
with  in  men  than  in  women.  The  patients  were  men  in  15  of  21  of 
Liebermeister's  cases,  in  51  of  73  of  Murchison's,  and  in  72  of  106  cases 
collected  by  Na'cke.  It  is  rarer  in  children  than  in  adults.  Killiet, 
Barthez,  and  Taupin  met  with  it  only  three  times  in  232  children  under 
treatment.  Murchison  has,  however,  had  a  fatal  case  in  a  child  of  five 
years  of  age.  It  is  also  not  common  after  forty  years  of  age,  but  does 
occasionally  occur,  although  the  contrary  has  been  asserted. 

Perforation  is  most  likely  to  happen  during  or  after  the  third  week  of 
the  disease,  but  it  has  been  met  with  as  early  as  the  eighth  day,  as  in  a 
case  reported  by  Peacock.  On  the  other  hand,  in  three  cases  cited  by 
Morin  3  it  did  not  occur  until  the  seventy-second,  seventy-sixth,  and  one 
hundred  and  tenth  day,  respectively.  Instances  are  on  record  in  which 
it  has  taken  place  after  the  patient  was  supposed  to  be  thoroughly  con- 
valescent and  had  returned  to  his  occupation.  When  it  occurs  early  it  is 
due  to  the  separation  of  a  slough.  After  the  middle  or  end  of  the  third 
week  it  is  probably  always  the  result  of  the  extension  of  the  ulcerative 
process  to  the  peritoneal  coat.  In  a  large  proportion  of  cases  the  perfora- 
tion has  been  preceded  by  symptoms  of  great  gravity,  such  as  severe 
diarrhoea,  great  tympany  and  tenderness  of  the  abdomen,  and  intestinal 
hemorrhage,  but  in  a  certain  number  of  instances  the  cases  in  which  it 
has  occurred  have  been  of  a  mild  character,  the  patient  in  many  of  them 
not  considering  himself  sick  enough  to  take  to  his  bed  or  even  to  abstain 
from  his  daily  labor.  After  death  the  perforating  ulcer  has  been  found 
to  be  the  only  one. 

The  most  frequent  causes  of  perforation  are  the  irritation  arising  from 

1  Transactions  of  the  Pathological  Society  of  London,  vol.  xi.  p.  115. 

*  Cited  by  Murchison.  3  Quoted  by  Mutch  ison. 


CLINICAL  DESCRIPTION.  291 

indigestible  and  unsuitable  food,  distension  of  the  bowels  by  feces  or  gas, 
vomiting,  and  movements  on  the  part  of  the  patient.  Liebermeister  calls 
attention  to  the  frequency  with  which  ascarides  are  found  in  the  intestines 
of  those  who  die  of  perforation,  and  is  inclined  to  think  they  may  have 
something  to  do  with  causing  it.  Moriu l  reports  a  case  in  which  the 
perforation  appeared  to  be  caused  by  the  administration  of  an  enema. 

For  our  knowledge  of  the  changes  in  the  composition  of  the  urine  we 
are  largely  indebted  to  Parkes  and  certain  German  observers.  As  the  disease 
generally  begins  insidiously,  the  condition  of  the  urine  before  the  attack 
and  during  the  first  two  or  three  days  has  not  been  ascertained  with  cer- 
tainty. During  the  latter  part  of  the  first  week  the  amount  of  water 
is  greatly  diminished,  occasionally  falling  to  one-fourth  or  one-sixth  of 
the  usual  quantity.  In  the  second  and  third  weeks  it  increases,  and  at 
the  end  of  the  fourth  week  may  again  be  normal.  The  amount  may, 
however,  vary  from  day  to  day,  but  its  variations  do  not  stand  in  close 
relation  to  those  of  the  febrile  heat ;  that  is,  the  thermometer  may  mark 
one  day  104°,  and  the  next  day  100°,  while  the  amount  of  urine  remains 
the  same.  Still,  when  the  temperature  begins  to  fall  permanently  it 
increases  at  once,  or,  according  to  Thierfelder,  two  or  three  days  after. 
The  specific  gravity  is  usually  high  in  almost  all  cases  in  which  the 
urine  is  scanty,  and  may  be  as  high  1038.  With  the  establishment  of 
convalescence  the  specific  gravity  often  diminishes  before  the  water  begins 
to  increase.  In  other  words,  the  lessening  of  the  solids  of  the  urine  fre- 
quently takes  place  prior  to  the  increase  of  the  water. 

The  reaction  of  the  urine  is  very  acid  in  the  beginning,  but  the  acidity 
is  not  due  to  an  increased  secretion  of  acid,  but  simply  to  concentration. 
Later  it  may  become  alkaline,  and  even  ammoniacal.  The  color  of  the 
urine  is  darker  than  in  health  during  the  early  part  of  the  febrile  period. 
This  is  due  partly  to  concentration,  and  partly  to  increased  disintegration 
of  the  blood-corpuscles,  which  is  a  consequence  of  the  fever. 

The  quantity  of  urea  is  augmented  during  the  fever,  and  especially 
during  the  first  week,  when  the  water  and  chlorides  of  sodium  are  most 
diminished.  As  a  general  rule,  the  higher  the  temperature  the  greater 
the  amount  of  urea.  It  may,  however,  be  very  much  diminished  during 
the  presence  of  inflammatory  complications.  On  the  other  hand,  it  is 
not  affected  by  diarrhoea.  Uric  acid  is  uniformly  increased,  the  amount 
of  increase  being  relatively  greater  than  that  of  the  urea ;  it  is  often 
doubled,  and  sometimes  the  increase  is  even  more  than  this.  This 
increase  takes  place,  according  to  Zimmer,  up  to  the  fourteenth  day. 
It  diminishes  after  this,  and  during  convalescence  may  fall  below  the 
normal  amount.  Copious  deposits  of  urates  may  occur  at  any  time  in 
the  course  of  the  disease.  The  chloride  of  sodium  is  usually  diminished 
in  amount.  This  diminution  is  partly  due  to  a  less  amount  of  this  salt 
being  taken  with  the  food,  and  partly  to  the  fact  that  large  quantities  of 
it  pass  away  with  the  stools.  As  the  diminution  cannot  always  be  fully 
accounte'd  for  in  this  way,  it  would  appear  that  it  is  also  stored  up  in  the 
body  during  the  fever.  In  cases  in  which  sweating  and  purging  are 
absent  the  sulphuric  acid  is  increased  in  amount.  The  phosphoric  acid 
is  at  first  slightly  diminished,  but  later  undergoes  an  increase.  The  hip- 
puric  acid  is  also  diminished. 

1  Quoted  by  Murchison. 


292  TYPHOID  FEVER. 

Parkes  found  albumen  in  the  urine  in  7  out  of  21  cases.  In  5  of 
these  it  was  temporary,  and  entirely  disappeared  before  the  patients  left 
the  hospital.  Becquerel  found  it  in  8  out  of  38  cases,  Andral  in  only  4 
out  of  34  cases.  Griesinger  found  it  commonly,  though  it  was  usually 
temporary.  He  met  with  only  four  or  five  cases  in  which  it  was  never 
present.  Kerchensteiner  found  albumen  in  a  fourth  part  of  the  severe 
cases.  BrattTer  noticed  it  in  9  out  of  23  cases.  I  have  very  frequently 
found  it  myself,  but  it  has  always  been  in  my  cases  a  temporary  phe- 
nomenon. Desquamative  nephritis  may  occur  occasionally  in  the  course 
of  typhoid  fever,  and  give  rise  to  the  appearance  of  a  large  amount  of 
albumen  in  the  urine,  and  also  occasionally  of  blood.  Renal  epithelia 
and  casts  are  sometimes  seen  in  cases  in  which  there  is  albuminuria,  but 
usually  soon  disappear.  Zimmermann  asserts  that  in  all  but  very  slight 
cases  casts  may  be  found  even  when  no  albumen  can  be  detected.  The 
statement  is  probably  too  general,  but  there  is  no  doubt  of  the  occasional 
presence  of  casts  under  these  circumstances.  Bladder  epithelia  and 
pus-cells  are  «een  in  a  few  cases  in  small  quantities,  but  decided  cystitis 
is  rare,  unless  it  has  ensued  upon  retention  of  urine.  Sugar  has  not 
been  found  except  in  the  urine  of  diabetic  patients,  who  may  have  hap- 
pened to  contract  typhoid  fever.  In  these  patients  the  sugar  diminishes, 
and  is  sometimes  wholly  absent  during  the  continuance  of  the  fever. 
Leucin  and  tyrosin  have  been  found  by  Frerichs,  but  at  present  no 
observations  have  been  made  as  to  the  frequency  or  import  of  their 
occurrence. 

In  many  cases,  when  the  prostration  is  extreme,  the  urine  is  passed 
involuntarily,  but  in  some  of  these  cases  the  incontinence  of  the  urine  is 
only  apparent,  and  is  really  the  result  of  over-distension  of  the  bladder. 
This  is  a  condition  which  is  very  apt  to  be  overlooked,  and  I  have  known 
paralysis  of  the  bladder  to  result  in  consequence  of  this  neglect,  and  to 
continue  sometimes  after  convalescence  has  been  established. 

COMPLICATIONS  AND  SEQUELS. — Although  cerebral  symptoms  are 
among  the  commonest  manifestations  of  the  disturbing  effects  produced 
in  the  economy  by  the  typhoid  fever  poison,  they  are  almost  always  inde- 
pendent of  inflammation  of  the  brain  and  its  membranes.  »In  a  few 
cases,  however,  the  lesions  of  meningitis  have  been  found  after  death.  In 
some  of  these  it  has  come  on  without  assignable  cause,  in  others  it  has 
been  the  consequence  of  pyamia,  of  tubercles,  or  of  the  extension  of 
inflammation  from  the  petrous  portion  of  the  temporal  fyone.  Occa- 
sionally, during  convalescence,  some  impairment  of  the  intellect  is 
observed.  This  may  consist  in  simply  some  loss  of  memory  or  child- 
ishness of  manner.  At  other  times  delusions  of  a  mild  form  are  present, 
or  else  the  patient  is  liable  to  attacks  of  acute  mania,  sometimes  violent, 
coming  on  suddenly  and  without  fever.  In  a  few  instances  the  moral 
sense  seems  to  have  been  perverted,  as  in  the  case  reported  by  Dr.  Nathan 
Smith,  already  referred  to,  in  which  a  young  man  of  previously  good 
character  developed  a  propensity  to  steal  after  his  attack.  Recovery  with 
the  re-establishment  of  the  physical  health  almost  occurs  in  these  cases. 
Murchison  says  he  knows  of  no  case  in  which  this  condition  has  been  per- 
manent. On  the  other  hand,  Dr.  C.  M.  Campbell,1  who  had  the  oppor- 
tunity of  observing  an  attack  of  typhoid  fever  among  some  insane  patients 
1  The  Journal  of  Mental  Science,  July,  1882. 


COMPLICATIONS  AND  SEQUELS.  293 

at  the  Durham  County  Asylum,  reports  that  the  mental  state  was  in  no 
case  injuriously  affected  by  the  disease,  but,  on  the  contrary,  underwent  a 
marked  improvement  in  several  of  the  cases.  Indeed,  in  two  of  the 
cases,  in  which  the  prognosis  had  become  very  unfavorable,  mental 
recovery  began  during  the  attack  of  fever. 

Paralysis,  muscular  tremors,  and  chorea  are  also  occasionally  observed 
after  attacks  of  typhoid  fever.  According  to  Murchison,  paralysis  does 
not  supervene  until  several  weeks  after  the  commencement  of  conva- 
lescence. It  may  last  for  several  weeks  or  months,  but  recovery  in  the 
majority  of  instances  eventually  takes  place.  According  to  Nothnagel,1 
the  most  common  form  is  paraplegia,  but  it  may  also  take  the  form  of 
hemiplegia,  strabismus,  paralysis  of  the  portio  dura,  motor  paralysis  of 
individual  spinal  nerves,  such  as  the  ulnar  or  peroneal,  or  local  anes- 
thesia. On  the  other  hand,  neuralgias  and  disturbances  of  sensation  are 
not  common  sequelae  of  typhoid  fever. 

Degeneration  of  the  muscular  tissue  of  the  heart  is  probably  present 
in  some  degree  iu  every  case  of  typhoid  fever,  being,  of  course,  most 
marked  in  the  severest  cases.  There  would  seem,  however,  to  be  no 
special  tendency  to  disease  of  its  valves  or  membranes.  Arterial  throm- 
bosis or  embolism,  giving  rise  to  gangrene  of  the  part  supplied  by  the 
obstructed  artery,  is  of  occasional  occurrence.  Patry,2  Hayem,3  Trousseau,4 
and  others  report  or  refer  to  several  cases  in  which  gangrene  of  the  leg, 
hand,  or  cheek  was  observed,  and  among  others  a  case  in  which  sphacelus 
depending  upon  obstruction  of  the  carotid  artery,  the  result,  as  Patry 
thought,  of  arteritis,  commenced  in  the  left  ear,  and  extended  from  there 
to  the  forehead  and  cheek.5  A.  Martin6  reports  the  case  of  a  woman  who 
expelled  from  the  vagina  a  fetid-smelling  structure  of  cylindrical  form, 
which  proved  to  be  the  cervix  of  the  uterus,  with  the  upper  part  of  the 
vagina,  and  in  whom  menstruation  was  not  re-established  until  after  the 
performance  of  an  operation.  Spillmann7  has  also  called  attention  to  the 
occurrence  of  gangrene  of  the  vagina  and  vulva  in  cases  of  typhoid  fever. 

1  Cited  by  Murchison.  See  also  article  by  Paget,  St.  Bartholomews  Hospital  Report, 
vol.  xii.  "  Archives  generates  de  Medicine,  1863,  vol.  i.  pp.  129-549. 

3  Loc.  cit.  *  Clinique  medicate. 

6  Since  the  above  was  written  Bari£  has  called  attention  in  the  Revue  de  Medicine,  Jan. 
and  Feb.,  1884,  to  the  frequency  with  which  acute  inflammation  of  the  arteries  occurs  as 
a  sequel  of  typhoid  fever.  The  author,  whose  investigations  were  limited  to  the  larger 
arteries,  found  that  the  vessels  generally  implicated  are  in  the  order  of  their  frequency, 
the  posterior  tibial,  the  femoral,  and  the  dorsal  artery  of  the  foot.  The  affection  is  usually 
unilateral,  appears  during  convalesence  or  when  the  patient  leaves  his  bed,  and  occurs 
just  as  often  after  light  as  after  severe  cases.  He  distinguishes  two  varieties :  1,  acute 
obliterating  arteritis,  and,  2,  acute  parietal  arteritis.  The  first  variety  is  characterized  by 
embryonal  infiltration  of  all  the  tissues,  by  disappearance  of  the  smoothness  of  the  intima, 
which  becomes  uneven  and  granular,  and  by  the  formation  of  a  secondary  thrombus,  and 
almost  invariably  terminates  in  dry  gangrene.  The  second  is  merely  an  inflammation 
without  such  a  clot,  and  always  terminates  in  recovery  without  gangrene. 

The  symptoms  of  obliterating  arteritis  are — pain,  more  or  less  sudden  in  its  onset, 
directly  over  the  course  of  affected  vessels,  and  increased  by  pressure,  by  the  erect  position, 
and  by  walking ;  diminution,  and  then  absence,  of  pulsation ;  swelling  of  the  limb,  with- 
out ffidema  or  redness ;  and,  later,  the  appearance  of  bluish  mottling  of  the  surface,  and, 
more  rarely,  of  patches  of  purpura ;  lowering  of  the  temperature,  with  or  without  troubles 
of  sensibility,  such  as  formication,  anaesthesia,  etc.,  and  the  appearance  of  a  hard  and 
painful  cord,  due  to  the  formation  of  the  thrombus.  In  the  parietal  form  the  diminution 
of  the  pulsations  is  sometimes  preceded  by  a  considerable  exaggeration  of  their  amplitude, 
and,  while  the. temperature  on  the  affected  side  is  usually  lowered,  it  may  sometimes  be 
increased.  •  Centralblatt  f.  Gynakol,  1881.  7  Archives  generale,  Mars,  1881. 


294  TYPHOID  FEVER. 

This  complication  is  generally  met  with  toward  the  end  of  the  febrile 
period. 

Venous  thrombosis,  the  result  of  weakness  of  the  heart's  action,  is 
more  frequently  observed.  It  occurs  generally  during  the  convalescence 
of  cases  which  have  run  a  severe  course,  and  usually  aifects  the  veins  of 
the  lower  extremities.  I  have  seen  both  the  femoral  veins  obstructed 
from  this  cause  at  the  same  time.  All  the  cases  which  have  come  under 
my  own  observation  have  ended  in  recovery,  and  only  2  of  31  collected 
by  Liebermeister  terminated  fatally.  Death  occurred  in  3  of  the  17  cases 
collected  by  Murchison,  but  in  none  of  them  was  this  result  attributable 
to  this  complication  alone.  There  is,  however,  always  danger  of  a  por- 
tion of  the  thrombus  becoming  detached  and  producing  embolism  of  the 
pulmonary  artery. 

Pyaemia  is  said  by  Murchison  and  other  authors  to  be  an  occasional 
complication,  but  it  is  certainly  rare  in  this  country.  In  the  milder  cases 
abscesses  form  during  convalescence  beneath  the  skin  in  different  parts  of 
the  body.  In  the  more  severe  cases  pus  is  deposited  in  the  joints  or  in 
the  internal  organs.  Albert  Robin1  has  reported  two  cases  in  which 
there  was  suppurative  joint  affection.  In  one  of  these  the  joints  of  the 
fingers  and  toes,  with  the  sheaths  of  the  corresponding  extensor  tendons 
and  both  knee-joints  and  one  shoulder-joint,  were  affected.  In  the  other 
the  left  knee  was  filled  with  pus.  In  both  cases  the  fever  soon  assumed 
an  adynamic  character. 

Laryngitis  may  sometimes  occur  in  the  course  of  typhoid  fever,  and 
when  it  assumes  the  diphtheritic  form  and  runs  on  to  the  formation  of 
ulcers  is  a  very  serious  complication  of  typhoid  fever,  as  it  is  not  infre- 
quently accompanied  by  oedema  of  the  glottis  and  gives  rise  to  the  neces- 
sity for  tracheotomy.  It  is  fortunately,  at  least  in  its  worst  forms,  rare 
in  this  country.  In  Germany,  judging  from  the  number  of  cases  col- 
lected by  Hoffmann  and  Griesinger,  it  is  of  more  common  occurrence. 
The  ulcers  are  oftener  met  with  in  some  epidemics  than  in  others.  Dur- 
ing the  winter  of  1860-61,  which  I  passed  in  Vienna,  the  frequency 
with  which  they  occurred  was  the  subject  of  remark  among  those  who 
were  in  attendance  upon  the  various  clinics. 

I  have  already  called  attention  to  the  frequency  with  which  bronchitis 
in  some  form  or  other  attends  upon  typhoid  fever.  When  it  invades  the 
smaller  bronchial  tubes  it  occasionally  gives  rise  to  lobular  pneumonia 
or  to  collapse  of  some  of  the  lobules  of  the  lung.  Lobar  pneumonia 
may  also  occur  in  the  course  of  typhoid  fever.  It  was  observed  52  times 
in  1420  cases  of  typhoid  fever  under  treatment  at  the  Basle  hospital  from 
1865—68.  When  it  comes  on  late  in  the  disease,  especially  if  the  patient 
is  comatose,  or  even  semi-conscious,  it  may  be  entirely  overlooked,  unless 
the  lungs  are  carefully  examined,  as  it  often  does  not  reveal  itself  to  us 
by  any  of  the  ordinary  symptoms.  It  may,  however,  occur  early,  and  I 
have  known  it  so  prominent  in  the  beginning  of  an  attack  that  the  exist- 
ence of  typhoid  fever  was  not  suspected.  It  sometimes  terminates  in 
abscess  or  gangrene,  but  is  more  usually  followed  by  chronic  pneumonia, 
which  may  eventually  either  end  in  recovery  or  lay  the  foundation  for 
phthisis.  Pleurisy  with  effusion  is  also  not  an  uncommon  complication. 
It  was  observed,  according  to  Liebermeister,  at  the  hospital  at  Basle  64 

1  Gazelle  de  Paris,  1881. 


COMPLICATIONS  AND  SEQUELJE.  296 

limes  in  1743  cases  of  fever.  It  is  also  a  serious  complication,  as  21  of 
the  64  cases  terminated  fatally.  Murchisou  refers  to  three  cases  in 
which  it  was  followed  by  empyema.  Other  morbid  conditions  of  the 
respiratory  organs  which  may  occur  as  complications  of  typhoid  fever  are 
oedema,  infarction,  hypostatic  congestion  of  the  lungs,  emphysema,  and 
pneumothorax.  Acute  miliary  tuberculosis  is  also  an  occasional  compli- 
cation, but  is  ofteuer  met  with  as  a  sequel.  According  to  Liebermeister, 
the  tendency  to  pulmonary  complications  has  diminished  since  the  intro- 
duction of  the  cold-water  treatment. 

Catarrhal  or  diphtheritic  inflammation  of  the  fauces  and  pharynx 
occurs  in  a  large  number  of  cases,  and  frequently  gives  rise  to  a  great 
deal  of  difficulty  in  swallowing.  Indeed,  it  has  been  so  frequently 
observed  in  some  epidemics  that  a  few  writers  have  regarded  it  as  a 
symptom  rather  than  a  complication  of  the  disease.  Either  of  the 
varieties  of  inflammation  may  extend  through  the  Eustachian  tube  to 
the  middle  ear  and  be  the  cause  of  deafness,  which  usually  passes  off  as 
the  inflammation  subsides.  Occasionally,  however,  the  affection  of  the 
middle  ear  gives  rise  to  perforation  of  the  tympanum  or  to  caries  of  the 
petrous  portion  of  the  temporal  bone. 

Murchison  says  he  has  known  the  symptoms  of  and  lesions  of  dysen- 
tery to  coexist  with  those  of  typhoid  fever  in  several  cases,  and  Lieber- 
meister asserts  that  diphtheria  of  the  intestinal  mucous  membrane  is  an 
occasional  sequel  to  severe  cases,  especially  when  other  mucous  mem- 
branes are  the  seat  of  diphtheritic  inflammation.  In  a  few  instances 
which  have  come  under  his  observation  it  had  given  rise  to  perforation 
of  the  boAvel  or  to  gangrene  of  the  intestinal  mucous  membrane. 

Jaundice  occasionally  occurs  in  the  course  of  the  disease.  I  have 
never  happened  to  see  this  complication,  and  am  inclined  to  think  it  is 
rare  in  this  country.  Liebermeister,  however,  met  with  it  6  times  in 
1420  cases,  and  Gricsiuger  10  times  in  600  cases.  Hoffmann  found  it 
in  10  of  250  fatal  cases,  and  Murchison  was  able  to  collect  9  cases,  all 
of  which  but  one  terminated  in  death.  Several  of  Griesinger's  cases, 
however,  ended  in  recovery.  In  a  few  cases  the  jaundice  may  be  attrib- 
uted to  catarrh  of  the  biliary  ducts,  but  this  solution  of  the  question  will 
not  explain  those  cases  in  which  the  feces  remain  colored  throughout.  In 
fatal  cases  marked  degeneration  of  the  liver  has  been  found,  which  Lie- 
bermeister regards  as  of  similar  character  to  that  which  occurs  in  acute 
yellow  atrophy.  In  two  of  .Murchison's  cases  the  liver  was  small  and 
its  secreting  cells  loaded  with  oil.  In  most  cases  it  does  not  appear 
until  late  in  the  disease,  but  it  has  been  observed  as  early  as  the  fifth 
day. 

Abscess  of  the  liver  and  diphtheritic  inflammation  of  the  mucous 
membrane  of  the  gall-bladder  are  among  the  rarer  sequelae  of  typhoid 
fever. 

Peritonitis  is  the  most  serious  of  all  the  complications  of  typhoid 
fever.  Its  most  common  cause  is  perforation  of  the  bowel,  but  it  may 
also  be  due  to  the  extension  of  inflammation  to  the  peritoneal  mem- 
brane without  ulceration.  Liebermeister  believes  that  it  is  sometimes 
the  result  of  the  typhoid  infiltration  so  frequent  in  various  tissues  of 
the  body  taking  place  in  the  serous  membrane.  In  other  cases  it 
arises  from  the  rupture  of  softened  mesenteric  glands,  of  softened  infarc- 


296  TYPHOID  FEVER. 

tions  in  the  spleen,  or  of  the  abscesses  which  are  sometimes  the  conse- 
quence of  the  circumscribed  inflammation  by  which  perforation  is  occa- 
sionally prevented  from  proving  immediately  fatal.  Less  frequent  causes 
of  it  are  rupture  of  the  gall-bladder,  with  the  escape  of  gall-stones  into 
the  cavity  of  the  abdomen,  abscesses  of  the  ovary,  and  abscesses  in  the 
walls  of  the  urinary  bladder.  It  is  said  by  Murchison  to  have  been  in 
one  case  the  result  of  a  pseudo-abscess  in  the  sheath  of  the  rectus  muscle 
bursting  inward. 

Swelling  of  the  parotid  gland  occasionally  occurs  in  typhoid  fever,  but 
is  much  less  common  than  in  typhus.  It  is  most  frequently  met  with  in 
bad  cases  about  the  end  of  the  third  week  or  later,  and  generally  involves 
one  side  only.  The  swelling  is  hard  and  firm  in  the  beginning,  and  may 
terminate  in  resolution  or  suppuration.  I  have  seen  it  three  times  only, 
twice  in  my  own  practice,  and  once  in  that  of  a  medical  friend.  One 
of  my  cases  was  fatal,  the  other  ended  in  recovery,  as  did,  I  believe,  the 
third  case.  Murchison  saw  it  in  only  6  cases,  5  of  which  were  fatal. 
According  to  Hoffmann,1  16  cases  of  suppurative  parotitis  were  found  at 
Basle  among  about  1600  typhoid  fever  patients,  7  of  the  16  ending  fatally. 
Parotitis  without  suppuration  occurred  three  times.  In  15  cases  the 
attack  was  confined  to  one  side,  9  times  to  the  right  and  6  to  the  left ;  in 
4  it  was  double.  Trousseau 2  looks  upon  these  swellings  as  a  very  grave 
accident,  and  says  that  he  has  scarcely  ever  seen  a  case  recover  in  which 
it  has  occurred,  either  in  the  course  of  typhoid  fever  or  any  other  disease. 
Chomel,  on  the  other  hand,  is  said  to  have  regarded  them  as  critical  and 
auspicious. 

Menstruation  occasionally  occurs  during  typhoid  fever,  and  may  be 
profuse.  Bartels,3  who  has  investigated  the  histories  of  172  patients  in 
reference  to  this  point,  says  that  the  catamenia  always  appear  if  the 
menstrual  period  falls  within  the  first  five  days  of  the  fever,  and  that 
they  do  so  in  two-thirds  of  the  cases  if  they  are  expected  between  the 
sixth  and  fourteenth  days.  On  the  other  hand,  menstruation  does  not 
occur  if  the  time  for  it  falls  in  the  third  week.  He  says  also  that  the 
catamenia  generally  appeal's  about  the  time  they  are  expected,  or  later, 
and  very  seldom  earlier.  Liebermeister,  on  the  contrary,  says  that  they 
often  occur  prematurely.  Other  uterine  hemorrhages  seldom  occur,  and 
never  in  those  who  have  ceased  to  menstruate  or  in  whom  the  function 
has  not  been  established. 

Suppuration  of  Bartholini's  glands  is  said  by  Speilman  to  have  taken 
place  in  one  case.4  In  the  fourth  week  the  patient  complained  of  vio- 
lent pains  in  the  right  nympha,  which,  upon  examination,  was  found  to 
be  swollen.  A  tumor  as  large  as  a  nut,  which  was  red  and  painful  on 
pressure,  could  also  be  felt  in  the  vagina. 

Pregnancy  was  formerly  thought  to  confer  an  entire  immunity  from 
typhoid  fever,  but  recent  and  accurate  investigations  have  shown  that 
if  this  immunity  really  exists,  it  is  only  relative,  not  absolute.  Gus- 
serow5  says  that  the  disease  is  more  frequently  met  with  in  the  first 
half  than  in  the  latter  half  of  pregnancy.  Abortion  under  these  circum- 
stances commonly  occurs.  Gusserow  says  that  it  takes  place  in  from  60 

1  Quoted  by  Liebermeister,  3  Clinique  medicate  de  I' Hotel  Dieu,  t.  i.  1861. 

8  Fetersb.  Med.  Wochemchr.,  1881.  *  Arch,  generates,  Mars,  1882. 

6  Schmidt's  Jahrbuch,  Bd.  193,  No.  1,  1880,  from  Berl.  klin.  Wochenschr.,  1880. 


COMPLICATIONS  AND  SEQUELS.  297 

to  80  per  cent,  of  the  cases.  He  believes  it  to  be  due  to  the  high  temper- 
ature, which  causes  the  death  of  the  foetus,  which  is  then  expelled  from 
the  uterus.  In  a  few  cases,  however,  the  child  is  born  living.  Of  Mur- 
chison's  14  cases,  10  recovered,  and  two  of  the  ten  patients  carried  the 
child,  at  the  fourth  and  eighth  months  respectively,  throughout  the  attack. 
All  the  others  miscarried  or  aborted,  only  one  of  them  being  delivered 
of  a  living  child.  Out  of  18  pregnant  women1  treated  in  the  hospital 
of  Basle  for  typhoid  fever,  between  the  years  1865  and  1868,  15  mis- 
carried or  aborted.  In  the  three  years  following  the  introduction  of  the 
anti-pyretic  treatment  only  five  cases  of  abortion  occurred,  and  but  one 
of  these  proved  fatal.  This  accident  generally  happens  during  the  second 
or  third  week  of  the  fever.  It  is  always  a  serious  complication,  and  if 
it  occurs  in  the  first  three  months  of  pregnancy  it  generally  gives  rise  to 
profuse  hemorrhage,  which  is  usually  followed  by  a  fall  of  temperature 
as  marked  as  that  observed  in  hemorrhage  from  the  intestines.  Just 
as  in  the  latter  case,  the  fall  is  only  temporary,  being  soon  succeeded  by 
a  rapid  rise  of  the  temperature  to  its  former  height,  or  even  beyond  it. 

The  danger  of  bed-sores  occurring  in  typhoid  fever  is  in  consequence 
of  the  impaired  nutrition  of  the  tissues,  the  length  of  time  the  disease 
lasts,  and  the  great  emaciation  which  usually  attends  it — greater  than  in 
any  other  acute  disease.  They  constitute  a  very  serious  and  troublesome 
complication,  and  may  occur  on  any  part  of  the  body  subjected  to  pres- 
sure, but  are  most  frequent  over  the  sacrum  and  trochanters.  (Edema  of 
the  lower  extremities  from  feebleness  of  the  circulation  is  occasionally 
observed  in  the  convalescence  from  protracted  attacks.  Lendel  has  pub- 
lished a  series  of  7  cases  observed  at  Rouen,  in  which  the  entire  body 
became  very  O3dematous  in  the  second  or  third  week  of  the  attack  or 
during  convalescence.  In  none  of  the  cases  was  the  urine  albuminous. 
All  the  patients  recovered  except  one,  who  died  of  peritonitis.  Similar 
cases  have  been  reported  by  other  observers.  Barthez  and  Rilliet  have 
seen  several  cases  in  children. 

Periostitis  is  an  occasional  sequel.  I  have  seen  it  in  one  case  only. 
Sir  James  Paget,2  who  appears  to  have  met  with  it  in  several  cases,  says 
that  it  never  occurs  in  the  continuity  of  the  fever,  but  always  when  the 
patient  is  apparently  convalescent,  when  his  temperature  is  normal  and 
constant,  and  he  is  beginning  to  move  about  and  to  grow  stronger  and 
stouter.  Its  most  usual  seat  is  the  tibia,  but  it  is  also  met  with  in  the 
femur,  ulna,  and  parietal  bone.  Except  in  one  case,  Sir  James  has  never 
seen  it  in  more  than  one  bone  in  the  same  person.  It  is  always  circum- 
scribed within  a  space  of  from  one  to  three  inches  in  extent,  and  usually 
subsides  without  necrosis  or  other  abiding  change  of  structure ;  but  in 
some  cases  the  patient  has  remained  for  some  time  subject  to  repeated 
attacks  of  pain  and  swelling  of  periosteum.  In  the  few  cases,  he  says, 
in  which  the  periostitis  is  followed  by  necrosis  the  extent  of  dead  bone 
has  always  been  less  than  that  of  the  inflammation  over  it.  Murchison, 
however,  refers  to  two  cases  of  necrosis  of  the  tibia,  to  one  of  the  tem- 
poral bone,  and  to  two  in  which  extensive  necrosis  of  the  lower  jaw 
occurred.  Gay3  also  reports  a  case  of  extensive  necrosis  of  the  thigh- 
bone in  a  child  three  years  old,  following  an  attack  of  typhoid  fever. 

1  Liebermeister,  loc.  cit.  '  St.  Bartholomew's  Hospital  Report,  vol.  xxi. 

3  Path.  Trans.  Land.,  vol.  xx.,  p.  290. 


298  TYPHOID  FEVER. 

Very  frequently  after  an  attack  of  typhoid  fever  the  patient  evinces 
a  tendency  to  grow  stout,  which  is  either  continuous  or  else  is  gradually 
lost  after  he  fully  recovers  his  health.  This  increase  in  flesh  is  not 
always  accompanied  by  a  corresponding  gain  in  physical  strength,  and  he 
may  remain  for  a  long  time  after  convalescence  is  apparently  complete 
incapacitated  for  much  bodily  or  mental  exertion.  Sometimes,  on  the 
other  hand,  the  patient,  instead  of  gaining  flesh  and  strength,  may  con- 
tinue weak  and  emaciated,  even  when  he  is  taking  a  full  amount  of 
nourishment,  which  he  is,  however,  unable  to  assimilate.  Cases  of  this 
kind  may  terminate  in  phthisis,  but  they  occasionally  prove  fatal,  without 
any  discoverable  lesion  after  death  except  an  abnormally  smooth  appear- 
ance of  the  mucous  membrane  of  the  ileuru  and  a  shrivelled  condition 
of  the  mesenteric  glands.1 

Patients  suffering  from  typhoid  fever  may  occasionally  contract  other 
specific  diseases.  Murchisou  has  notes  of  eight  cases  in  which  the  erup- 
tion of  this  disease  coexisted  with  that  of  scarlatina,  and  says  that  it  was  not 
uncommon  in  the  London  Fever  Hospital  for  a  patient  suffering  from 
the  former  disease  to  contract  the  latter.  Similar  cases  are  recorded  by 
other  observers.  Typhoid  fever  may  also  be  complicated  with  rubeola, 
pertussis,  diphtheria,  variola,  and  vaccinia.  I  have  repeatedly  seen 
children  convalescent  from  typhoid  fever  in  the  hospitals  of  Paris  con- 
tract one  or  other  of  the  eruptive  fevers. 

VARIETIES. — A  great  variety  of  forms  of  typhoid  fever  has  been 
described  by  various  authors,  but  as  many  of  them  present  few  points  of 
difference  from  the  usual  form  of  the  disease,  it  will  not  be  necessary  to 
discuss  them  at  any  length.  They  derive  their  names  from  some 
peculiarity  of  the  mode  of  seizure,  from  the  prominence  of  some  one 
symptom  or  set  of  symptoms,  or  from  the  presence  of  complications. 
They  are — (1)  The  adynamic  form,  in  which  prostration  is  marked  in 
the  beginning  and  throughout  the  attack.  (2)  The  ataxic  or  nervous 
form,  which  is  characterized  by  the  predominance  of  delirium,  subsultus 
tendinum,  and  other  nervous  symptoms.  (3)  The  hemorrhagic  form,  in 
which  there  is  a  special  tendency  to  hemorrhage  from  the  different 
mucous  membranes.  (4)  The  abdominal  form,  in  which  the  abdominal 
symptoms,  such  as  diarrhoea  and  tympanites,  are  well  developed.  (5) 
The  thoracic  form,  so  called  from  the  presence  of  some  thoracic  compli- 
cation. (6)  The  gastric  or  bilious  form,  in  which  the  disease  is  com- 
plicated at  its  commencement  by  gastro-intestinal  catarrh.  La  forme 
muqueuse  of  French  authors  is  probably  identical  with  the  above.  (7) 
The  acute  form,  in  which  the  disease  begins  abruptly  and  with  great  vio- 
lence, and  runs  a  very  rapid  course,  terminating  usually  in  death  before 
the  end  of  the  first  week  or  early  in  the  second,  before  ulceration  can 
have  taken  place.  Delirium  is  an  early  and  prominent  symptom  in  this 
form,  so  that  it  has  sometimes  been  mistaken  for  meningitis. 

Certain  forms  of  the  disease  deserve  a  little  fuller  consideration.  One 
of  the  most  important  of  these  is  the  abortive  form,  iii  which,  as  its 
names  implies,  the  fever  is  cut  short  in  its  course,  and  in  which  there  is 
every  reason  to  believe  that  infiltration  of  Foyer's  glands  takes  place  as 
usual,  but  that  the  subsequent  course  of  the  disease  is  different,  the  glands 
undergoing  resolution  instead  of  advancing  to  ulceration.  The  majority 

1  Murchison. 


VARIETIES.  299 

of  observers  agree  that  in  the  beginning  there  is  nothing  to  distinguish 
such  attacks  from  those  which  follow  their  usual  course.  Liebermeister 
and  Jaccoud  state,  however,  that  their  commencement  is  usually  more 
abrupt  than  in  the  ordinary  variety,  the  former  asserting  that  the  tem- 
perature generally  reaches  its  maximum  earlier,  and  the  same  opinion 
is  expressed  by  other  authors.  They  are  occasionally  characterized  by 
severe  symptoms,  including  a  high  temperature.  In  the  few  cases  which 
have  come  under  my  own  observation  the  symptoms  have  been  mild,  but 
they  were  sufficiently  developed  to  leave  no  doubt  on  the  mind  as  to  the 
nature  of  the  disease.  In  a  case  which  aborted  on  the  twelfth  day  there 
were  hebetude,  diarrhoea,  tympany,  and  rose-colored  spots  persisting  even 
after  the  subsidence  of  the  fever.  Constipation  would  appear,  however, 
to  be  more  frequent  than  diarrhoea  in  this  class  of  cases.  The  subsi- 
dence of  the  fever  may  occur  at  any  time  between  the  seventh  and  four- 
teenth days ;  Griesinger  has  seen  it  occur  as  early  as  the  fifth  day.  Some- 
times the  defervescence  occurs  abruptly,  with  copious  perspiration  ;  at 
others  it  is  gradual  and  similar  to  that  which  takes  place  in  ordinary 
attacks.  Between  the  abortive  form  of  typhoid  fever  and  simple  con- 
tinued fever  there  are,  of  course,  many  points  of  resemblance,  but  cases 
of  the  former  may  generally  be  recognized  by  the  presence  of  this  rose- 
colored  eruption  and  enlargement  of  the  spleen,  or,  where  these  are 
absent,  by  their  occurring  in  the  same  house  or  under  the  same  circum- 
stances as  typical  cases  of  the  disease. 

Liebermeister  has  called  attention  in  his  article  on  typhoid  fever  in 
Ziemssen's  Cyclopcedia  to  a  class  of  cases  which,  he  thinks,  is  also  caused 
by  the  typhoid  infection,  and  of  which  the  prominent  feature  is  the 
insignificance  of  the  fever  or  the  entire  absence  of  it  which  characterizes 
them.  Such  cases  appear  to  be  of  frequent  occurrence  in  Basle.  Many 
of  them,  he  says,  never  show  during  their  entire  course  any  rise  of  the  tem- 
perature, or  occasionally  a  slight  elevation  only,  but  an  enlargement  of 
the  spleen  could  generally  be  detected,  and  occasionally  an  unmistak- 
able rose-colored  eruption.  The  action  of  the  bowels  was  usually 
irregular ;  sometimes  there  was  diarrhoea,  and  sometimes,  on  the  other 
hand,  obstinate  constipation.  The  other  symptoms  were  prostration, 
pains  throughout  the  body,  often  headache,  persistent  loss  of  appetite, 
with  more  or  less  swollen  and  furred  tongue,  and  markedly  diminished 
frequency  of  the  pulse,  which  disappears  with  convalescence,  while  its 
quality  is  not  appreciably  altered.  The  long  duration  of  an  apparently 
trifling  indisposition  he  considers  as  especially  characteristic.  Cayley 
also  refers  to  cases,  and  even  epidemics,  of  typhoid  fever  in  which  the 
temperature  has  been  below  the  normal  throughout  the  whole  course  of 
the  attack.  Strube1  had  the  opportunity  of  observing  such  an  out- 
break during  the  siege  of  Paris  by  the  Germans  in  1870.  "  In  many  of 
the  cases,"  he  says,  "  the  temperature  throughout  was  subnormal,  and  in 
others  never  exceeded  the  normal  point.  The  roseola  was  usually  pro- 
fuse ;  the  nerve  symptoms  were  of  marked  severity,  and  were  in  inverse 
ratio  to  the  temperature,  consisting  of  violent  delirium  alternating  with 
stupor ;  the  duration  of  the  fever  was  very  short,  defervescence  usually 
taking  place  at  the  end  of  a  fortnight.  Of  the  23  fatal  cases,  in  20 
death  took  place  during  the  first  fourteen  days.  The  abdominal 

1  Quoted  by  Dr.  Cayley. 


300  TYPHOID  FEVER. 


symptoms  were  slight,  but  the  characteristic  lesions  were  found  on  post- 
mortem examination.  All  the  cases  were  characterized  by  great  prostra- 
tion. These  cases  presented  some  features  which  were  probably  due  to 
this  peculiarity  of  the  temperature ;  thus,  the  pulse  was  but  little  accele- 
rated, seldom  exceeding  a  hundred  ;  the  tongue  did  not  become  dry  and 
brown ;  and  the  enlargement  of  the  spleen  was  either  absent  or  much 
less  marked  than  usual.  Strube  attributed  the  peculiar  features  of  this 
epidemic  to  the  depressed  condition  of  the  troops ;  they  had  been  exposed 
to  great  hardships  on  the  way  to  Paris,  over-fatigued  by  forced  marches, 
and  very  insufficiently  supplied  with  food." 

A  mild  form  of  the  disease  has  been  described  by  certain  authors,  in 
which  the  symptoms,  although  not  severe,  are  characteristic,  and  in  which 
there  is  therefore,  with  due  care,  little  danger  of  making  a  mistake  in 
diagnosis.  It  therefore  seems  an  unnecessary  refinement  to  set  apart  such 
cases  under  a  separate  head. 

The  latent  form,  or  the  typhus  ambulatorius  of  the  Germans,  is  of 
more  importance  from  the  fact  that  the  symptoms  are  so  mild,  or  that  so 
many  of  the  ordinary  symptoms  are  wanting  or  masked  by  those  due  to 
complications,  that  there  is  great  danger  of  regarding  the  attack  as  of 
little  moment.  In  many  cases  there  is  no  symptom  present  but  prostra- 
tion and  fever  to  indicate  that  the  patient  is  ill,  and  these  may  be  so  slight 
that  he  may  positively  refuse  to  go  to  his  bed,  and  may  even  insist  upon 
pursuing  his  ordinary  avocation,  in  the  midst  of  which  he  is  often  sud- 
denly seized  with  alarming  symptoms,  such  as  violent  delirium,  intestinal 
hemorrhage,  or,  what  is  more  common,  those  due  to  perforation  of  the 
bowel.  Still,  even  in  these  cases  a  careful  examination  will  often  disclose 
the  presence  of  some  symptom  which  had  failed  before  to  attract  atten- 
tion, and  which  will  often  reveal  to  us  the  true  nature  of  the  disease.  I 
was  myself  the  subject  of  such  an  attack  nearly  twenty  years  ago.  Sup- 
posing that  the  excessive  prostration  from  which  I  was  suffering  was  due 
to  overwork  at  a  large  army  hospital  in  the  neighborhood  of  Phila- 
delphia, I  determined  to  seek  repose  in  travel  and  in  change  of  scene. 
On  the  eve  of  doing  so  I  fortunately  sent  for  a  medical  friend,  who,  after 
a  thorough  investigation  of  my  symptoms,  succeeded  in  finding  a  few 
rose-colored  spots  upon  my  abdomen.  The  attack  subsequently  ran  a 
mild  but  well-marked  course.  Occasionally,  the  symptoms  due  to  a  com- 
plication so  predominate  over  those  arising  from  the  disease  itself  that 
they  completely  mask  it.  I  have  known  bronchitis  so  severe  as  to  divert 
in  this  way  the  attention  of  a  skilful  diagnostician  from  the  primary 
disease.  When  vomiting,  together  with  other  symptoms  of  hepatic 
derangement,  is  especially  prominent  in  the  beginning  of  typhoid  fever, 
the  mistake  is  not  infrequently  made  of  attributing  these  symptoms  to  a 
"  bilious  attack." 

TYPHO-MALARIAL  FEVER. — Under  this  name,  which  was  orig- 
inally suggested  by  J.  J.  Woodward,  Surgeon  U.  S.  A.,  early  in  the 
summer  of  1862,  as  a  designation  for  a  class  of  cases  in  which 
the  symptoms  of  typhoid  fever  are  associated  with  those  of  remittent, 
and  which  was  especially  common  among  the  soldiers  of  the  United 
States  Army  during  the  late  Civil  War,  are  probably  included  at  least 
t\vo  distinct  conditions :  1st,  remittent  fever,  in  which  the  disease,  on 
account  of  the  depressing  circumstances  surrounding  the  patient,  assumes 


TYPHOID  FEVER  IN  CHILDREN.  301 

a  typhoid  form ;  and,  2d,  typhoid  fever,  occurring  in  a  patient  who  has 
also  been  exposed  to  malarial  influence.  This  association  of  diseases 
is  of  course  not  new,  or  even  undescribed  before  this  name  was  sug- 
gested for  it.  Woodward  thinks  that  he  has  found  enough  in  the 
description  of  Roderer  and  Wagler  to  justify  him  in  concluding 
that  the  epidemic  which  occurred  at  Gottingen  in  1762  was  really 
of  this  character.  There  would  seem  also  to  be  no  doubt  from  the  de- 
scriptions of  Dawson1  and  Davis2  that  the  fever  which  decimated  the 
British  army  in  the  Walcheren  expedition  was  typhoid  fever,  modified 
by  the  malarial  influence  to  which  the  soldiers  were  subjected.  The 
latter  of  these  authors  says  that  the  ileum  and  jejunum  in  the  bodies  of 
those  who  died  of  this  disease  were  frequently  found  interspersed  with 
tubercles,  inflamed  and  ulcerated  in  different  parts. 

In  our  own  country  the  occasional  association  of  these  two  diseases  has 
also  long  been  recognized.  Drake  describes  it  under  the  name  of  remitto- 
typhoid,  and  Dickson  seems  to  have  been  perfectly  familiar  with  it,  for 
he  says  that  typhoid  lesions  will  sometimes  be  found  in  the  bodies  of 
those  dead  of  bilious  remittent.  Levick  recognized  the  presence  of 
the  symptoms  of  both  diseases  in  some  patients  who  were  under  his  care 
as  early  as  the  spring  of  1862,  and  proposed  the  name  of  miasmatic 
typhoid  fever  for  this  class  of  cases  in  the  following  June.3  Mere- 
dith Clymer  has  also  frequently  met  with  cases  in  which  the  symptoms 
of  the  two  diseases  were  coexistent.4 

As  is  indicated  by  the  name  given  to  it,  the  symptoms  in  this  form  of 
typhoid  fever  are  modified  by  the  presence  of  malarial  poisoning.  The 
cases  always  manifest  a  decided  tendency  to  periodicity,  the  evening 
exacerbations  are  more  decided  than  in  the  ordinary  form,  the  remissions 
are  often  ushered  in  with  a  profuse  sweating,  gastric  and  hepatic  derange- 
ments are  more  marked,  and  headache  is  more  severe.  There  is  fre- 
quently less  mental  hebetude  or  dulness  than  in  ordinary  typhoid  fever. 
In  some  of  the  cases  observed  by  Levick5  the  symptoms  were  those 
of  pernicious  congestive  remittent  fever,  such  as  copious  serous  discharges, 
not  unlike  those  of  Asiatic  cholera,  colliquative  sweats,  and  other  symp- 
toms of  exhaustion. 

TYPHOID  FEVER  IN  CHILDREN. — It  was  formerly  thought  that  infants 
and  very  young  children  were  not  often  the  subjects  of  typhoid  fever,  but,  so 
far  is  this  opinion  from  being  correct,  it  is  now  known  that  they  are  espe- 
cially liable  to  suffer  from  it.  The  rose-colored  eruption  is  more  often 
wanting  in  them  than  in  adults,  and  the  fever  more  apt  to  assume  a  dis- 
tinctly remittent  type ;  and  hence,  no  doubt,  the  difficulty  which  is  often 
experienced  in  diagnosticating  this  fever  from  other  forms  of  fever  in 
children.  There  is  no  doubt  that  many  cases  which  have  been  described 
by  authors  under  the  head  of  infantile  remittent  fever  are  really  examples 
of  typhoid  fever  modified  simply  by  the  age  of  the  patient.  It  may 
occur  in  infants  not  more  than  six  months  old,  and  is  not  infrequent  in 

1  Observations  on  the  Walcheren  Diseases,  Ipswich,  1810,  by  G.  P.  Dawson. 

2  A  Scientific  and  Popular  View  of  the  Fever  of  Walcheren,  J.  B.  Davis,  London,  1810. 
s  Med.  and  Surg.  Reporter,  June  21,  1862. 

4  The  Science  and  Practice  of  Medicine,  by  William  Aitken,  M.  D.,  3d  Amer.  ed. ;  with 
additions  by  Meredith  Clymer,  M.  D.,  Philadelphia,  1872. 
6  Amer.  Journal  of  the  Med.  Sci.,  April,  1864. 


302  TYPHOID  FEVER. 

children  of  two  or  three  years  of  age.  Henoch,1  who  has  had  the  oppor- 
tunity of  observing  a  large  number  of  cases,  says  that  the  rise  of  temper- 
ature is  commonly  more  abrupt  in  children  than  in  adults,  and  that  the 
disease  generally  runs  its  course  in  a  shorter  time.  The  pulse  is  more 
frequent,  and  may  be  as  high  as  144  in  cases  in  which  the  prognosis  is 
not  grave.  Dicrotism  is  very  rare.  Slowness  and  irregularity  of  the 
pulse,  like  that  observed  in  basillar  meningitis,  he  has  never  seen.  The 
nervous  symptoms  are  not  so  pronounced  even  when  the  temperature  is 
high,  and  they  bear  no  relation  in  severity  to  the  height  of  the  temperature. 
Diarrhoea  in  the  cases  observed  by  Henoch  was  often  absent  during  the 
whole  course  of  the  attack,  and  the  stools  were  often  brownish  or  greenish 
instead  of  yellow. 

TYPHOID  FEVER  OF  AGED  PERSONS. — The  modifications  which  the 
disease  undergoes  when  it  occurs  in  patients  advanced  in  life  are  precisely 
those  to  be  expected  from  the  diminished  activity  of  the  processes  of  life 
in  them,  as  compared  with  those  of  younger  persons.  The  febrile 
movement  is  generally  prolonged,  although  of  low  grade,  the  temperature 
rarely  rising  high,  and  frequently  during  convalescence  sinking  below  the 
normal.  The  diarrhoea  is  commonly  not  so  severe,  the  delirium  so  vio- 
lent, or  the  rose-colored  eruption  so  often  present.  On  the  other  hand, 
adynamic  symptoms,  such  as  excessive  prostration,  tremors,  subsultus 
tendinum,  and  the  like,  are  frequently  prominent  from  the  beginning  of 
the  attack. 

Several  authors,  among  whom  may  be  mentioned  Arnat,2  Hornburger,3 
and  Greenhow,4  have  described  a  renal  form  of  typhoid  fever.  In  this 
form  the  urine  is  blood  red  in  color  or  like  dark  broth.  It  often  contains 
albumen  during  the  first  week  of  this  disease,  usually  hyaline  or  more  or 
less  granular  casts,  and  occasionally  red  blood-discs,  white  cells,  epithelia 
of  kidneys  and  bladder,  and  epithelial  detritus.  The  specific  gravity  is 
high,  and  the  quantity  is  usually  diminished.  The  prominent  symptoms 
are  pain  in  the  region  of  the  kidneys,  oedema  of  face,  tense  and  frequent 
pulse,  great  prostration,  profuse  epistaxis,  violent  delirium,  and  hyper- 
pyrexia.  The  temperature  may  be  105.8°.  On  the  other  hand,  the  intes- 
tinal symptoms  are  less  marked.  In  fatal  cases  the  lesions  of  intestinal 
nephritis  have  been  found  at  the  autopsy. 

RELAPSES. — Much  difference  of  opinion  will  be  found  to  exist  among 
authors  in  regard  to  the  frequency  with  which  relapses  occur  in  typhoid 
fever,  and  this  difference  does  not  appear  to  be  due  to  any  greater  fre- 
quency of  this  accident  in  some  countries  than  in  others,  since  Lieber- 
meister  met  with  them  in  8.6  per  cent,  of  the  cases  treated  at  the  hospital 
at  Basle,  while,  according  to  other  German  observers  quoted  by  him,  they 
occur  in  6.3  per  cent.  (Gerhardt),  in  11  per  cent.  (Baumler),  and  in  3.3 
per  cent.  (Biermer).  Murchison  noted  them  in  80  of  2591  cases  in  the 
London  Fever  Hospital,  or  in  3  per  cent.,  and  Maclagan  in  13  of  128 
cases  at  Dundee,  or  in  10  per  cent,  about.  Immermann 5  of  Basle  says 
that  they  occur  in  15  per  cent,  of  the  cases,  and  that  in  very  unfavorable 
years  the  proportion  may  be  as  high  as  18  or  19  per  cent.  Prof.  Henoch6 
observed  relapses  in  16  cases  out  of  96,  or  16.6  per  cent.  In  my  own 

1  Charite  Ann.,  1875.  2  Thesis,  Sur  la  Fievre  typhoide  d  forme  renale.. 

8  fierlin  kiln.  Wochenschrift,  1881.  *  Transactions  of  Clinical  Society  of  London,  1880. 

*  Schweiz.  Corr.  BL,  viii.  1878.  6  Charite  Ann.,  ii.  1875. 


RELAPSES.  303 

practice  they  have  not  been  very  numerous.  I  find  that  in  80  cases  of 
which  I  have  full  notes  they  are  recorded  five  times,  or  in  6.25  per  cent., 
and  I  believe  this  ratio  correctly  represents  the  frequency  with  which 
they  have  happened  in  all  the  other  cases  which  have  come  under  my 
care.  Part  of  this  difference  of  opinion  is  unquestionably  attributable  to 
the  fact  that  under  the  term  relapse  are  sometimes  included  two  distinct 
conditions :  (1)  Mere  recrudescences  of  fever,  which  occur  during  the 
stage  of  defervescence  or  that  of  convalescence,  and  which  are  provoked 
by  errors  of  diet,  mental  or  bodily  fatigue,  or  some  other  irritating  cause. 
They  usually  last  a  day  or  two,  and  are  entirely  distinct  from  (2),  true 
relapses,  in  which  all  the  characteristic  symptoms  of  the  primary  attack 
are  reproduced,  and  which  commonly  occur  some  time  after  the  disease 
has  apparently  run  its  course.  There  is  occasionally  no  distinct  apyretic 
interval  between  the  two  attacks,  but  in  by  far  the  greater  number  of 
instances  the  relapse  occurs  in  the  second  or  third  week,  or  even  later, 
after  the  establishment  of  convalescence.  In  20  cases  reported  by  W. 
M.  Ord  and  Seymour  Taylor l  the  relapse  occurred  in  the  third  week 
of  the  disease  in  1  ;  in  the  fourth  week  in  5  ;  in  the  sixth  week  in  3 ;  in 
the  seventh  week  in  7 ;  in  the  eighth  week  in  3 ;  in  the  ninth  week 
in  1.  James  Jackson  refers  to  a  case  in  which  the  date  of  the  relapse  is 
not  given,  but  in  which  he  was  able  to  detect  the  rose-colored  eruption 
in  the  sixty-sixth  day2  from  the  commencement  of  the  disease.  In  my 
five  cases  the  relapse  occurred  on  the  seventh,  eighth,  ninth,  eleventh, 
and  twentieth  day  after  the  apparent  establishment  of  convalescence.  In 
these  cases  the  duration  of  the  relapse  was  11,  13,  17,  20,  and  13  days 
respectively.  The  highest  temperature  noted  in  any  of  the  relapses  was 
105°,  which  occurred  in  two  cases.  In  both  of  these  this  temperature 
had  also  occurred  in  the  original  attacks.  In  one  of  the  others,  however, 
a  temperature  of  over  104°  F.  was  repeatedly  observed  in  the  relapse, 
while  in  the  primary  attack  it  had  never  risen  above  102°. 

The  onset  of  a  relapse  is  usually  much  more  abrupt  than  that  of  the 
original  attack.  It  is  rarely  preceded  by  prodromata.  The  temperature 
rises  more  rapidly  and  attains  its  maximum  earlier,  which  may  be  much 
greater  than  in  the  original  attack.  In  one  case  under  my  care  it  reached 
105°  on  the  evening  of  the  first  day,  and  temperatures  of  103.5°  and 
104°  on  the  evening  of  the  second  day  are  not  infrequent. 

1  St.  Thomads  Hospital  Report,  vol.  ix.,  London,  1879. 

2  Since  the  above  was  written  I  have  had  under  my  care  a  case  of  typhoid  fever  in 
which  a  third  relapse  occurred   nearly  four  months  after  the  patient,  a  woman  aped 
thirty  years,  was  first  taken  ill.     The  following  is  a  brief  abstract  of  the  history  of  this 
remarkable  case:  The  original  attack  began  about  Sept.  20,  1883,  was  of  moderate  sever- 
ity, and  lasted  between  three  and  four  weeks.     Convalescence,  which  seems  to  have  been 
nearly  complete,  as  the  patient  had  left  her  bed,  was  interrupted  on  Nov.  1st  by  a  relapse, 
during  which  she  was  admitted  into  the  Pennsylvania  Hospital.     This  relapse  was  severe, 
and  before  it  had  entirely  run  its  course  was  itself  interrupted,  on  Nov.  17th,  by  an  intercur- 
rent  relapse,  which  lasted  two  weeks.  During  these  two  relapses  extensive  bed-sores  formed 
upon  the  nates,  occasioning  more  or  less  irritation  and  consequent  febrile  reaction.     On 
Jan.  11,  1884,  a  third  relapse  occurred.    This  relapse  was  accompanied  by  diarrhoea,  rose- 
colored  spots,  tympany,  dry  and  brown  tongue,  and  other  characteristic  symptoms  of 
typhoid  fever,  the  diagnosis  being  fully  concurred  in  by  my  colleague,  Dr.  Morris  Long- 
streth,  who  saw  the  case  with  me.     Convalescence  was  again  interrupted  on  Feb.  13th 
by  fever,  which  continued  for  two  weeks,  but  which  possessed  none  of  the  characters 
of  typhoid  fever,  and  was  clearly  due  to  imprudence  on  the  part  of  the  patient.     The 
patient  is  now  (April  25,  1884)  entirely  well,  and  will  shortly  be  discharged  from  the 
hospital. 


304  TYPHOID  FEVER. 

The  rose-colored  eruption  appears  earlier.  In  38  cases  investigated  by 
Murchison  with  reference  to  this  point,  it  appeared  on  the  third  day  in  7  ; 
on  the  fourth  in  8  ;  on  the  fifth  in  7  ;  on  the  sixth  in  2 ;  on  the  seventh 
in  12;  and  at  a  later  date  in  2.  In  the  case  the  history  of  which  is 
given  below  it  was  detected  on  the  second  day.  The  delirium  also  comes 
on  sooner.  The  relapse  is  usually  less  severe,  and  is  of  shorter  dura- 
tion, than  the  primary  attack.  All  my  cases  terminated  in  recovery. 
Occasionally,  however,  it  is  much  more  severe.  In  one  case  in  which 
the  primary  attack  was  so  mild  that  the  patient  could  scarcely  be  per- 
suaded to  remain  in  bed,  the  relapse  was  so  severe  that  for  many  days 
it  was  uncertain  whether  the  patient  would  recover.  In  another 
intestinal  hemorrhages  to  an  alarming  extent  occurred  on  two  occa- 
sions. Moreover,  of  Murchison's  53  cases,  7  were  fatal ;  in  2  of 
the  cases  death  was  due  to  perforation ;  in  2  to  peritonitis,  induced  by 
infarction  of  the  spleen ;  and  in  1  to  abortion ;  and  of  Ebstein's  13 
cases,  3  were  also  fatal.  Occasionally,  a  second,  and  it  is  said  even  a 
third,  relapse  is  noted.  In  one  of  Da  Costa's  cases  hemorrhage  from 
the  bowels  took  place  during  a  second  relapse. 

FIG.  15. 


Pulse. 


The  following  histories  and  temperature  charts  illustrate  the  prominent 
peculiarities  of  relapses  occurring  in  typhoid  fever : 

TYPHOID  FEVER  (with  a  relapse). — G L ,  set.  20,  single,  sea- 
man, Italian,  admitted  March  6,  1878 ;  April  30,  1878,  left  in  ward. 
Patient  is  unable  to  speak  English.  The  following  history  is  obtained 
through  an  interpreter :  His  family  history  is  good,  and  he  is  naturally 
a  healthy  man,  never  having  had  any  serious  illness — no  venereal  dis- 
ease, no  cough  or  rheumatism,  no  intermittent  fever,  and  he  has  not  been 
in  the  habit  of  drinking  to  excess.  His  vessel  has  been  lying  off  Glou- 
cester Point,  and  two  seamen  have  recently  been  similarly  affected  on 
another  vessel  anchored  near  by.  For  about  two  weeks  he  has  had 
malaise,  but  not  until  three  days  ago  was  he  so  ill  that  he  was  obliged 
to  give  up  work.  He  was  then  taken  with  cough,  chills  followed  by 
fever,  diarrhoea,  headache,  and  pain  in  the  abdomen.  Has  had  no  epis- 
taxis  or  vomiting. 

Upon  admission  patient  has  fever,  his  face  is  flushed,  his  tongue  coated 
with  a  brown  fur  in  the  centre,  dry,  fissured,  and  red  and  glossy  at  the 
tip  and  edges.  He  has  hebetude  and  some  delirium,  though  not  very 
active ;  he  is  deaf.  His  abdomen  is  somewhat  tense  and  tympanitic,  and 
covered  with  very  numerous  rose-colored  spots,  which  disappear  moment- 
arily on  pressure ;  they  are  also  distributed  over  thighs  and  chest.  There 
seems  to  be  no  tenderness  on  pressure  over  abdomen,  and  there  is  no 
gurgling  felt.  Has  moderate  diarrhoea,  having  about  three  stools  daily, 
which  are  light  yellow  in  color  and  are  loose  and  fetid.  Urine  cloudy 
orange  red,  acid,  1021.  No  albumen. 


ABORTIVE  ATTACK,  FOLLOWED  BY  TYPICAL  ATTACK.      305 

3.7.  Ord.  Ol.  Terebinth,  gtt.  x ;  Acid.  Miiriat.  dil.  gtt.  v  every  two 
hours,  with  Quinine  gr.  viij  daily,  and  restricted  diet, 

3.8.  Tongue  not  so  dry ;  is  better.    Whiskey  fgij. 

3.9.  Temperature  elevated.     Ord.  to  be  sponged. 

3.10.  Has  had  four  stools  in  the  last  twenty-four  hours.     Some  sonor- 
ous rales  over  chest  posteriorly.     Sponging  to  be  repeated  when  tempera- 
ture rises. 

3.11.  There  is  some  subsultus.     There  are  more  numerous  rales  heard 
over  chest  posteriorly. 

Ord. whiskey f|v  daily;  turpentine  stupes  to  chest.  His  diarrhoea  is 
better ,  considerable  hebetude. 

3.12.  Tongue  is  not  so  dry,  and  is  cleaner.     The  spots  over  his  body 
are  beginning  to  assume  more  the  appearance  of  petechise.     They  are 
found  everywhere  on  his  body.     Has  had  but  one  stool  within  the  last 
twenty-four  hours. 

3.13.  He  is  brighter ;  skin  feels  better ;  tongue  cleaner ;  pulse  but  80. 
Fewer  rales  heard  in  chest.     No  change  in  his  treatment. 

3.14-  Spots  disappearing.  Two  stools  in  last  twenty-four  hours,  not 
so  loose  in  character.  Pulse  dicrotic. 

3.15.  There  is  no  tympany.     Had  one  natural  stool  yesterday.     Suda- 
minse  over  abdomen. 

3.16.  Doing  well.     Pulse  very  slow. 

3. 17.  Tongue  moist  and  clean  ;  no  diarrhoea. 

3.18.  No  diarrhoea ;  spots  are  still  to  be  seen,  but  are  fading  every 
day. 

3J20.  Takes  a  little  lemon-juice,  as  the  gums  are  disposed  to  be  a  little 
spongy. 

Stop  turpentine  and  muriatic  acid. 

3.%5.  Bowels  somewhat  constipated. 

Ord.  enema  of  castor  oil. 

3.26.  Stop  quinine ;  give  whiskey  f  3iij  only.  Allowed  chicken  and 
two  eggs  daily. 

Ord.  Tr.  Cinch.  Co.  f  gij  s.  t.  d. 

4-4-  Slight  chill,  headache,  and  pain  in  side.     Temp.  101°. 

4-5.  Temp,  normal  again ;  as  well  as  before. 

4-8.  Has  been  up  for  a  week,  and  steadily  gaining  in  strength,  except 
the  slight  attack  on  the  4th,  when  to-day,  without  his  having  taken  any 
indigestible  food,  or  indeed  any  reason  to  which  it  could  be  assigned,  he 
was  seized  with  a  relapse,  his  temperature  rising  to  105°,  but  being 
reduced  a  half  degree  by  sponging. 

4-9.  Spots  have  again  appeared  in  great  numbers,  and  they  are  very 
large.  Last  evening  his  temperature  reached  104f  °,  and  was  reduced  tc 
101°  by  sponging. 

4-10.  Doing  very  well ;  spots  are  still  making  their  appearance. 

4-13.  Diarrhoea  not  at  all  excessive. 

4- 15.  Spots  are  very  numerous. 

4-%0.  Temperature  nearly  normal. 

4*%5.  Doing  perfectly  well ;  up  and  about. 

4-30.  Left  in  ward,  upon  completion  of  my  term  of  service. 

ABORTIVE  ATTACK,  FOLLOWED  BY  TYPICAL  ATTACK. — Thomas 
Rogers,  October  15,  born  in  Philadelphia,  assistant  nurse.  Admitted 

VOL.  L— 20 


FIG.  16. 


10   U   12   13   14   15   16   17   18   19   20   21 


Respiration  _  24_  2o|gQ  20^26   24  -24  2-1,24   24J24  24J28  26.20   20 ' go  20 '20   go  -20  20;20  1S!18   13   18    18   18   IS  20  20  20  20  20  20  20  20|gO   181 18 

Chart  of  Typhoid  Fever  with  relapse. — Original  attack. 

FIG.  17. 


U.-spiralion  M  2j  24  24|2-i  20   24 ;  24   34  24|24  22  [24   24   24  --    L.   _      -J     :    |li   I.?|l8, 18    13,18    18,18   IS  18    li  1?    IS  20   2.  2)    2'i,24  24,22   24^4 

Chart  of  Typhoid  Fever  with  relapse.— Relapse. 
306 


ABORTIVE  ATTACK,  FOLLOWED  BY  TYPICAL  ATTACK.      307 

January  25,  1883  ;  discharged  March  26,  1883,  cured.  Father  died  of 
hemorrhage  from  the  lungs;  mother  living  and  healthy.  Two  years  ago 
he  sustained  a  compound  fracture  of  the  left  leg  from  a  bale  of  cotton 
falling  011  him ;  otherwise  he  has  always  enjoyed  good  health.  For  the 
past  three  months  he  has  been  assisting  the  nurse  in  the  receiving  ward 
of  this  hospital.  Four  days  before  admission,  without  unusual  exposure, 
he  had  a  slight  chill,  and  felt  cold  for  several  hours.  This  was  followed 
by  fever  and  a  feeling  of  weakness.  He  also  had  slight  headache  and 
the  bowels  were  constipated  ;  no  epistaxis. 

Upon  admission  patient  has  a  good  deal  of  hebetude,  face  flushed,  tem- 
perature 102°,  pulse  106,  tongue  slightly  coated,  moist.  Has  slight  pain 
in  right  lumbar  region,  but  no  distension  of  abdomen.  Urine  negative. 

Ord.  quinine  gr.  viij.  daily ;  liq.  ammon.  acet.  fs'ij.  q.q.h. 

Jan.  29th.  More  hebetude  ;  tongue  more  coated  with  brownish  fur,  red 
at  tip  ;  bowels  continue  costive  ;  opened  by  an  enema. 

31st.  Is  brighter  and  better.  One  doubtful  rose-colored  spot  seen  on 
abdomen. 

Feb.  4th.  The  morning  temperatures  for  the  past  two  days  have  been 
subnormal  and  the  evening  rise  is  very  slight.  All  the  symptoms  also 
indicate  the  approach  of  convalescence. 

6th.  More  fever ;  pulse  weaker  ;  functional  murmur  heard  over  heart ; 
sudamina  out  over  abdomen.  Ord.  whiskey  f  §ij. 

8th.  Some  fulness  of  abdomen ;  had  three  loose  yellowish-colored  stools 
in  the  last  twelve  hours. 

9th.  A  few  doubtful  rose  spots  out  over  abdomen  and  back ;  sudamina 
still  abundant. 

10th.  More  tympany ;  numerous  rose-colored  spots  out  over  abdomen 
and  back  ;  slight  epistax-is  and  bronchitis. 

llth.  Pulse  more  feeble ;  still  slight  diarrhoea.  Increase  whiskey  to 
fgiv. 

15th.  Has  a  good  deal  of  hebetude,  but  no  headache ;  fewer  spots ; 
pulse  weaker ;  temperature  lower.  Increase  whiskey  to  f  3vj. 

17th.  Temperature  high  again ;  most  of  the  spots  have  disappeared ; 
slight  epistaxis  and  subsultus;  no  delirium;  bowels  not  open  for  two 
days. 

20th.  Temperature  falling ;  spots  disappearing  ;  still  fulness  of  abdo- 
men. 

26ih.  Temperature  has  been  subnormal  for  several  days,  and  he  is 
doing  well ;  tongue  cleaning.  Has  emaciated  a  good  deal,  and  is  weak. 

March  1st.  Is  convalescent ;  tongue  has  lost  its  redness. 

8th.  Continues  to  improve ;  allowed  semi-solid  food. 

17th.  Is  now  quite  well ;  has  gained  a  good  deal  in  flesh,  and  is 
stronger. 

The  examination  of  the  bodies  of  those  who  have  died  during  a  relapse 
reveals  the  presence  of  two  sets  of  lesions  in  the  cicatrizing  ulcers  of  the 
primary  attack  and  the  recent  ulcerations  of  the  relapse.  The  latter  are 
usually  less  extensive,  and  are  found  to  be  situated  at  a  greater  distance 
from  the  lower  end  of  the  small  intestine,  than  the  former,  for  the  reason 
that  the  Fever's  patches  most  remote  from  the  ileo-csecal  valve  are  least 
apt  to  be  affected  in  the  primary  attack. 

No  satisfactory  explanation  of  these  relapses  has  as  yet  been  discovered. 


ABORTIVE  ATTACK,   FOLLOWED  BY  TYPICAL  ATTACK.       309 

They  occur  in  patients  of  both  sexes  and  of  all  ages  with  about  the  same 
frequency.  They  have  been  attributed  to  errors  of  diet,  mental  and 
bodily  fatigue,  and  the  like,  but,  while  we  know  that  causes  of  this  cha- 
racter often  provoke  recrudescences  of  fever,  and  can  understand  that  they 
may  act  as  exciting  causes  of  a  relapse  in  cases  in  which  the  predisposition 
exists,  it  does  not  seem  possible  that  they  should  by  themselves  be  able  to 
bring  back  all  the  characteristic  symptoms  of  a  specific  disease.  It  has 
been  maintained  by  some  authors  that  a  relapse  indicates  that  a  new  infec- 
tion has  taken  place ;  but  this  hypothesis,  even  if  we  admit  that  it  accounts 
for  those  cases  in  which  the  patient  is  allowed  to  remain  in  the  place  in 
which  he  has  acquired  the  disease,  does  not  explain  those  in  which  he 
is  removed  during  the  first  attack  to  a  hospital  where  all  the  sanitary 
arrangements  are  presumably  perfect.  Griesinger  has  endeavored  to 
explain  relapses  occurring  in  hospitals  by  suggesting  that  they  may  pos- 
sibly be  due  to  a  fresh  contagion  from  other  patients  with  typhoid  fever 
in  the  same  ward ;  but  this  explanation  is  rendered  improbable  by  the 
fact  that  relapses  have  occurred  when  cases  have  been  thoroughly  isolated. 
As  I  have  already  said,  during  a  long  connection  with  the  Pennsylvania 
Hospital  I  have  only  known  a  single  case  of  typhoid  fever  to  originate 
within  its  walls,  although  relapses  probably  occur  in  its  wards  with  the 
same  frequency  as  in  other  hospitals.  To  adopt  Griesinger's  explanation, 
it  would  therefore  be  necessary  to  assume  that  a  patient  just  recovered 
from  an  attack  of  the  disease  is  more  susceptible  to  the  action  of  its  con- 
tagion than  patients  suffering  from  other  disease ;  which  seems  improbable, 
to  say  the  least.  It  has  also  been  maintained  that  relapses  are  due  to  the 
inoculation  of  the  previously  healthy  Peyer's  patches  by  the  typhoid  poison 
which  is  thrown  off  with  the  sloughs  from  those  first  affected.  Maclagan 
alleges  that  relapses  are  more  frequently  met  with  in  cases  in  which  con- 
stipation is  present  in  the  primary  attack,  a  condition  which  he  regards  as 
favorable  to  absorption  ;  but  this  is  opposed  to  the  experience  of  almost 
every  one  who  has  paid  any  attention  to  the  subject.  In  the  cases  which 
have  come  under  my  own  observation  it  certainly  was  not  the  case,  diar- 
rhoaa  having  been  present  in  all  of  them.  It  is  more  likely,  as  suggested 
by  Liebermeister,  that  part  of  the  poison  remains  latent  somewhere  in  the 
body,  not  developed,  destroyed,  nor  expelled  during  the  first  attack,  but 
brought  later  into  activity  by  some  exciting  cause.  Da  Costa  adopts  this 
view,  and  says  that  relapses  of  typhoid  fever  are  not  unlike  the  outbreaks 
of  malarial  fever  which  occur  after  worry  or  fatigue  and  when  there  has 
been  no  chance  for  a  fresh  infection.  Different  plans  of  treatment  have 
at  various  times  been  charged  with  increasing  the  predisposition  to 
relapses.  This  is  especially  true  of  the  cold-water  treatment,  and  the 
records  at  the  hospital  at  Basle  show  that  the  proportion  of  relapses  and 
the  number  of  deaths  from  them  are  both  increased  under  the  use  of  cold 
water.  Liebermeister  thinks,  however,  that  this  does  not  necessarily 
prove  that  this  treatment  favors  the  occurrence  of  relapses,  since  before 
the  introduction  of  this  plan  of  treatment  many  more  typhoid  fever 
patients  died  in  the  first  attack  of  the  disease.  Employing  those  cases 
only  for  statistical  purposes  in  which  the  patients  have  survived  the  first 
attack,  he  finds  that  the  difference  at  once  disappears,  there  being  9  per 
cent,  of  relapses  before  the  use  of  cold  water,  and  10-^j-  per  cent,  after  its 
use. 


310  TYPHOID  FEVER. 

Gerhardt1  asserts  that  in  cases  in  which  relapses  occur  the  enlargement 
of  the  spleen  does  not  diminish  during  the  non-febrile  period  that  inter- 
venes between  the  original  attack  and  the  relapse. 

Da  Costa 2  has  shown  that  the  appearance  of  the  white  line  and  furrow 
left  by  the  primary  attack,  to  which  attention  has  already  been  drawn, 
may  sometimes  be  of  service  to  us  in  diagnosis  when  we  see  the  patient 
lor' the  first  time  during  the  relapse.  In  a  case  which  was  recently  under 
jny  care  their  appearance  certainly  rendered  the  nature  of  the  previous 
illness  from  which  the  patient  had  suffered  much  clearer  than  it  M  aild 
otherwise  have  been. 

DURATION. — The  mode  of  invasion  of  typhoid  fever  is  generally  so 
insidious,  and  the  first  symptoms  so  little  pronounced,  that  the  patient, 
even  if  free  from  mental  hebetude  and  confusion  at  the  time  when  he  first 
comes  under  the  care  of  a  physician,  is  usually  unable  to  fix  with  cer- 
tainty the  time  of  the  beginning  of  his  illness.  This  inability  is  of  course 
most  marked  in  what  are  known  as  walking  cases,  in  which,  notwithstand- 
ing that  the  disease  is  far  advanced,  the  patient  continues  to  pursue  his 
ordinary  avocations  or  at  least  refuses  to  go  to  bed.  In  a  few  cases,  how- 
ever, either  in  consequence  of  the  violence  of  the  first  symptoms  or  from 
some  other  cause,  opportunity  is  afforded  to  the  physician  of  observing 
the  disease  from  its  onset.  In  many  others  the  date  of  commencement 
may  be  approximately  ascertained.  The  average  duration  of  such  cases, 
if  uncomplicated,  has  been  found  to  be  between  three  and  four  weeks. 
According  to  Bartlett,  the  average  duration  of  255  cases  at  the  Massa- 
chusetts General  Hospital  between  the  years  1824  and  1835,  inclusive, 
was  twenty-two  days.  It  was  a  little  less  than  this  in  patients  under 
twenty-one  years  of  age,  and  a  little  more  in  those  over.  As  these  cases 
occurred  before  the  introduction  into  use  of  the  clinical  thermometer,  and 
as  the  commencement  of  convalescence  is  fixed  in  them  at  the  time  when 
the  patients  were  able  to  take  a  little  solid  food,  it  is  possible  the  fever 
may  have  continued  in  them  some  time  after  convalescence  was  supposed 
to  have  been  established.  Of  200  cases  which  ended  in  recovery,  and  in 
which  Murchison  was  able  to  ascertain  with  precision  the  date  of  com- 
mencement, the  duration  was  10  to  14  days  in  7  cases,  15  to  21  days  in 
49  cases,  22  to  28  days  in  111  cases,  and  29  to  35  days  in  33  cases.  The 
mean  duration  of  these  200  cases  was  24.3  days,  while  that  of  112  fatal 
cases  was  27.67  days.  From  the  same  author  we  learn  that  the  average 
stay  in  hospital  of  500  cases  which  recovered  was  31.24  days,  and  of  100 
fatal  cases  was  16.52  days,  while  the  average  duration  of  the  illness  before 
admission  in  the  600  cases  was  10.78  days.  During  the  twenty  years  from 
Jan.  1, 1862,  to  Dec.  31, 1881,  621  cases  of  typhoid  fever,  121of  which  were 
fatal,  were  admitted  into  the  Pennsylvania  Hospital.  No  notes  of  many 
of  these  cases  were  taken,  and  of  some  of  the  others  the  notes  are  incom- 
plete or  inaccessible,  so  that  they  cannot,  unfortunately,  be  used  for  the 
purpose  of  determining  the  duration  of  the  disease.  The  books  of  the 
hospital,  however,  show  the  length  of  time  each  patient  remained  in  the 
wards.  From  these  we  learn  that  the  average  stay  of  the  500  patients 
who  recovered  was  43.5  days,  while  that  of  the  121  patients  who  died 
was  only  8.75  days,  and  that  of  these  a  large  number  (28)  died  within 

Ziemxsen's  Cyclopedia,  vol.  i.  p.  193. 
*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  3d  S.,  vol.  iii. 


DIAGNOSIS.  311 

48  hours  after  their  admission  to  the  hospital.  As  a  rule,  patients  are 
retained  at  the  Pennsylvania  Hospital  until  they  are  fully  able  to 
return  to  work,  while  at  the  English  and  continental  hospitals  it  is  usual 
to  discharge  them  when  they  cease  to  need  active  treatment.  This  cir- 
cumstance probably  explains  the  much  greater  average  duration  of  the 
cases  admitted  to  the  Pennsylvania  Hospital  than  that  of  the  cases  referred 
to  by  Murchison.  In  the  abortive  form  the  duration  of  the  disease  may 
not  exceed  ten  days,  and  there  are  authors  who  contend  that  it  may  occa- 
sionally be  very  much  less. 

Death  may  occur  at  almost  any  time  in  the  course  of  typhoid  fever. 
I  have  never  seen  it  myself  take  place  before  the  seventh  day.  Mur- 
chison reports  two  cases  in  one  of  which  the  disease  terminated  fatally 
within  twenty-seven  hours  of  its  commencement,  and  in  the  other  on  the 
second  day.  Instances  are  more  numerous  in  which  death  has  occurred 
on  the  fourth,  fifth,  or  sixth  day,  but  still  they  are  comparatively  infre- 
quent, and,  as  a  rule,  the  fatal  termination  takes  place  most  frequently 
during  the  course  of  the  third  week.  On  the  other  hand,  death  may 
sometimes  occur  at  a  very  much  later  period.  This  is,  of  course,  the 
case  when  it  occurs  during  a  relapse,  but  if  the  fever  continues  after  the 
third  week  the  patient  may  sometimes  die  from  exhaustion  or  from  the 
intercurrence  of  a  complication.  Death  may  also  be  the  result  of  a 
sequela  long  after  the  disease  has  run  its  course. 

DIAGNOSIS. — The  insidious  invasion  of  typhoid  fever,  together  with 
the  absence  of  pathognomonic  symptoms  in  the  beginning,  always  renders 
the  diagnosis  difficult,  and  sometimes  impossible,  during  the  first  week. 
Still,  even  at  this  time  the  existence  of  the  disease  may  be  suspected  if 
the  frequent  use  of  the  thermometer  reveals  from  day  to  day  a  gradual 
increase  of  the  fever  and  the  existence  of  evening  exacerbations  followed 
by  morning  remissions,  the  temperature  rising  each  evening  from  a  degree 
to  two  degrees  higher  than  it  had  done  the  preceding  evening.  If  in  addi- 
tion to  this  character  of  the  pyrexia  there  are  diarrhoea  with  ochrey-yellow 
stools  or  an  increased  susceptibility  to  the  action  of  cathartic  medicines, 
epistaxis,  enlargement  of  the  spleen,  slight  fulness  of  the  abdomen,  with 
tenderness  and  gurgling  in  the  right  iliac  region,  slight  hebetude  and 
some  confusion  of  ideas  upon  awakening,  the  diagnosis  becomes  more 
probable.  During  the  next  week  the  symptoms  are  usually  much  more 
characteristic.  The  presence  of  marked  abdominal  symptoms,  together 
with  the  eruption  of  rose-colored  spots,  will  generally  render  the  recog- 
nition of  the  disease  at  this  time  an  easy  matter.  There  are,  however,  a 
few  cases  in  which  no  rose-colored  spots  can  be  found,  and  in  which  the 
abdominal  symptoms,  if  they  exist  at  all,  are  so  little  marked  that  they 
do  not  arrest  attention.  Even  in  these  cases  the  temperature  record, 
when  carefully  studied,  will  often  throw  a  good  deal  of  light  upon  the 
nature  of  the  disease.  If  the  febrile  movement  resembles  that  usual  in 
typhoid  fever,  if  it  has  continued  for  more  than  a  week,  if  the  patient 
has  not  been  recently  exposed  to  malarial  influences,  and  presents  no 
symptoms  of  local  disease,  the  diagnosis  may  still  be  made  with  at  least 
an  approach  to  certainty. 

The  following  are  the  diseases  which  are  most  likely  to  be  mistaken 
for  typhoid  fever : 

Typhus   fever   has   a  course  which    is   so  essentially  different  from 


312  TYPHOID  FEVER. 

that  of  typhoid  that  in  well-marked  cases  it  would  scarcely  be  pos- 
sible to  mistake  one  for  the  other.  Cases,  however,  do  occur  which,  in 
consequence  of  a  very  profuse  and  dark-colored  eruption  in  the  latter, 
or  of  the  existence  of  abdominal  symptoms  in  the  former,  present  at  first 
a  good  deal  of  difficulty  in  diagnosis.  The  invasion  of  the  former  is 
more  abrupt  and  its  duration  shorter  than  in  typhoid  fever.  The  erup- 
tion is  usually  also  much  more  copious,  and  appears  in  the  former  as 
early  as  the  fourth,  fifth,  or  sixth  day,  while  that  of  the  latter  is  rarely 
observed  before  the  seventh  day.  The  fever  in  the  former  is  much  more 
nearly  continued  in  type  than  that  of  the  latter.  Defervescence  occurs 
in  the  former  by  crisis ;  in  the  latter,  by  lysis.  The  expression  of  the 
physiognomy  is  different  in  the  two  diseases.  In  typhus  there  is  a  uni- 
form dusky  hue  of  the  face,  with  injection  of  the  conjunctiva?  and  con- 
traction of  the  pupils.  In  typhoid  fever  the  pupils  are  often  widely 
dilated,  the  conjunctivse  clear,  and  the  face  pallid,  with  the  exception  of 
a  circumscribed  flush  on  each  cheek.  Diarrhoea  is  much  less  frequent  in 
the  former  than  in  the  latter,  and  when  it  does  occur  is  not  accompanied 
by  ochrey-yellow  stools.  Epistaxis,  tympanites,  pain,  and  gurgling  in 
the  right  iliac  region,  and  intestinal  hemorrhage,  common  symptoms  in 
the  latter,  are  very  infrequently  met  with  in  the  former.  On  the  other 
hand,  petechise  and  vibices,  which  are  of  almost  constant  occurrence  in 
the  former,  are  rarely  met  with  in  the  latter.  The  circumstances  also 
under  which  the  two  diseases  are  contracted  are  different.  Typhus  orig- 
inates from  overcrowding  or  is  due  to  direct  contagion.  The  origin  of 
typhoid  fever  is  often  involved  in  more  obscurity,  but  it  can  generally 
be  traced  either  to  a  polluted  water-supply  or  to  defective  drainage. 

Relapsing  fever,  with  due  care,  is  not  likely  to  be  confounded  with 
typhoid  fever.  The  abrupt  commencement  of  the  former,  the  high  fever, 
lasting  for  from  five  to  seven  days  only,  and  terminating  by  crisis  with 
a  profuse  sweat,  and  the  period  of  complete  apyrexia  of  a  week's  dura- 
tion, followed  by  the  relapse  in  which  the  temperature  rises  even  higher 
than  in  the  primary  paroxysm,  and  which  also  terminates  by  crisis,  form 
a  chain  of  symptoms  which  has  no  counterpart  in  the  latter.  The  mind 
in  relapsing  fever  is  usually  clear,  there  being  none  of  the  hebetude  and 
mental  confusion  commonly  observed  in  typhoid  fever.  The  rose-colored 
eruption  is,  moreover,  wanting,  and  diarrhoea  and  tympanites  are  absent. 
On  the  other  hand,  jaundice  and  tenderness  in  the  epigastric  zone  are 
more  common  than  in  typhoid  fever. 

Influenza  sometimes,  Murchison  says,  when  epidemic,  closely  simulates 

typhoid  fever,  but  as  the  two  diseases  occur  in  this  country  the  resem- 

between  them  is  not  often  sufficiently  strong  to  lead  the  careful 

^server  astray.     In  both  there  are  fever,  prostration,  sleeplessness,  delir- 

sweatmg,  and  occasionally  deafness,  diarrhoea,  epistaxis,  and  a 

1  tongue;  but  the  onset  of  the  attack  in  the  former  is  more  abrupt, 

shorter,  and  subsequent  convalescence  more  rapid  than  in 

The  prostration,  too,  is  more  decided  in  proportion  to 

degree  of  fever  present,     Coryza  and  bronchial  catarrh  are  much 

marked  symptoms  in  the  former  than  in  the  latter,  while  hyper- 

sthesia  of  he  surface  which  is  present  in  almost  every  case  of  influenza, 

is  only  rarely  met  with  in  typhoid  fever. 

Remittent  and  typhoid  fevers  often  prevail  together  in  the  malarious 


DIAGNOSIS.  313 

districts  of  this  country,  and,  as  they  present  many  points  of  resemblance, 
they  are  sometimes  with  difficulty  distinguished  from  each  other.  They 
both  may  begin  with  nausea  and  vomiting;  abdominal  and  cerebral 
symptoms  are  common  to  both,  and  so  is  enlargement  of  the  spleen.  The 
typhoid  state  may  supervene  in  either,  and  in  both  the  febrile  move- 
ment is  remittent  in  character.  In  remittent  fever,  however,  the  remis- 
sions are  more  marked,  and  are  usually  accompanied  with  more  profuse 
sweating,  than  in  typhoid  fever.  Jaundice  and  other  symptoms  of  hepatic 
derangement  are  also  more  common,  and  the  pains  in  the  back  and  limbs 
are  more  frequent  and  more  severe.  The  eifect,  too,  of  quinine  in  producing 
a  permanent  reduction  of  the  temperature,  is  generally  more  decided.  On 
the  other  hand,  the  rose-colored  eruption  of  typhoid  fever  is  never  pres- 
ent in  pure  remittent  fever.  Occasionally,  in  cases  of  the  variety  of 
typhoid  fever  known  as  typho-malarial  fever,  the  symptoms  of  the  latter 
may  be  so  prominent  as  entirely  to  mask  those  of  the  former.  In  such 
cases  the  discovery  of  a  few  rose-colored  spots  somewhere  on  the  surface 
will  clearly  reveal  the  true  nature  of  the  disease. 

Epidemic  cerebro-spinal  meningitis  diifers  from  typhoid  fever  by  its 
more  abrupt  invasion,  by  the  retraction  of  the  head  which  rapidly  super- 
venes, and  by  the  appearance  a  short  time  afterward  upon  diiferent  parts 
of  the  body  of  petechiae,  which  are  not  likely,  even  at  first,  to  be  mistaken 
for  the  rose-colored  spots  of  typhoid  fever.  The  fever  has,  moreover,  no 
constant  character,  but  is  remarkable,  on  the  contrary,  for  its  great  irreg- 
ularity. The  duration  of  the  disease  is  in  fatal  cases  much  shorter,  death 
taking  place  not  infrequently  within  the  first  week,  and  occasionally  as 
early  as  the  second  or  third  day.  On  the  other  hand,  the  duration  in 
cases  which  recover  may  be  even  longer  than  in  typhoid  fever. 

Simple  continued  fever  may  readily  be  mistaken  in  the  beginning  for 
typhoid  fever,  especially  in  those  cases  complicated  by  diarrhoea,  but,  as  a 
general  rule,  the  diiferent  character  of  the  febrile  movement,  its  more 
abrupt  commencement  and  termination,  and  its  shorter  duration,  together 
with  the  absence  of  the  rose-colored  eruption,  will  usually  serve  to  dis- 
tinguish it. 

The  eruptive  fevers  are  always  readily  distinguishable  at  the  period  of 
invasion  from  typhoid  fever,  and  the  mistake  of  confounding  them  with 
the  latter  disease  may  generally  be  avoided  by  a  close  study  of  the  charac- 
ter of  the  pyrexia.  In  the  eruptive  fevers  the  temperature  rises  abruptly, 
frequently  attaining  its  maximum  in  the  course  of  twenty-four  hours,  and 
sometimes  in  very  much  less  time.  There  are  also  in  all  of  them  early 
symptoms  which  indicate  pretty  clearly  their  true  nature,  as,  for  instance, 
the  sore  throat  of  scarlatina,  the  naso-pulmonary  catarrh  of  measles,  and 
the  rachialgia  of  small- pox.  The  uncertainty,  moreover,  is  of  short  dura- 
tion, as  the  characteristic  eruption  appears  in  all  of  them  before  the  fourth 
day. 

Acute  tuberculosis  of  the  lungs  is  the  condition  which  in  my  experience 
has  been  the  most  difficult  to  distinguish  from  typhoid  fever.  Indeed,  in 
some  cases  which  have  come  under  my  observation  physicians  of  recog- 
nized skill  as  diagnosticians  have  been  unable  to  make  the  discrimination 
until  after  the  death  of  the  patient.  Muscular  prostration,  a  dry  brown 
tongue,  delirium,  stupor,  bronchitic  rales,  dyspnoea,  and  even  cyanosis, 
are  symptoms  frequently  met  with  in  both  diseases,  so  that  when  the 


314  TYPHOID  FEVER. 

rose-colored  eruption  and  enlargement  of  the  spleen  happen  to  be  wanting 
in  typhoid  fever,  or  diarrhoea  and  tympany  present  in  acute  tuberculosis, 
as  they  may  be,  the  distinction  is  often  impossible.  The  diagnosis  may, 
however,  even  in  these  cases,  be  sometimes  made  after  a  careful  study  of 
the  temperature  range,  which  in  acute  tuberculosis  is  irregular  and  .rarely 
presents  any  resemblance  to  that  which  is  typical  of  typhoid  fever. 

Acute  tubercular  meningitis  has  also  many  symptoms  in  common  with 
typhoid  fever,  such  as  high  fever,  headache,  vomiting,  delirium,  and  stu- 
por, but  in  the  former  disease  the  rose-colored  eruption,  epistaxis,  enlarge- 
ment of  the  spleen,  and  intestinal  hemorrhage  do  not  occur.  Diarrhoea  is 
also  rare,  and  the  abdomen,  instead  of  being  tympanitic,  is  flat,  and  in 
many  cases  even  scaphoid.  The  headache,  too,  is  much  more  acute  than 
in  typhoid  fever,  and  is  very  apt  to  be  associated  with  retraction  of  the 
head.  Here,  again,  the  frequent  use  of  the  thermometer  will  yield  very 
important  results  in  diagnosis,  as  the  temperature  range  in  tubercular 
meningitis  is  always  irregular  and  does  not  present  any  resemblance  to 
that  usually  observed  in  typhoid  fever. 

Several  of  the  inflammations,  especially  when  associated  with  the 
typhoid  state,  have  so  many  symptoms  in  common  with  typhoid  fever 
that  they  may  very  readily  be  mistaken  for  one  another  by  a  careless 
observer.  I  have  known,  for  instance,  the  general  disease  to  be  entirely 
overlooked  in  a  case  of  typhoid  fever  complicated  by  pneumonia,  and,  on 
the  other  hand,  it  has  sometimes  been  supposed  to  be  present  in  a  case  of 
pure  typhoid  pneumonia.  Gastro-enteritis  is  another  disease  which  is 
also  occasionally  confounded  with  typhoid  fever.  The  diagnosis  in  these 
cases  will  rest  principally  upon  the  presence  or  absence  of  epistaxis, 
enlargement  of  the  spleen,  tympanites,  the  rose-colored  eruption,  and 
of  a  temperature  range  presenting  some  similarity  to  that  usual  in 
typhoid  fever. 

Trichiniasis  is  not  likely  to  give  rise  to  much  difficulty  in  diagnosis, 
for  although  vomiting,  diarrhoea,  and  the  typhoid  state  occur  in  it  as  well 
as  in  typhoid  fever,  the  former  disease  may  usually  be  recognized  by  the 
severe  muscular  pains  and  the  local  oedema  which  are  constant  accom- 
paniments of  it,  and  by  the  absence  of  the  characteristic  symptoms  of 
the  latter. 

PROGNOSIS. — There  is  no  other  disease  in  which  the  physician  should  be 
more  careful  in  making  a  positive  prognosis  than  in  typhoid  fever.  On 
the  one  hand,  accidents  of  a  fatal  character  frequently  occur  in  cases  which 
are  apparently  progressing  favorably,  and,  on  the  other,  recovery  has 
often  taken  place  after  all  hope  of  it  had  been  abandoned.  But,  although 
t  is  impossible  to  foretell  with  absolute  certainty  the  result  in  any  par- 
ticular case,  there  are  certain  symptoms  which  furnish  very  important 
indications  for  prognosis,  and  the  proper  appreciation  of  which  will  gen- 
erally enable  us  to  arrive  at  a  correct  conclusion  as  regards  the  gravity  of 
the  disease.  Prominent  among  these  is  the  character  of  the  pyrexia. 
A  fever  characterized  by  high  temperature  should  always  give  occasion 
for  great  anxiety.  This  is  very  fully  shown  by  the  statistics  of  the  hos- 
Thus  of  those  patients  in  whom  the  temperature  did  not 
4°,  only  9.6  per  cent  died ;  of  those  in  which  it  reached  or 
exceeded  104°,  29.1  per  cent,  died;  and,  finally,  of  those  in  whose  axilla 
the  temperature  rose  to  or  above  105.8°,  more  than  half  died.  Wunder- 


PROGNOSIS.  315 

lich  has  arrived  at  very  nearly  the  same  conclusions,  for  he  says  that  the 
prognosis  is  very  unfavorable  when  the  temperature  rises  to  106.16°,  that 
the  deaths  are  almost  twice  as  numerous  as  the  recoveries  when  it  rises  to 
107.06°,  and  that  recoveries  are  rare  when  it  rises  to  107.24°.  Murchi- 
son  has,  however,  known  recovery  to  follow  a  temperature  of  108°.  The 
highest  temperature  recorded  in  any  of  my  cases  was  106°  F.  In  this 
case,  which  proved  fatal,  the  temperature  reached  105°  F.  five  times.  In 
three  other  cases,  in  all  of  which  recovery  took  place,  a  temperature  of 
105.5°  F.  was  observed.  In  twelve  cases  the  temperature  reached 
105°  F.  on  more  than  one  occasion.  Six  of  these  ended  fatally ;  in  the 
others  the  patients  recovered. 

The  prognosis  is  more  unfavorable  in  a  fever  in  which  the  temperature 
is  continuously  high,  and  in  which  the  morning  remissions  are  slight  or 
wanting,  than  in  one  in  which  the  daily  fluctuations  are  greater,  even 
though  the  temperature  may  reach  a  higher  point  during  the  evening 
exacerbations  in  the  latter  variety  than  is  attained  at  any  time  in  the 
former.  Occasional  remissions,  even  if  produced  by  quinia  or  other 
remedies,  are  to  be  regarded  as  favorable  omens,  as  they  indicate  that 
the  fever  tends  to  subside.  A  high  morning  temperature  ought,  there- 
fore, to  give  rise  to  more  alarm  than  a  high  evening  temperature. 
The  prognosis  is  grave  when  the  morning  temperature  rises  to  104° 
or  is  persistently  above  103°.  Murchison  says  that  recovery  is  rare 
after  a  morning  temperature  of  105°.  Fiedler1  saw,  with  a  single 
exception,  all  patients  die  whose  temperature  in  the  morning  rose 
to  or  exceeded  106.25°,  while  of  those  whose  temperature  in  the  morn- 
ing rose  to  105.44°,  if  only  on  one  day,  more  than  half  died.  Any 
marked  deviation  from  the  usual  temperature  range  in  the  course  of  the 
fever  is  unfavorable.  A  rapid  rise  of  temperature  indicates  increased 
danger :  it  may  be  due  to  the  occurrence  or  a  complication  or  of  some 
other  cause  acting  unfavorably  upon  the  patient.  A  sudden  and  decided 
fall  should  excite  even  more  alarm,  as  it  is  generally  the  consequence  of  a 
free  intestinal  hemorrhage.  A  temporary  abatement  of  the  fever,  with 
amelioration  of  the  other  symptoms,  occurring  between  the  tenth  and 
twentieth  days,  and  giving  rise  to  the  hope  that  convalescence  is  about  to 
commence,  but  followed  by  a  return  of  the  symptoms  in  an  aggravated 
form,  is  also  unfavorable.  Such  cases,  according  to  Chomel,  Louis,  Bart- 
lett,  and  Murchison,  almost  invariably  terminate  fatally. 

The  prognosis  is  bad  in  cases  in  which  coma  or  wild  or  violent  delir- 
ium comes  on  early.  A  moderate  amount  of  delirium,  especially  when  it 
occurs  only  at  night  or  upon  wakening  in  the  morning,  and  is  readily 
dissipated  by  attracting  the  patient's  attention,  or  stupor  which  disappears 
when  he  is  thoroughly  roused,  is  not  unfavorable.  Insomnia,  subsultus 
tendinum,  carphologia,  slipping  down  in  bed,  incontinence  of  the  urine 
or  feces,  and  retention  of  urine,  are  all  symptoms  of  bad  omen.  Rigid- 
ity of  the  limbs  is  also  a  bad  symptom ;  Dr.  Jackson  reports  six  cases  in 
which  this  symptom  occurred,  only  one  of  which  recovered.  Excessive 
subsultus  is  especially  unfavorable,  as  it  is  generally  most  marked  in  cases 
in  which  the  ulcerations  of  the  intestines  are  most  extensive.  Extreme 
deafness  occurs  in  mild  as  well  as  severe  cases ;  it  is  therefore  without 
significance  in  prognosis. 

1  Quoted  by  Liebermeister. 


316  TYPHOID  FEVER. 

In  estimating  the  importance,  in  a  prognostic  point  of  view,  of  these 
various  nervous  symptoms,  it  is  important  to  bear  in  mind  that  a  degree  of 
fever  which  produces  no  disturbance  of  the  mental  functions  in  a  phleg- 
matic person  will  give  rise  to  active  delirium  and  other  marked  cerebral 
symptoms  in  a  person  of  an  excitable  temperament. 

A  change  in  the  character  of  the  pulse  and  of  the  action  of  the  heart  is 
often  the  earliest  indication  of  the  approach  of  danger  in  typhoid  fever, 
and  both  pulse  and  heart  should  therefore  be  carefully  examined  at  every 
visit.  The  first  change  is  usually  a  diminution  in  the  intensity  of  the 
first  sound  of  the  heart.  This  is  significant,  as  it  is  frequently  the  earliest 
premonition  of  cardiac  failure,  to  which  a  large  proportion  of  the  deaths 
in  typhoid  fever  is  due.  A  pulse  of  120  and  over,  especially  if  it  is  at 
the  same  time  feeble,  is  also  unfavorable.  The  important  part  which  the 
frequency  of  the  pulse  plays  in  the  prognosis  is  shown  by  the  following 
observations  made  by  Liebermeister  at  the  hospital  in  Basle :  Of  63  cases 
in  which  the  pulse  rose  to  or  above  120,  40  were  fatal,  or  nearly  two- 
thirds.  Among  these  63  were  37  in  which  it  did  not  rise  to  140 ;  of 
these,  19  were  fatal,  or  about  one-half;  in  26  it  rose  above  140  ;  of  these, 
21,  or  about  four-fifths,  were  fatal.  In  12  patients  it  rose  above  150; 
of  these,  11  died.  Of  those  in  which  the  pulse  rose  to  160,  the  only 
case  that  ended  in  recovery  was  that  of  a  girl  twenty-one  years  old  suf- 
fering from  an  imperfectly  developed  typhoid.  Intermittence  of  the 
pulse  is  unfavorable,  especially,  according  to  Hayem,1  when  it  occurs 
during  the  first  week  of  the  disease.  In  convalescence  intermittence  is 
not  to  be  regarded  as  an  unfavorable  symptom.  The  prognosis  is  bad 
also  in  those  cases  in  which,  with  excessive  weakness  of  the  pulse,  there 
are  other  evidences  of  cardiac  failure,  as,  for  instance,  congestion  of  the 
lungs,  cyanosis  of  the  surface,  coldness  of  the  extremities.  A  very 
frequent  pulse  is  not  so  unfavorable  in  a  child  as  in  an  adult,  or  in  a 
person  of  a  nervous  temperament  as  in  one  of  a  different  disposition. 

Other  unfavorable  symptoms  are  a  dry,  brown  tongue,  excessive  tym- 
panites with  great  abdominal  tenderness,  severe  diarrhoea,  vomiting  when 
it  occurs  late  in  the  disease,  intestinal  hemorrhage,  and  colliquative 
sweats.  The  delusion  sometimes  observed  in  very  severe  cases,  in  which 
the  patient  declares  that  he  is  not  ill,  is  a  very  bad  sign,  many  authors, 
and  among  them  Louis,  asserting  that  they  have  never  known  recovery 
to  take  place  after  it  has  been  manifested.  Peritonitis  is  a  very  serious 
complication,  whether  due  to  perforation  or  to  some  other  cause.  Still, 
it  would  appear  not  to  be  invariably  fatal,  since  recovery  has  occurred 
in  cases  in  which  all  the  symptoms  of  this  complication  were  present. 

Favorable  symptoms,  on  the  other  hand,  are  a  gradual  decrease  of  the 
temperature  with  increasing  morning  remissions,  moistening  and  cleansing 
of  the  tongue,  a  lessening  of  the  delirium,  and  other  nervous  symptoms, 
reappearance  of  an  intelligent  expression,  recognition  by  the  patient  of 
friends  and  attendants,  and  a  diminution  of  the  diarrhoea.  A  copious 
eruption  is  also  regarded  by  many  as  a  favorable  symptom.  Cases  in 
which  constipation  exists  generally  do  well.  Nathan  Smith  never  knew 
a  patient  to  die  whose  bowels  were  constipated  throughout  the  attack. 

I  he  death-rate  of  typhoid  fever  is  found  to  vary  very  considerably  in 
•ent  years  and  in  the  different  seasons  of  the  year,  as  will  be  seen 

1  Loc.  cit. 


PROGNOSIS. 


317 


from  the  two  following  tables.  Statistics  as  to  the  mortality  of  the  disease 
to  be  reliable  must  therefore  be  based  upon  a  large  number  of  cases  extend- 
ing over  a  series  of  years. 

The  following  table  shows  the  number  of  cases  admitted  into  the 
Pennsylvania  Hospital  during  each  of  the  twenty  years  ending  Dec.  31, 
1881,  and  the  ratio  of  mortality  among  them  : 

TABLE  No.  1. 


3 

60 

a 

a 

.9 

• 

id 

<J-  +^ 

•g 

§ 
3 

0 

*'£ 

I 

*fH 

® 

to 

a 
11 

1 

3 
<« 

OB 

111 

YEAR. 

'  3 

O 

1 

ui.2 
11 

| 

.g 

Ss's 

O 

£J 

13 

^n 

^ 

bk 

o 

®  rt  rf 

O 

"3 

O 

"s-g 

*  • 
"S  *•» 

1 

a 

so0""1 

h 

h 

<B  o> 

s, 

5 

-2  a  OT 

1 

£ 

1 

•°  3 

II 

1 

a 

s~  ^ 
o  o  3 

a 

3 

a 

a  o 

0) 

s 

g  3  0 

3 

3 

3 

3.3 

t»  l-l 

a3 

«>OM 

« 

& 

fc 

fc 

•"! 

PH 

PH 

1862 

89 

68 

21 

7 

544 

8 

23.6 

17.7 

1863 

36 

33 

3 

2 

32| 

3^ 

8.3 

2.9 

1864 

43 

35 

8 

1 

38J 

8 

18.6 

16.3 

1865 

36 

31 

5 

1 

38.  V 

5* 

13.9 

11.4 

1866 

23 

17 

6 

0 

451 

9 

26 

1867 

24 

20 

4 

0 

37} 

6| 

16.6 

1868 

27 

23 

4 

0 

44} 

10 

14.8 

1869 

21 

16 

5 

1 

35  1 

14 

23.8 

20 

1870 

24 

19 

5 

1 

47  -]j- 

11 

20.8 

17.4 

1871 

32 

26 

6 

1 

37| 

18J 

18.8 

15.0 

1872 

21 

16 

5 

3 

37^ 

23.8 

11.1 

1873 

12 

8 

4 

2 

34 

92 

33.3 

20 

1874 

16 

12 

4 

0 

54| 

9| 

25 

1875 

20 

18 

2 

1 

48 

4 

10 

5.3 

1876 

30 

21 

9 

2 

454 

11 

30 

25 

1877 

48 

34 

14 

4 

124 

29.2 

22.7 

1878 

8 

5 

3 

0 

49* 

37.5 

1879 

17 

15 

2 

0 

53^ 

8^ 

11.8 

1880 

40 

35 

5 

2 

47 

10| 

12.5 

8 

1881 

54 

48 

6 

0 

41  1 

8 

11.1 

Totals, 

621 

500 

121 

28 

43* 

8f 

19.5 

15.7 

Out  of  the  621  cases  admitted,  121  were  fatal.  This  gives  a  death- 
rate  of  19.4  per  cent. ;  but  if  we  deduct  the  28  cases  in  which  the  patients 
died  within  forty-eight  hours  of  their  admission,  it  falls  to  15.68  per 
cent.,  or  about  the  same  ratio  as  Murchison  found  to  exist  among  the 
cases  treated  at  the  London  Fever  Hospital.  Other  observers  have 
obtained  slightly  diiferent  results.  Thus,  the  mortality  was  11.16  per 
cent,  in  197  cases  analyzed  by  Dr.  Hale,  and  13.5  per  cent,  in  303  cases 
collected  by  Dr.  James  Jackson.  Dr.  Cayley1  found  the  death-rate  of 
the  several  hospitals  in  London  to  be  17.8  per  cent.,  and  Geissler2  that 
it  was  in  all  the  German  hospitals  12.8  per  cent,  in  1877,  and  13.5  per 
cent,  in  1878.  Flint  had  1 8  deaths  in  73  cases,  or  24.4  per  cent.  Accord- 
ing to  Liebermeister,  the  ratio  of  mortality  at  the  hospital  at  Basle  during 
the  twenty-two  years  from  1843  to  1864,  or  before  the  introduction  of  a 

1  Med.  Times  and  Gaz  ,  1880.  2  Schmidt'*  Jahrbuch. 


318 


TYPHOID  FEVER. 


systematic  anti-pyretic  treatment,  was  27.3  per  cent.,  and  only  8.2  per 
cent,  during  the  six  years  immediately  following  its  adoption.  As  the 
results  obtained  at  the  Pennsylvania  Hospital  are  apparently  not  so 
favorable  as  those  reported  at  some  of  the  continental  hospitals,  it  is 
only  proper  to  state  that  a  large  proportion  of  the  cases  were  severe, 
that  many  of  them  were  far  advanced  in  the  disease  when  admitted,  and 
that  very  few  of  the  patients  were  under  twenty-one  years  of  age.  These 
are  all  circumstances  which  influence  very  decidedly  the  prognosis  in 
typhoid  fever.  In  no  other  city  are  the  laboring  classes  able  to  surround 
themselves  with  so  many  comforts  as  in  Philadelphia.  This  fact,  fortu- 
nate as  it  is  in  the  main,  often  operates  to  the  disadvantage  of  the  patient 
by  enabling  his  family  to  indulge  for  a  time  the  reluctance  which  it  natu- 
rally feels  to  part  with  a  member  when  sick.  In  the  case  of  the  young 
this  reluctance  is  so  hard  to  overcome  that  children  with  acute  affections  are 
rarely  brought  to  hospitals  for  treatment.  There  were  also  special  causes 
for  the  large  mortality  in  certain  years.  This  was  particularly  the  case 
in  1862,  when  a  large  number  of  soldiers  fresh  from  the  battlefields  of 
Virginia,  and  suffering  from  the  typho-malarial  form  of  the  disease,  were 
admitted  into  the  hospital.  Many  of  them  were  moribund  upon  admis- 
sion, and  others,  exhausted  by  the  fatigue  incident  to  transportation  here 
and  by  previous  hardships,  soon  succumbed  to  the  disease. 

Table  2  gives  the  number  of  cases,  with  the  number  of  deaths  occur- 
ring in  each  season,  at  the  Pennsylvania  Hospital  during  the  last  twenty 
years : 

TABLE  No.  2. 


Spring. 

Summer. 

Autumn. 

Winter. 

Number  of  cases  

89 

259 

182 

Q1 

Recoveries  

73 

191 

163 

73 

Deaths  

16 

68 

10. 

18 

Percentage  of  mortality  

18.0 

26.2 

10.4 

19.8 

It  will  be  seen  from  this  table  that  the  highest  death-rate  occurred  in 
the  summer  and  the  lowest  in  autumn,  while  there  was  only  a  slight  dif- 
ference between  the  death-rate  of  spring  and  that  of  winter.    Murchison's 
experience,  based  on  a  much  larger  number  of  cases,  has  led  him  to  con- 
clude that  while  the  disease  is  a  little  less  fatal  in  autumn,  the  difference 
in  the  mortality  at  different  seasons  is  very  inconsiderable.      Chomel 
believed  that  the  percentage  of  deaths  was  highest  in  France  during  the 
wii.ttT  months,  and  Bartlett  held  the  same  opinion  as  regards  America. 
Epidemics  of  great  severity  have  undoubtedly  prevailed  in  winter,  as 
<»><•  in  Lowell,  Mass.,  referred  to  by  Bartlett,  but  there  can  be  little 
that  the  death-rate  is  highest  in  this  country  during  the  warm 
s  ot   the  year.     Dr.  Cleemann1  found  that  the  monthly  average 
•ortahtv   ,n    Philadelphia  for  the  ten  years  from   1866   to   1875   was 
August,  and  next  highest  in  September,  confessedly  the  two 
3  of  the  year  when  the  heat  in  this  city  is  most  exhausting.     I  feel 
have  lost  patients  with  typhoid  fever  in  these  months 

1  Transactions  of  the  College  of  Physicians  of  Philadelphia,  3d  S.,  vols.  ii.  and  iii. 


PROGNOSIS.  319 

and  in  July  who  would  probably  have  recovered  if  the  weather  had  been 
cooler.  With  a  temperature  often  rising  above  90°  F.  at  midday,  and 
sometimes  for  several  days  at  a  time  never  falling  below  80°,  all  radi- 
ation of  heat  from  the  surface  of  the  body  is  arrested,  and  death  fre- 
quently occurs  as  the  result  of  hyperpyrexia. 

The  stage  of  the  disease  at  which  efficient  treatment  is  begun  has  a 
manifest  influence  upon  the  result.  This  is  strikingly  shown  by  some 
observations  of  Jackson :  90  cases  were  admitted  into  the  Massachusetts 
General  Hospital  during  the  first  week — of  these  7  died,  or  1  in  12.85 ; 
139  cases  were  admitted  in  the  second  week — of  these  16  died,  or  1  in 
8.68 ;  46  cases  were  admitted  in  the  third  week — of  these  10  died,  or  1 
in  4.60;  and  21  cases  were  admitted  in  the  fourth  week,  and -of  these  5 
died,  or  1  in  4.20.  Convalescence  also  occurred  much  earlier  in  those 
who  were  admitted  early. 

Murchison  found  that  in  a  large  number  of  cases  the  death-rate  varied 
at  different  ages  as  follows:  Under  ten  years  it  was  11.36  per  cent.; 
from  ten  to  fourteen  years  it  was  12.86  per  cent. ;  from  fifteen  to  nine- 
teen years  it  was  15.48  per  cent. ;  from  twenty  to  twenty-nine  years  it 
was  20.46  per  cent. ;  from  thirty  to  thirty-nine  years  it  was  25.90  per 
cent. ;  from  forty  to  forty-nine  years  it  was  25  per  cent. ;  and  above  fifty 
years  it  was  34.94  per  cent. 

According  to  Liebermeister,  among  the  1743  patients  treated  for 
typhoid  fever  in  the  hospital  at  Basle  from  1865  to  1870,  inclusive,  there 
were  130  who  were  more  than  forty  years  old;  of  these  39,  or  30  per 
cent.,  died,  while  the  mortality  among  the  patients  under  forty  amounted 
only  to  11.8  per  cent.  Among  the  cases  of  typhoid  fever  in  individuals 
over  forty  years  of  age  collected  by  Uhle,  more  than  half  proved  fatal. 
According  to  Friedrich,1  there  were,  among  16,084  children  treated  in 
the  Children's  Hospital  at  Dresden,  275  cases  of  typhoid  fever,  of  which 
31,  or  not  quite  11  per  cent.,  proved  fatal.  Age,  therefore,  exercises  a 
positive  influence  upon  the  mortality  of  typhoid  fever.  Its  influence  is 
less  decided  in  this  disease  than  in  typhus,  in  which  the  death-rate  does 
not  reach  4  per  cent,  until  after  the  age  of  twenty,  when  it  rapidly  rises 
from  12.34  per  cent,  until  it  reaches  57.03  per  cent,  in  patients  above 
fifty  years  of  age.  The  comparatively  slight  mortality  of  typhoid  fever 
among  children  is  probably  due  to  the  fact  that  the  temperature  is  less 
often  continuously  high  in  them  than  in  adults,  and  that  while  hyper- 
pyrexia is  frequently  present,  it  is  generally  better  borne  and  less  likely 
to  produce  paralysis  of  the  heart.  Liebermeister  says  that  the  only  case 
which  he  has  seen  recover  after  the  temperature  had  repeatedly  risen  to 
107.5°  F.  was  that  of  a  girl  fourteen  years  of  age.  It  is  also  said  that 
the  intestinal  lesions  are  not  so  severe,  and  the  liability  to  complications 
and  sequelae  less  marked,  in  children. 

Typhoid  fever  appears  to  be  a  slightly  more  fatal  disease,  in  women 
than  in  men,  for  while  in  some  local  epidemics  the  percentage  of  deaths 
is  greater  among  the  latter  than  among  the  former,  the  reverse  is  found  to 
be  the  case  when  the  records  of  a  large  hospital  for  a  number  of  years  are 
Carefully  examined.  According  to  Murchison,  the  mortality  at  the  Lon- 
don Fever  Hospital  was  about  1  per  cent,  higher  among  the  female  than 
among  the  male  patients,  and  about  the  same  difference  in  the  death-rate 

1  Quoted  by  Liebermeister. 


320  TYPHOID  FEVER. 

of  the  two  sexes  has  been  reported  by  continental  physicians.  A  greater 
disparity  even  than  this  has  been  observed  by  Liebermeister  at  the  hospi- 
tal at  Basle,  where  the  death-rate  for  women  was  14.8  per  cent.,  and  only 
12  per  cent,  for  men.  Murchison  says  that  this  excess  of  mortality  among 
the  former  cannot  be  accounted  for  by  the  influence  of  child-bearing  upon 
the  course  of  the  fever,  since  it  is  much  more  decided  between  the  ages  of 
five  and  fifteen  than  in  the  period  of  child-bearing. 

The  rich  are  not  only  as  liable  to  contract  typhoid  fever  as  the  poor, 
but  the  disease  is  also  quite  as  fatal  among  them.  Murchison  found 
from  the  statistics  of  the  London  Fever  Hospital  that  the  mortality  is 
not  greater  among  the  destitute  than  among  the  better  class  of  patients, 
and  expresses  the  opinion  that  in  private  practice  enteric  fever  is  prob- 
ably more  fatal  among  the  upper  classes  than  among  the  very  poor. 
Chomel  and  Forget  seem  to  have  reached  a  similar  conclusion. 

All  authors  agree  that  the  prognosis  is  unfavorable  in  corpulent 
persons,  not  only  on  account  of  the  diminished  power  of  resistance  to 
disease  generally  which  such  persons  exhibit,  but  also  because  the  febrile 
movement  is  often  intense  in  them,  and  the  degenerative  changes  of 
the  muscles  and  organs  of  the  body  which  it  induces  are  generally 
early  developed  and  of  high  grade.  Liebermeister  goes  so  far  as  to 
say  that  even  in  the  case  of  ill-nourished,  anaemic,  or  chlorotic  indi- 
viduals the  chances  for  life  are  better  than  in  the  corpulent.  Mur- 
chison has  also  expressed  the  opinion  that  a  large,  muscular  development 
is  likewise  an  unfavorable  element  in  prognosis,  having  seen  the  strong 
and  robust  succumb  to  the  disease  oftener  than  the  feeble.  The  mortality 
from  the  disease  appears  to  be  greater  in  certain  families  than  in  others. 
This  has  been  ascribed  by  some  writers  to  peculiarities  of  constitution, 
but  it  may  be  due  to  other  causes,  as,  for  instance,  difference  in  the  inten- 
sity of  the  poison.  The  disease  is  also  often  very  fatal  among  the  intem- 
perate, who  usually  bear  the  disease  badly  in  consequence  of  the  presence 
of  various  degenerations  of  one  or  more  of  the  important  organs  of  the 
body  caused  by  the  excessive  indulgence  in  alcoholic  stimulants ;  paralysis 
of  the  heart  being  not  an  infrequent  cause  of  death  among  them. 

Certain  epidemics  have  been  exceedingly  fatal,  while  in  others  the 
percentage  of  deaths  has  been  very  small.  There  can  be  no  doubt 
that  in  most  of  these  cases  there  has  been  a  difference  in  the  viru- 
lence of  the  poison.  Recent  residence  in  an  infected  locality  has 
been  shown  by  Murchison  and  other  writers  to  have  a  decided  influ- 
ence in  increasing  the  fatality  of  the  disease.  Second  attacks  are,  on 
the  other  hand,  usually  mild.  Some  diversity  of  opinion  exists  among 
authors  in  regard  to  the  effect  that  pregnancy  has  upon  the  course  of 
;ase.  Murchison  believes  that  it  is  a  far  less  formidable  compil- 
ation than  is  usually  thought,  while  Liebermeister,  on  the  contrary, 
diroftly  opposite  opinion.  He  also  regards  the  prognosis  as 
•able  when  the  disease  occurs  in  childbed  or  a  short  time  after- 

rd  Individuals  with  disease  of  the  heart,  emphysema,  or  bronchial 
rrh  who  contract  typhoid  fever  are  said  to  be  more  liable  to  paral- 
s  heart  than  others,  hence  the  existence  of  these  diseases  mate- 
rial iy  ,  imimshes  their  chances  of  recovery. 

TREATMENT.— Inasmuch  as  the  spread  and  propagation  of  typhoid 
r  may  be  prevented  to  a  great  extent,  if  not  entirely,  by  the  employ- 


TREATMENT.  321 

ment  of  judicious  sanitary  measures,  it  is  proper,  before  entering  upon  the 
discussion  of  its  curative  treatment,  to  devote  a  few  words  to  the  prophy- 
laxis of  the  disease. 

Whether  the  physician  accepts  the  theory  so  ably  advocated  by  Mur- 
chison,  that  typhoid  fever  may  arise  from  exposure  to  the  products  of  the 
fermentation  of  healthy  feces,  or  adopts  the  view  now  held  by  a  large 
number  of  investigators,  that  the  disease  is  never  generated  in  the  absence 
of  the  specific  germ,  he  will  admit  the  great  importance  of  an  efficient 
system  of  sewerage,  with  a  thorough  flushing  of  the  sewers  at  regular  and 
frequent  intervals,  for  disposing  of  the  fecal  discharges  of  the  population 
of  all  towns,  no  matter  how  inconsiderable  in  size.  No  less  important  is 
it  that  the  drains  of  every  dwelling  should  be  well  constructed  and  kept 
in  good  order.  They  should  be  trapped  just  before  they  empty  into  the 
sewer,  and  should  be  provided  with  the  means  of  thorough  ventilation 
between  the  trap  and  the  walls  of  the  house  by  a  free  communication  with 
the  outer  air.  The  soil-pipe  should  be  carried  up  three  or  four  feet  above 
the  top  of  the  house,  and  every  water-closet,  bath-tub,  stationary  wash- 
stand,  and  sink  should  have  its  own  separate  trap,  and  none  of  them 
should  be  placed  in  rooms  unprovided  with  a  window  or  with  some  other 
sufficient  means  of  ventilation.  Physicians  should,  as  sanitarians,  urge 
upon  the  authorities  of  all  cities  and  towns  the  importance  of  deriving 
their  water-supply  from  a  source  unpolluted  by  sewerage  or  by  any  other 
substances  likely  to  be  deleterious  to  health.  They  should  also  see  that 
when  water  is  stored  in  a  tank  inside  of  a  house  the  overflow  pipe  does 
not  communicate  directly  with  the  drain,  since  if  this  is  allowed  to  occur 
the  water  may  very  soon  become  contaminated  with  sewer  gas,  and  conse- 
quently unfit  for  internal  use. 

In  the  case  of  isolated  country-houses  and  of  small  villages  some  other 
means  of  disposing  of  the  fecal  discharges  of  the  inhabitants  than  by 
sewers  has  to  be  found.  In  the  great  majority  of  instances  no  better  way 
presents  itself  than  by  the  ordinary  cesspool.  Care  should,  however,  be 
taken  that  this  is  so  constructed  and  situated  that  there  can  be  no  filtra- 
tion of  its  contents  into  wells  from  which  water  for  drinking  is  obtained. 

As  the  alvine  dejections  of  the  sick  are  beyond  question  the  medium 
by  which  typhoid  fever  is  most  frequently  communicated  to  others,  the 
importance  of  thoroughly  disinfecting  them  before  they  have  acquired 
the  power  of  imparting  the  disease  cannot  well  be  overestimated.  Lie- 
bermeister  recommends  that  the  bottom  of  the  bed-pan  should  be  strewed, 
each  time  before  being  used,  with  a  layer  of  sulphate  of  iron,  and  that  im- 
mediately after  a  passage  crude  muriatic  acid  should  be  poured  over  the  fecal 
mass,  as  much  as  one-third  or  one-half  of  the  bulk  of  the  latter  being  used. 
He  also  urges,  whenever  it  is  practicable,  that  the  contents  of  the  bed- 
pan should  be  emptied  into  trenches  dug  anew  every  two  days  and  filled 
up  when  discarded,  care  being  of  course  taken  that  they  are  not  located 
anywhere  in  the  vicinity  of  wells.  Murchison  seems  to  prefer  carbolic 
acid  to  other  chemical  agents  as  a  means  of  preventing  fecal  fermentation. 
For  this  purpose  the  liquid  carbolic  acid  may  be  diluted  with  water  in  the 
proportion  of  1  to  40  to  1  to  20,  or  it  may  be  mixed  with  sand  or  saw- 
dust. I  have  myself  employed  as  a  disinfectant  with  success  the  solution 
of  the  chlorides  sold  under  the  name  of  Platt's  chlorides.  As  the  dis- 
charges must  in  cities,  in  the  great  majority  of  instances,  be  emptied  into 
VOL.  I.— 21 


322  TYPHOID  FEVER. 

water-closets,  these  should  be  freely  flushed  with  water  after  every  time 
they  are  used ;  and  it  is  well  to  impress  upon  the  attendant  on  the  sick 
the  importance  of  doing  this.  The  bed-linen  of  the  patient  and  his 
clothes,  if  they  are  soiled  by  his  discharges,  should  be  removed  as  soon  as 
possible,  and  subjected  to  a  high  degree  of  heat  (248°  F.)  or  soaked  in  a 
solution  of  the  chlorides  or  of  carbolic  acid  for  several  hours  before  being 
washed.  If  these  precautions  are  observed,  cases  of  typhoid  fever  may 
be  treated  in  the  wards  of  general  hospitals  without  danger  to  the  other 
patients. 

In  the  doubt  and  obscurity  which  generally  envelop  the  diagnosis  of 
the  disease  when  the  physician  is  first  called  upon  to  treat  it,  it  is  impos- 
sible to  lay  down  any  positive  rules  for  the  management  of  typhoid  fever 
at  its  commencement.  But  even  in  those  cases  which  begin  insidiously, 
if  the  patient  is  carefully  examined  enough  of  the  early  symptoms  of 
typhoid  fever  will  be  detected  to  put  the  physician  on  his  guard.  The 
thermometer  will  show  the  existence  of  fever,  which  has  a  tendency  to 
increase  at  night.  There  will  generally  be  found  to  be  a  little  diarrhoea, 
or  at  least  an  increased  susceptibility  to  the  action  of  purgative  medicines ; 
perhaps  a  little  tympany  and  tenderness  in  the  right  iliac  fossa,  and  more- 
over a  prostration  which  is  out  of  all  proportion  to  the  other  symptoms. 

These  symptoms,  it  is  true,  are  not  infrequent  concomitants  of  many 
diseases  besides  the  one  under  consideration ;  but  when  their  presence 
cannot  be  otherwise  satisfactorily  explained,  especially  if  they  have  con- 
tinued for  several  days,  it  is  a  safe  rule  in  practice  to  regard  the  case  as 
one  of  typhoid  fever,  and  to  regulate  the  treatment  accordingly.  The 
patient  must  be  put  to  bed  at  once,  and  not  allowed  to  leave  it  on  any 
pretext,  not  even  to  empty  his  bladder,  after  the  first  week.  This  is  a 
rule  which  should  be  rigidly  enforced  in  every  case,  no  matter  how  mild 
the  symptoms  may  be.  Its  non-observance,  either  through  the  neglect 
of  the  physician  or  the  ignorance  or  wilfulness  of  the  patient,  has  been 
the  cause  of  some  disastrous  results ;  in  illustration  of  which  it  is  only 
necessary  to  refer  to  the  frequency  with  which  perforation  of  the  bowel 
occurs  in  walking  cases  of  typhoid  fever.  Perfect  quiet  should  be  main- 
tained in  the  sick  room.  Visitors  should  be  excluded  from  it,  and  the 
attendants  limited  in  number  to  those  actually  necessary  to  carry  out  the 
directions  of  the  physician.  All  unnecessary  talking  is  to  be  avoided, 
and  especially  conversation  carried  on  in  a  low  tone  of  voice,  which  is 
always  annoying  to  the  sick. 

There  is  only  one  condition  under  which  I  should  be  disposed 
to  break  the  rule  of  absolute  quiet  and  rest  laid  down  above,  and  that  is 
when  called  upon  to  treat  typhoid  fever  in  the  built-up  portion  of  our 
large  cities  during  the  summer  season.  If  the  patient  were  still  in  the 
first  week  of  the  disease,  if  his  circumstances  were  sufficiently  affluent  to 
enable  him  to  surround  himself  with  every  comfort,  and  if  it  did  not 
involve  a  journey  of  more  than  a  few  hours,  I  should  unhesitatingly  send 
him  to  the  sea-coast.  I  have  so  often  seen  cases  prove  fatal  in  summer  in 
consequence  of  the  great  heat  of  the  city— a  heat,  too,  which  is  sometimes 
ilmost  as  great  at  night  as  in  the  day-time— that  I  should  feel  that  I  was 
giving  him  an  additional  chance  of  life  by  sending  him  where  the  heat  was, 
at  least  occasionally,  tempered  by  cool  breezes  from  the  ocean.  During  the 
late  war  numbers  of  soldiers  were  frequently  sent  in  the  early  stages  of 


TREATMENT.  323 

typhoid  fever  from  the  camps  in  the  South  to  their  homes  or  hospitals  in 
the  North,  and  it  is  fair  to  say  that  they  did  at  least  as  well  as  those  who 
remained  behind.  But  when  the  journey  may  be  accomplished  by  means 
of  Pullman  cars  and  the  other  appliances  of  modern  travel  the  risk,  and 
even  discomfort,  it  involves  to  the  patient  is  reduced  to  the  minimum. 

As  the  disease  is  usually  one  of  long  duration,  the  patient  being  rarely 
able  to  leave  his  bed  under  four  weeks,  and  more  frequently  being  obliged 
to  keep  it  for  a  much  longer  time,  the  sick  room  should,  wherever  practi- 
cable, be  large,  airy,  and  provided  with  an  open  fireplace,  which  is  a  much 
more  efficient  means  of  securing  thorough  ventilation  than  an  open 
window,  while  it  is  not  liable  to  the  objection  sometimes  applicable  to  the 
latter  of  causing  a  direct  draught  upon  the  patient.  It  is  well,  however, 
for  the  physician  to  remember  that  the  danger  from  this  source  is  very 
much  exaggerated  by  the  laity,  and  that  patients  in  the  febrile  stage  of 
typhoid  fever  do  not  readily  take  cold.  Still,  the  same  end  may  gener- 
ally be  attained  without  the  least  risk  to  the  patient  by  opening  a  window 
in  an  adjoining  room.  The  temperature  of  the  sick  room  should  be 
steadily  maintained  at  between  65°  and  68°  F. 

The  careful  regulation  of  the  diet  is  also  a  point  of  great  importance 
in  the  management  of  typhoid  fever ;  for  in  this  disease  there  are  not 
merely  the  high  fever  and  other  exhausting  symptoms,  speedily  inducing 
excessive  prostration,  loss  of  strength,  and  emaciation,  common  to  many 
fevers,  but  there  is  also  the  peculiar  ulceration  of  the  bowels,  which  gives 
rise  to  danger  of  its  own  and  demands  special  consideration  in  treatment. 
The  food  must  therefore  be  not  only  nourishing,  but  also  readily  digest- 
ible, and  not  likely  to  create  irritation  in  its  passage  through  the  intes- 
tines. All  solid  food  should  therefore  be  excluded  from  the  dietary  of 
the  patient  as  long  as  the  fever  lasts.  Indeed,  it  is  better  to  continue  this 
prohibition  even  after  the  subsidence  of  the  fever  if  rose-colored  spots 
are  still  to  be  seen  on  the  abdomen  or  elsewhere,  or  if  there  exists  a  tend- 
ency to  diarrhoea  or  any  other  symptom  indicating  that  the  disease  has 
not  fully  run  its  course.  Having  myself  seen  some  rather  disastrous 
results  from  a  too  early  return  to  solid  food,  I  have  been  accustomed  in 
my  own  practice  to  interdict  its  use  until  at  least  two  weeks  after  the 
beginning  of  convalescence.  Jaccoud  also  lays  much  stress  upon  this 
point,  saying  that  the  early  administration  of  meat  always  gives  rise  to 
fever,  to  which,  from  its  cause,  he  gives  the  name  of  febris  carnis.  On 
the  other  hand,  Flint1  and  Peabody  have  recently  advocated  the  giving 
of  solid  food  immediately  after  the  cessation  of  fever,  in  the  belief  that 
recovery  is  thereby  promoted.  Milk  as  an  article  of  diet  is  unquestion- 
ably to  be  preferred  to  all  others  in  typhoid  fever.  It  is  open,  it  is  true, 
to  the  objection  of  occasionally  forming  tough  curds  in  the  stomach,  but 
this  may  generally  be  prevented  by  giving  the  milk  in  small  quantities  at 
a  time,  diluted  with  lime-water  or  barley-water  or  mixed  with  some 
farinaceous  substance.  No  positive  general  rule  can  be  laid  down  as  to 
the  amount  to  be  given.  This  will  be  found  to  vary  not  only  in  different 
cases,  but  also  in  the  same  case  at  different  times.  Indeed,  in  those  cases 
which  begin  abruptly  with  symptoms  of  gastro-intestinal  irritation,  if  it 
is  forced  upon  the  patient  in  large  quantities  it  is  not  only  usually 
rejected,  but  also  causes  an  aggravation  of  the  symptoms,  while  after 
1  Medical  News,  Mch.  29  and  Apl.  5,  1884. 


324  TYPHOID  FEVER. 

this  irritation  is  allayed  it  will  be  digested  without  difficulty.  As  a 
general  rule,  most  adult  patients  will  be  able  to  take  from  a  quart  and  a 
half  to  two  quarts  of  milk  daily,  given  in  quantities  of  from  four  to  six 
ounces  every  two  or  three  hours.  It  should  be  remembered,  however, 
that  if  more  is  taken  than  can  be  assimilated  it  will  act  as  an  irritant  and 
increase  the  diarrhoea.  If,  therefore,  the  stools  contain  undigested  milk, 
the  quantity  should  be  diminished.  Patients  are  occasionally  met  with, 
but  not  in  as  great  number  as  is  often  asserted,  with  whom  milk  habit- 
ually disagrees.  In  these  cases  it  must  of  course  be  replaced  in  whole 
or  in  parT  by  some  other  article  of  food.  Under  these  circumstances 
some  one  of  the  liquid  preparations  of  beef  may  be  given  with  advan- 
tage, although  it  may  be  objected  to  them  also  that  they  sometimes  occa- 
sion an  increase  of  diarrhoea.  Beef-tea  or  beef-essence,  made  from  the 
fresh  meat  whenever  this  can  be  obtained,  is  to  be  preferred  to  all  others ; 
but  when  it  cannot,  that  made  from  the  preparations  of  Johnston  or 
Brand  is  the  best  substitute.  When  the  stomach  is  very  irritable,  Valen- 
tine's meat-juice,  in  consequence  of  the.  smaller  bulk  in  which  it  is  given, 
often  answers  an  admirable  purpose. 

Various  farinaceous  substances,  such  as  farina,  corn-starch,  and  arrow- 
root, are  also  occasionally  given  in  typhoid  fever,  and,  although  the  last 
named  would  seem  to  be  indicated  in  cases  in  which  diarrhoea  is  a  promi- 
nent symptom,  their  tendency  to  cause  flatulence  is  so  great  that  their  use 
in  the  acute  stage  of  the  fever  has  not  found  favor  among  physicians 
generally.  In  convalescence,  on  the  other  hand,  they  are  generally  per- 
fectly well  borne. 

The  subject  of  the  administration  of  alcoholic  stimulants  in  typhoid 
fever  may  be  conveniently  considered  in  this  connection.  Some  difference 
of  opinion  exists  in  regard  to  the  quantity  in  which  they  should  be  given, 
and  indeed  in  regard  to  the  necessity  for  their  use  at  all  in  many  cases, 
as,  for  instance,  in  those  of  young  persons  whose  health  and  habits  had 
been  good  previously  to  the  attack.  I  have  myself  treated  several  such 
cases  without  alcohol,  and  have  not  been  able  to  perceive  that  their  dura- 
tion was  longer  and  the  result  less  favorable  than  in  cases  in  which  it 
was  given  in  the  usual  amount.  It  is,  moreover,  not  necessary  to  pre- 
scribe it  always,  even  in  very  severe  cases,  at  the  beginning  of  an  attack. 
When  given  at  this  time,  it  not  infrequently  does  harm  by  increasing 
the  fever.  It  should  be  reserved,  therefore,  until  the  action  of  the  heart 
grows  feeble  and  the  first  sound  becomes  indistinct.  It  is  not  possible  to 
lay  down  any  general  rule  as  to  the  amount  to  be  given,  even  in  severe 
attacks.  This  will  vary  in  different  cases,  and  to  a  certain  extent  will  be 
determined  by^the  effects  it  produces.  If  the  pulse  grows  stronger  and 
the  delirium  diminishes  under  its  use,  it  is  doing  good  and  should  be  con- 
tinued ;  if,  on  the  other  hand,  there  is  increase  of  delirium  and  restless- 
ness, the  quantity  should  be  diminished. 

In  cases  in  which  only  a  gentle  stimulus  is  required  wine  in  the  form 
of  wine-whey  will  often  be  found  to  meet  the  indication  fully.  Gener- 
ally, however,  it  will  be  necessary  to  have  recourse  to  whiskey  or  brandy. 
The  choice  between  these  may  usually  be  left  to  the  patient's  fancy ; 
randy  is,  however,  to  be  preferred  in  cases  in  which  diarrhoea  is  a  promi- 
t  symptom.  These  stimulants  should  be  given  in  small  quantities  fre- 
quently repeated.  In  many  cases  a  dessertspoonful  every  two  or  three  hours, 


TREATMENT.  325 

either  diluted  with  water  or,  when  the  stomach  is  irritable,  with  carbonic 
acid  water  or  given  in  the  form  of  milk  punch,  will  be  sufficient.  In 
others  a  tablespoonful  every  two  hours,  or  even  at  shorter  intervals,  will 
be  required,  but  it  will  rarely  be  necessary  to  exceed  eight  ounces  a  day 
for  more  than  a  few  days  at  a  time. 

Although  the  physician  will  not  often  be  called  upon  at  the  present 
day  to  encounter  and  combat  the  prejudice  so  common  formerly  against 
the  free  administration  of  water  in  the  febrile  condition,  he  will  fre- 
quently find  nurses  and  others  not  sufficiently  alive  to  the  importance  of 
supplying  it  when  the  patient,  having  fallen  into  the  typhoid  state,  ceases 
to  ask  for  it.  The  high  temperature  which  is  generally  present  in  this 
condition,  and  the  rapid  combustion  of  tissue  which  it  causes,  make  a 
full  supply  of  liquid  an  urgent  necessity  which  it  is  dangerous  to  dis- 
regard. Water  is  the  best  of  all  diuretics,  and  it  is  important  in  this 
disease,  as  indeed  it  is  in  many  others,  that  the  functions  of  the  kidneys 
should  be  kept  active,  so  that  the  products  of  the  combustion  of  the 
tissues  may  be  eliminated  with  their  secretion.  Care,  however,  should 
of  course  be  taken,  as  pointed  out  by  Da  Costa,1  that  water  is  not  given 
in  such  quantity  that  the  desire  for  and  capability  of  digesting  food  is 
destroyed  by  it. 

In  the  few  cases  which  begin  abruptly  with  symptoms  simulating  those 
of  a  so-called  bilious  attack  the  practitioner  will  usually  content  himself 
with  the  administration  of  medicines  calculated  to  allay  the  irritability 
of  the  stomach  and  bowels.  For  this  purpose  I  have  found  the  bicar- 
bonate of  potassa  in  solution,  to  which  lemon-juice  is  added  at  the 
moment  it  is  taken,  so  as  to  produce  an  extemporaneous  effervescing 
draught,  often  an  admirable  remedy.  In  other  cases  I  have  used  with 
advantage  small  doses  of  calomel  or  blue  mass,  followed,  if  necessary,  by 
a  gentle  saline  purge.  When  the  symptoms  have  occurred  soon  after  a 
hearty  meal,  or  when  there  is  evidence  that  the  stomach  is  overloaded,  it 
will  occasionally  be  necessary  to  have  recourse  to  an  emetic.  Usually, 
the  indications  for  treatment  at  the  beginning  of  an  attack  are  much  less 
definite,  and  even  in  the  class  of  cases  just  referred  to  they  become  so 
after  the  subsidence  of  the  gastro-intestinal  symptoms.  Indeed,  the 
treatment  in  the  larger  number  of  cases  must  be  purely  symptomatic 
until  the  nature  of  the  disease  has  fully  declared  itself.  The  presence 
of  fever  will  suggest  the  use  of  the  neutral  mixture,  effervescing  draught, 
or  spirit  of  Mindererus,  combined,  if  there  is  decided  tendency  to  even- 
ing exacerbations,  with  sulphate  of  quinia  in  full  doses.  If  there  is 
much  diarrhoea,  Hope's  camphor  mixture  or  opium  in  some  other  form 
may  be  given ;  if  delirium  is  a  prominent  symptom,  ice  or  cloths  wrung 
out  of  cold  water  should  be  kept  constantly  applied  to  the  head. 

But  even  after  all  doubt  in  regard  to  the  diagnosis  has  been  dispelled 
and  the  existence  of  typhoid  fever  has  been  recognized,  the  treatment 
most  in  favor  with  physicians  is  in  large  measure  symptomatic  in  charac- 
ter. It  is  true  that  various  specific  treatments,  to  which  fuller  reference 
will  be  made  hereafter,  have  been  lately  proposed,  but  the  results  obtained 
by  them  up  to  the  present  time  where  they  have  been  fairly  tested  are  not 
so  favorable  as  to  induce  the  body  of  the  profession  to  adopt  them  to  the 
exclusion  of  all  other  methods.  It  is  certain  that  no  remedy  or  plan  of 
1  Preface  to  Wilson's  Treatise  on  the  Continued  Fevers. 


326  TYPHOID  FEVER. 

treatment  has  yet  been  discovered  which  has  the  power  of  cutting  the 
disease  short,  although  this  power  has  been  claimed  at  different  times  for 
several.  Thus,  at  one  time  quinia  in  very  large  doses  was  believed  to 
possess  it,  at  another  venesection,  and  at  another  cold  baths.  But  expe- 
rience has  shown  that  these  and  other  perturbating  remedies  often  do 
harm,  and  there  is  good  reason  to  believe  that  the  apparent  good  which 
has  followed  their  use  in  a  comparatively  small  number  of  instances  may 
be  better  explained  by  supposing  that  an  error  of  diagnosis  has  been 
made  than  by  attributing  to  them  the  power  of  arresting  the  progress 
of  the  disease.  Medicines  are,  however,  by  no  means  useless  in  the 
treatment  of  typhoid  fever.  There  is  no  question  that  the  disease  is  not 
only  generally  conducted  to  a  favorable  issue,  but  that  its  duration  is 
often  materially  shortened,  by  their  judicious  use.  It  is  evident, 
however,  that  the  treatment  must  vary  with  the  severity  of  the 
attack.  In  a  few  cases  it  is  scarcely  necessary  to  interfere  with  the 
course  of  the  disease  by  the  administration  of  medicines.  In  others, 
on  the  contrary,  it  is  necessary  to  act  promptly  and  energetically  in 
order  to  save  life. 

When  called  upon  to  treat  typhoid  fever,  if  the  case  is  a  mild  one  with 
no  bad  symptoms,  such  as  excessive  diarrhoea,  delirium,  tremors,  and  the 
like,  and  especially  if  the  temperature  does  not  rise  higher  than  102°  F., 
I  am  accustomed,  after  giving  minute  directions  as  to  the  diet  and  gen- 
eral care  of  the  patient,  to  prescribe  from  two  to  three  grains  of  sulphate 
of  quinia  four  times  daily.  No  great  power  in  reducing  the  temperature 
of  the  body  can,  of  course,  be  claimed  for  these  doses,  but  experience 
has  shown  that  the  impression  which  they  make  is  useful,  and  they  do  not 
interfere  with  the  administration  of  the  drug  in  larger  quantities  should  this 
become  necessary  Their  action,  too,  is  tonic,  and,  as  they  rarely  produce 
cinchonism,  the  objection  often  made  to  the  use  of  larger  doses  does  not 
apply  to  them.  I  am  also  in  the  habit  of  adding  to  each  dose  of  quinia 
from  ten  to  fifteen  drops  of  one  of  the  mineral  acids.  These  acids  were 
originally  prescribed  in  typhoid  fever  under  the  impression  that  they 
neutralized  the  cause  of  the  disease,  which  was  supposed  to  be  an  alkaline 
poison.  Although  the  results  of  recent  research,  which  tend  to  show 
that  the  cause  of  the  disease  is  an  organized  germ,  give  no  support  to 
this  theory,  they  continue  to  be  used  by  a  large  number  of  physicians 
of  experience.  I  do  not  know  that  any  satisfactory  explanation  of  their 
action  in  typhoid  fever  has  ever  been  given.  They  are  certainly  tonics, 
and  are  therefore  indicated,  if  not  in  the  beginning  of  the  disease,  as 
soon  as  the  strength  begins  to  fail.  If,  as  the  disease  progresses,  the 
tongue  becomes  dry  and  fissured,  and  if  there  is  much  tympany,  it  will 
be  well  to  give,  in  addition  to  the  quinia,  ten  drops  of  the  oil  of  turpen- 
tine in  mucilage  every  two  hours.  This  was  a  favorite  remedy  of  the 
late  George  B.  Wood,  the  distinguished  professor  of  the  Theory  and 
Practice  of  Medicine  in  the  University  of  Pennsylvania,  who  attributed 
the  improvement  in  the  symptoms  which  generally  follows  its  use  to  a 
direct  influence  of  this  medicine  upon  the  ulcers  in  the  intestines. 
Although  inclined  to  believe  that  the  correct  explanation  of  this 

mprovement  is  its  stimulating  action  upon  the  circulation  and  secre- 
tions, I  tully  agree  with  him  in  regard  to  its  usefulness  in  many  cases. 

Under  its  use  ..  have  often  seen  the  dry,  fissured,  and  shrivelled  tongue 


TREATMENT.  327 

grow  moist  and  throw  off  its  coating  much  earlier  than  in  all  probability 
it  would  otherwise  have  done. 

No  other  than  this  simple  treatment  is  required  in  a  large  number  of 
cases,  but  even  in  mild  cases  symptoms  occasionally  arise  which  render 
necessary  some  modification  of  it.  It  will,  however,  be  more  convenient 
to  postpone  the  discussion  of  this  part  of  the  treatment  of  typhoid  fever 
until  after  the  treatment  of  the  more  serious  forms  of  the  disease  has 
been  considered. 

When  typhoid  fever  assumes  a  severe  type,  the  success  of  the  physician 
in  the  management  of  the  disease  will  depend  largely  upon  the  readiness 
with  which  he  detects  indications  for  treatment  and  the  promptness  with 
which  he  meets  them.  Usually,  one  of  the  first  symptoms  to  demand 
attention  is  the  high  temperature.  This  is  not  only  an  early  symptom  in 
many  bad  cases,  but  may  continue  throughout  the  attack ;  or  it  may  sud- 
denly supervene  in  cases  in  which  the  fever  has  previously  been  moderate 
in  degree,  anil  when  excessive  may  be  the  direct  or  indirect  cause  of  death. 
The  reduction  of  the  temperature  is  therefore  an  indication  the  importance 
of  which  cannot  well  be  overestimated.  Fortunately,  there  are  several 
methods  by  which  this  end  may  be  accomplished.  It  will,  however,  be 
necessary  for  our  purpose  to  consider  only  two  of  them  in  detail :  1,  the 
cold-water  treatment ;  2,  sulphate  of  quinia  in  full  doses. 

The  cold-water  treatment  is  not  new,  since  it  was  practised  in  the  form 
of  cold  effusion  in  the  treatment  of  fevers  as  long  ago  as  1787  by  Currie 
of  Liverpool,  who  may  be  said  to  have  introduced  it,  and  who  asserted 
that  it  had  the  power  not  merely  of  moderating  the  symptoms  of  these 
diseases,  but  also,  in  many  cases,  of  cutting  them  short.  It  enjoyed  at 
first  a  high  degree  of  popularity,  which  lasted  for  from  twenty  to  thirty 
years,  but  finally  fell  into  disuse,  probably  in  consequence  of  the  exag- 
gerated character  of  the  claims  which  were  made  for  it  by  its  advocates. 
Although  resorted  to  from  time  to  time  in  various  parts  of  the  world,  the 
merit  of  having  brought  it  again  into  notice  seems  to  be  due  to  Brand  of 
Stettin,  who  published  a  work  on  The  Hydrotherapy  of  Typhoid  Fever  in 
1861.  Still  more  recently,  the  recorded  observations  of  Bartels,  Jiirgen- 
sen,  Ziemssen,  and  Liebermeister  in  Germany,  and  of  Wilson  Fox  and 
others  in  England,  have  so  far  restored  the  treatment  to  professional  favor 
that  there  are  few  physicians  either  in  this  country  or  abroad  who  do  not 
occasionally  have  recourse  to  it. 

The  cold-water  treatment  may  be  applied  in  several  different  ways : 
1,  the  cold  bath ;  2,  the  graduated  bath ;  3,  cold  affusions ;  4,  the  cold 
pack ;  5,  cold  sponging ;  6,  cold  compresses ;  and  7,  frictions  with  ice. 
They  all  act  in  the  same  manner,  and  depend  for  their  efficacy  upon  their 
power  of  abstracting  heat  from  the  body,  and  are  useful  just  in  proportion 
as  they  do  this.  There  is  no  reason  for  believing  that  they  have  the 
power  to  modify  the  conditions  upon  which  the  production  of  heat 
depends,  but  there  is,  on  the  other  hand,  no  doubt  that  under  their  use 
distressing  and  dangerous  symptoms,  such  as  coma,  stupor,  subsultus, 
and  the  like,  are  often  much  relieved.  They  probably  act,  therefore,  by 
diminishing  the  metamorphosis  of  the  tissues,  and  the  consequent  loading 
of  the  blood  with  excrementitious  products  which  the  hyperpyrexia  has  a 
tendency  to  promote. 

The  cold  bath  is  the  most  effective  of  all  the  methods  of  applying  the 


328  TYPHOID  FEVER. 

cold-water  treatment.  Liebermeister  recommends  that  the  bath  for  an 
adult  should  be  at  the  temperature  of  68°  F.,  and  its  duration  should  be 
about  ten  minutes ;  if,  however,  the  patient  shows  signs  of  great  weak- 
ness, it  should  not  exceed  seven.  After  the  bath  he  should  be  wrapped 
up  in  a  dry  sheet  or  light  blanket  and  put  back  in  bed.  If  the  pulse 
should  then  show  signs  of  failing,  or  if  there  should  be  shivering  or  any 
other  evidence  of  weakness,  he  should  be  given  a  glass  of  wine  or  brandy 
or  a  dose  of  some  other  diffusible  stimulus,  and  bottles  containing  hot 
water  should  be  applied  to  his  feet.  The  process  of  cooling  goes  on  for 
some  time  after  the  patient's  removal  from  the  bath,  for  while  a  ther- 
mometer placed  in  the  axilla  will  show  that  the  external  temperature  is 
immediately  affected  by  it,  the  same  instrument  placed  in  the  rectum  will 
indicate  a  gradual  fall,  which  will  continue  in  many  cases  for  at  least  half 
an  hour.  Shortly  after  this  t'he  temperature  will  be  observed  to  rise,  and 
in  many  cases  it  will  not  be  more  than  two  hours  before  it  has  attained  its 
former  height.  Liebermeister  therefore  recommends  that  the  thermometer 
should  be  frequently  used,  and  that  the  baths  should  be  repeated  as  often 
as  the  temperature  rises  to  103°  F.  or  above  it.  He  has  himself  given 
them  as  often  as  every  two  hours,  or  as  many  as  two  hundred  during  an 
entire  illness,  but  usually  finds  that  not  more  than  six  or  eight  a  day  are 
required.  It  often  requires  some  persuasion  to  overcome  the  repugnance 
which  most  patients  feel  at  first  for  these  baths,  and  the  shock  of  being 
suddenly  immersed  in  cold  water  is  agreeable  to  very  few.  Later,  this 
repugnance,  he  says,  entirely  disappears.  Intestinal  hemorrhage,  perforation 
of  the  bowel,  and  great  weakness  of  the  heart's  action  are  all  contraindica- 
tions to  the  use  of  the  cold  bath.  They  are  especially  to  be  avoided, 
according  to  Liebermeister,  when  the  force  of  the  circulation  is  so  far 
reduced  that  the  surface  of  the  body  is  cold  while  the  interior  is  very  hot. 
On  the  other  hand,  the  advocates  of  this  plan  of  treatment  contend  that 
the  existence  of  pneumonia  or  of  hypostatic  congestion  of  the  lungs  is  not 
a  sufficient  reason  for  abandoning  it,  the  congestion  often  disappearing 
under  its  use. 

The  graduated  bath  possesses  some  advantages  over  the  cold  bath,  as 
its  use  involves  less  of  a  shock  to  the  system.  It  is  therefore  more  suit- 
able than  the  latter  for  nervous  and  excitable  patients,  for  persons  of 
advanced  age  or  of  general  feebleness  of  constitution,  or  for  very  young 
children.  In  it  the  temperature  of  the  water,  which  at  the  time  of  the 
immersion  of  the  patient  should  be  at  or  above  95°  F.,  is  cooled  by  the 
gradual  addition  of  cold  water  until  it  is  reduced  to  72°,  or  below  this 
:>int.  These  baths,  to  produce  the  same  effect  as  the  cold  baths,  must 
1  longer  duration.  They  are  contraindicated  in  the  same  conditions 
as  the  latter,  but  to  a  less  degree. 

Although  fully  willing  to  admit  the  good  effects  of  the  cold  bath  in 

ies,  having  been,  of  course,  myself  a  witness  of  them,  I  am 

1  to  have  recourse  to  it  except  in  cases  of  hyperpyrexia  of  such 

that  death  seems  imminent  and  only  to  be  averted  by  energetic 

'cnt,  or  m  cases  in  which  other  antipyretic  remedies  have  failed  to 

ace  the  temperature;  and  for  the  following  reasons:  1.  In  the  first 

is  generally  possible  to  produce  a  decided  effect  by  the  other 

5  of  applying  the  cold-water  treatment,  with  much  less  discomfort 

nt.     2.  In  a  private  house  it  is  not  always  practicable  to  have 


TREATMENT.  329 

a  bath  brought  to  the  bedside  of  the  patient,  and  in  a  general  hospital  to 
do  so  often  would  occasion  a  good  deal  of  annoyance  to  the  other  patients 
in  the  same  ward,  and  I  have  seen  ill  result  from  carrying  him  some  dis- 
tance to  the  bathroom.  But  even  where  the  bath  is  brought  directly  to 
his  bedside,  it  involves  so  much  movement,  and  is  sometimes  the  cause 
of  so  much  excitement,  that  its  good  effects  are  more  than  neutralized  by 
its  bad. 

Cold  affusions,  while  not  nearly  so  efficacious  in  reducing  the  tempera- 
ture of  the  body  as  the  cold  bath,  are  open  to  many  of  the  objections 
which  may  be  urged  against  the  latter  mode  of  treatment.  They  are, 
therefore,  rarely  employed  at  the  present  time.  Liebermeister,  however, 
thinks  that  they  may  sometimes  be  resorted  to  with  good  effect  for  their 
brisk  stimulating  effect  on  the  psychical  functions  or  the  respiration. 

The  cold  pack  possesses  the  advantage  over  the  cold  bath  and  cold 
affusions  of  involving  less  movement  on  the  part  of  the  patient  and  of 
being  less  terrifying  to  children,  and  may  therefore  be  resorted  to  in  cases 
in  which  the  latter  method  of  applying  the  cold-water  treatment  is  con- 
traindicated,  as,  for  instance,  in  persons  of  feeble  circulation.  It  is,  how- 
ever, inferior  to  either  of  th&ii  in  its  cooling  effects,  and  must  be  longer 
applied  to  produce  the  same  effect.  Liebermeister  estimates  that  a  course 
of  four  consecutive  packs,  of  from  ten  to  twenty  minutes'  duration  apiece, 
is  about  equivalent  in  effect  to  a  cold  bath  of  ten  minutes. 

Cold  sponging  is  assigned  a  very  low  place  among  the  methods  of 
abstracting  heat  from  the  body  by  many  writers.  It  has,  however,  often 
been  in  my  hands  of  much  service,  and  its  easy  application  and  the  com- 
fort which  patients  derive  from  it  are  certainly  strong  recommendations 
in  its  favor.  I  have  employed  it  frequently  in  cases  of  intestinal  hemor- 
rhage, and  even  in  cases  of  great  debility,  and  have  never  yet  had  any 
reason  to  repent  my  having  done  so.  The  addition  of  a  little  vinegar  to 
the  water  has  seemed  to  me  to  increase  the  effect  of  the  sponging. 

Cold  compresses,  either  in  the  form  of  cloths  wet  with  cold  water  or 
bladders  filled  with  ice,  can  only  produce  a  local  fall  of  temperature,  and 
therefore,  except  when  applied  to  the  head,  can  be  of  little  service. 

Frictions  with  ice  are  a  powerful  means  of  depressing  the  temperature 
of  the  body,  and  may  therefore  be  resorted  to  in  cases  of  intense  hyper- 
pyrexia  when  for  some  reason  the  cold  bath  cannot  be  obtained,  and  when 
there  are  no  contraindications  to  the  latter. 

Liebermeister  classes  cold  drinks,  the  internal  administration  of  ice, 
and  the  injection  of  cold  water  among  the  means  of  cooling  the  body  in 
fevers;  but  it  is  doubtful  if  any  great  reduction  of  temperature  can  be 
brought  about  by  any  of  these  remedies  in  the  quantities  in  which  it 
would  be  safe  to  use  them.  The  first  two,  and  to  a  less  extent  the 
last,  meet  a  very  important  indication,  that  of  supplying  water  to  the 
system.  Their  free  use,  therefore,  forms  a  very  important  part  of  the 
treatment  of  typhoid  fever. 

Luton  of  Rheims1  extols  the  Diseta  hydrica  in  the  treatment  of  typhoid 
fever.  The  patient  receives  absolutely  nothing  else  to  drink  but  water, 
which  is  given  in  large  quantities,  for  from  four  to  six  days.  No  nour- 
ishment is  given  until  the  beginning  of  the  third  week,  and  first  of 
all  milk.  If  fever  returns,  the  water  is  given  again.  Medicines  such  as 

1  Journal  de  therapie,  Oct.,  1880. 


330  TYPHOID  FEVER. 

quinia  and  eucalyptus  are  given  in  adynamic  conditions,  which  Luton 
says  are  rare  under  this  treatment,  He  believes  that  the  increase  of  the 
typhoid  germs  is  prevented  by  absolute  diet  and  abundant  supply  of 

water. 

Quinia  to  produce  a  decided  antipyretic  effect  must  be  given  in  large 
quantities.  Murchison  says  that  a  dose  of  from  fifteen  to  twenty  grains 
causes  within  an  hour  or  two  a  fall  of  the  temperature,  and,  to  a  less 
extent,  of  the  pulse,  which  may  last  from  twelve  to  eighteen  hours,  and 
that  he  has  never  known  any  other  disagreeable  symptoms  result  from  its 
use  than  noises  in  the  ears,  temporary  acceleration  and  irregularity  of  the 
respiration,  and  occasional  vomiting.  This  quantity  will  often,  however, 
be  found  to  be  insufficient  to  produce  a  notable  reduction  of  the  fever, 
and  it  is  therefore  necessary  occasionally  to  increase  it.  Liebermeister 
usually  gives  to  adults  from  twenty-two  to  forty-five  grains  of  the  sul- 
phate or  the  muriate  of  quinia,  and  this  dose  must  positively  be  taken 
within  the  space  of  half  an  hour,  or,  at  the  most,  an  hour,  as  it  is  use- 
less, he  says,  to  expect  the  full  benefit  of  this  dose  to  appear  if  the  dose 
is  divided  and  its  administration  is  extended  over  a  longer  time.  He 
never  repeats  it  in  less  than  twenty-four  hours,  and,  as  a  rule,  does  not 
give  it  again  under  two  days.  Jtirgensen  has  exceeded  the  dose  of  forty- 
five  grains  without  observing  any  bad  effects  from  it.  When  these  large 
doses  are  taken  the  fall  of  the  temperature  usually  begins  a  few  hours 
after  the  administration  of  the  medicine,  the  minimum  being  reached  in 
from  six  to  twelve  hours,  and  it  is  usually  not  until  the  second  day  that 
the  temperature  attains  its  former  height.  It  is  found  in  practice  that  the 
most  decided  results  are  obtained  when  the  medicine  is  given  in  the  even- 
ing, so  that  the  time  of  its  fullest  antipyretic  effects  will  coincide  with 
that  of  the  morning  remission.  When  these  large  doses  produce  vomit- 
ing, as  they  occasionally  will,  the  quinia  must  be  given  by  the  rectum  or 
hypodermically. 

Quinia  possesses  the  great  advantage  over  the  cold  bath  that  it  may  be 
given  in  conditions  in  which  it  would  be  dangerous  to  resort  to  the  latter. 
The  existence  of  great  cardiac  weakness,  of  perforation  of  the  bowel,  or  of 
intestinal  hemorrhage  do  not  usually  constitute  contraindications  to  its  use. 
In  my  own  practice  I  have  not  often  found  it  necessary  to  have  recourse 
to  much  larger  doses  than  those  recommended  by  Murchison,  preferring 
to  repeat  them  if  necessary  rather  than  to  give  a  single  dose  of  even  half 
a  drachm. 

It  will  be  well,  in  this  connection,  to  allude  briefly  to  a  few  other 
remedies  which  have  been  given  for  their  antipyretic  effect.  One  of  these 
is  digitalis,  which  has  been  administered  for  this  purpose  in  very  large 
Thus,  Liebermeister  recommends  that  from  eleven  to  twenty-two 
grams  should  be  given  in  the  course  of  thirty-six  hours.  I  have  never 
used  this  drug  in  these  doses,  and  therefore  cannot  speak  of  its  effects  from 
personal  knowledge  of  them.  I  have  frequently  had  recourse  to  it,  how- 
ever, in  more  moderate  doses,  and  I  think  with  advantage. 

Another  is  sodium  salicylate.  This  remedy  has  been  used  largely  in 
England  and  Germany,  and  to  a  less  extent  in  this  country.  It  has  been 
claimed  for  it  that  it  has  the  power  of  destroying  the  germs  of  typhoid 
lever,  but  btricker1  finds  it  difficult  to  accord  it  this  property  in  the  face 

1  Deutsche  Milit.-arzll  Zeitsch.,  1877. 


SYMPTOMS  REQUIRING  SPECIAL  TREATMENT.  331 

of  the  fact  that  he  has  had  three  cases  of  typhoid  fever  under  his  observa- 
tion which  occurred  in  patients  just  recovered  from  rheumatism,  which 
had  been  treated  by  this  drug.  My  own  experience  with  it  in  the  treat- 
ment of  this  disease  is  small,  but  has  been  unsatisfactory.  While  it  is 
undoubtedly  an  antipyretic,  the  pulse  becomes  weak  and  the  inspiration 
less  strong  under  its  use.  The  brain  symptons  do  not  diminish  under  its 
use.  Indeed,  it  is  said  to  produce  narcotism  in  some  cases.  Dr.  Jahn l 
and  Dr.  Jh.  Platzer2  speak  more  favorably  of  it,  but  admit  that  its 
administration  is  occasionally  attended  by  the  inconveniences  above 
referred  to.  The  verdict  of  the  profession  in  regard  to  it,  tersely 
expressed  by  one  who  had  given  it  a  fair  trial,  appears  to  be  that  it  is  a 
remedy  that  brings  nothing  but  disappointment  to  the  physician  and  dis- 
aster to  the  patient. 

Eucalyptus,  in  the  form  of  the  tincture,  is  also  a  favorite  remedy  with 
many  practitioners.  Dr.  Benj.  Bell3  is  in  the  habit  of  giving  a  teaspoon- 
ful  every  three  or  four  hours  in  a  wineglass  of  water,  and  asserts  that  it 
diminishes  the  tendency  to  diarrhoea  and  the  duration  of  the  illness. 

The  different  varieties  of  typhoid  fever  require  slight  modifications  only 
of  the  treatment  laid  down  above.  In  the  typho-malarial  form,  especially 
in  those  cases  in  which  the  malarial  element  predominates,  and  in  which 
there  is  a  marked  tendency  to  remission,  the  early  administration  of 
quinia  in  full  antiperiodic  doses  is  urgently  called  for.  In  some  cases 
which  he  had  the  opportunity  of  observing  in  the  army,  A.  L.  Cox4 
found  great  advantage  from  the  use  of  arsenious  acid  in  rather  large 
doses.  When  the  disease  attacks  elderly  people,  an  early  resort  to  alco- 
holic stimulants  is  usually  necessary,  in  consequence  of  the  excessive 
prostration  it  induces  in  them.  Henoch  and  Steffen5  assert  that  cold 
baths  are  not  so  well  borne  in  children  as  in  adults.  Their  influence  is 
transitory  only,  and  their  use  has  sometimes  been  followed  by  fatal  col- 
lapse. In  the  renal  form  dry,  and  in  some  cases  cut,  cups  should  be 
applied  externally  and  saline  diuretics  given  internally. 

SYMPTOMS  REQUIRING  SPECIAL  TREATMENT. — Vomiting,  when  it 
occurs  early  in  the  disease,  is  usually  checked  by  the  administration  of  an 
emetic  and  by  the  application  of  sinapisms  to  the  epigastrium.  The  use 
of  emetics  is  no  longer  advisable  when  it  occurs  after  the  first  week.  It 
is  better  then  to  trust  to  small  doses  of  hydrocyanic  or  carbolic  acid, 
aromatic  spirit  of  ammonia,  or  bismuth.  It  will  often  be  found  that 
lime-water  and  milk  will  remain  upon  the  stomach  when  every  other 
article  of  food  or  medicine  is  rejected.  In  some  severe  cases  which  have 
been  under  my  care  the  symptom  was  permanently  relieved  by  the  fre- 
quent administration  of  small  quantities  of  brandy  in  iced  soda-water. 
When  vomiting  is  a  consequence  of  peritonitis  it  usually  resists  every  form 
of  treatment. 

Diarrhoea,  if  the  number  of  the  stools  does  not  exceed  two  or  three  in  the 
course  of  twenty-four  hours,  does  not  need  special  treatment.  When, 
however,  it  is  more  severe,  prompt  measures  should  be  taken  to  check  it. 
Under  these  circumstances  laudanum  injections  have  seemed  to  me  to  be 

1  Deuisches  Arch.f.  klin.  Med.,  1877.  2  Sayr.  Arztl.  Intel!.  BL,  1877. 

3  Edin.  Med.  Jour.,  Aug.,  1881. 

*  Outlines  of  the  Chief  Camp  Diseases  of  the  United  States  Armies,  by  Joseph  Janvier 
Woodward,  M.  D.,  Philada.,  1863.  6  Jahrb.f.  Korhde,  1880. 


332  TYPHOID  FEVER. 

bv  far  the  best  remedy.  It  is  not  necessary  that  these  injections  should 
aiwavs  contain  a  large  amount  of  laudanum  or  that  they  should  be 
repeated  frequently.  In  many  cases  twenty  drops  once  a  day  will  be 
found  to  be  sufficient,  and  it  is  rarely  necessary  to  exceed  forty  drops 
twice  daily.  Opium  given  by  the  mouth  or  in  suppository  in  equivalent 
quantity  does  not  act  with  anything  like  the  same  efficacy.  If  the  lauda- 
num injections  fail  to  restrain  the  diarrhoea,  it  will  be  well  to  have 
recourse,  in  combination  with  opium,  to  the  subnitrate  of  bismuth  or 
the  acetate  of  lead.  Nitrate  of  silver  was  at  one  time  much  employed 
in  the  treatment  of  typhoid  fever,  especially  by  the  late  J.  K.  Mitchell 
of  this  city,  but  was  afterward  suffered  to  fall  into  neglect.  Its  use  has 
been  recently,  to  a  certain  extent,  revived  in  consequence  of  the  recom- 
mendation of  William  Pepper,1  who  claims  for  it  the  power  of  modifying 
the  course  of  the  disease.  I  have  given  it  in  a  number  of  cases,  but  have 
never  been  able  to  satisfy  myself  that  it  possessed  this  power.  I  have 
therefore  ceased  to  prescribe  it  except  in  the  later  stages  of  the  disease, 
when  the  symptoms  indicate  that  the  intestinal  ulcers  are  in  an  atonic 
condition.  Under  these  circumstances  it  has  appeared  to  me  to  promote, 
their  cicatrization.  It  is  important,  however,  to  remember  that  diarrhrea 
is  occasionally  caused  and  kept  up  by  more  food  being  given  to  the 
patient  than  he  can  assimilate,  and  it  is  therefore  a  good  rule  to  examine 
the  stools  from  time  to  time  to  see  whether  they  contain  curds  of  milk 
or  other  undigested  food.  If  such  is  found  to  be  the  case,  the  amount 
of  nourishment  should  be  diminished,  and  it  will  be  well  also  to  prescribe 
pepsin  either  in  powder  or  in  solution. 

Tympanites  also  occasionally  requires  treatment,  for  in  addition  to 
interference  with  the  descent  of  the  diaphragm  and  other  discomfort  it 
produces,  the  distended  condition  of  the  bowels  directly  increases  the 
risk  of  perforation.  It  is  usually  sufficient  to  employ  embrocations  or 
stupes  of  equal  parts  of  sweet  oil  and  oil  of  turpentine,  or  of  camphor 
liniment.  If  the  tympanites  coexist  with  constipation,  enemata,  either 
with  or  without  a  small  quantity  of  oil  of  turpentine,  may  often  be  used 
with  advantage.  If  it  is  extreme,  an  intestinal  tube  should  be  introduced 
very  _ carefully  into  the  rectum  and  the  gas  drawn  off.  Charcoal  has 
occasionally  been  administered  in  this  condition  with  a  view  of  prevent- 
ing decomposition  of  the  intestinal  contents.  Tympanites  occasionally 
rapidly  supervenes  upon  the  occurrence  of  perforation,  and  must  then, 
of  course,  be  treated  with  due  reference  to  the  latter  condition. 

Intestinal  hemorrhage  is  a  symptom  which  always  demands  prompt 
attention,  no  matter  how  slight  it  may  seem  to  be,  for  it  is  to  be  remem- 
bered that  not  only  is  there  a  danger  of  its  recurrence,  but  that  the 
quantity  of  blood  which  appears  in  the  stools  is  by  no  means  a  reliable 
measure  of  that  actually  lost,  as   more   blood   frequently   remains   in 
the  intestines  than  appears  externally.     In  estimating  its  severity,  it  is 
2tore  proper  to  take   into  consideration  the  gravity  of  the  other 
symptoms  which  attend  it,  such  as  the  fall  of  temperature,  feebleness 
of  the  pulse.     In  many  cases  the  enforcement  of  absolute  rest,  with  the 
rimin.stration  of  wld  drink  and  a  small  amount  of  opium  to  diminish 
ic  action  is  all  that  is  needed.     In  cases  in  which  the  symptoms 
t  will  be  necessary  to  have  recourse  to  more  energetic  meas- 
1  Philadelphia  Medical  Times,  Feb.  12,  1881. 


SYMPTOMS  REQUIRING  SPECIAL  TREATMENT.  333 

ures.  Under  these  circumstances  the  hypodermic  injection  of  from  three 
to  five  grains  of  ergotin,  repeated  if  necessary,  has  seldom  in  my  experi- 
ence failed  to  check  the  hemorrhage.  Dilute  sulphuric  acid,  oil  of  tur- 
pentine, and  acetate  of  lead  have  also  proved  themselves  useful  remedies 
in  my  hands.  The  application  of  ice  to  the  surface' of  the  abdomen  has 
also  been  said  to  be  attended  with  good  results,  but  the  objections  to  the 
use  of  this  remedy  in  the  condition  of  collapse,  which  is  so  apt  to  accom- 
pany profuse  intestinal  hemorrhage,  are  so  evident  that  it  is  unnecessary 
to  discuss  them  here.  MonsePs  solution,  tannic  acid,  and  various  other 
mineral  and  vegetable  astringents  have  been  recommended  for  their  direct 
effect  upon  the  bleeding  surface,  but,  even  admitting  that  they  can,  when 
administered  by  the  mouth,  reach  this  unaltered  or  in  a  sufficient  state 
of  concentration  to  be  active,  it  is  evident  that  they  could  only  do  so  after 
the  loss  of  valuable  time. 

When  perforation  occurs,  it  is  obvious  that  the  indications  for  treat- 
ment are  to  preclude  the  extravasation  of  the  contents  of  the  intestine 
into  the  cavity  of  the  peritoneum,  and  to  prevent  the  peritonitis  which  is 
a  consequence  of  this  accident  from  becoming  general.  Both  of  these 
indications  are  met  by  the  administration  of  opium,  which  diminishes, 
and,  if  pushed,  arrests,  the  peristaltic  action  of  the  intestines.  By  means 
of  it  the  bowels  may  be  kept  as  free  from  movement  as  if  "  placed  in 
splints."  A  grain  of  solid  opium  may  be  given  every  hour  until  a 
decided  effect  is  produced,  or  if  it  is  found  to  disagree  with  the  stomach 
an  equivalent  quantity  may  be  given  by  the  rectum,  or  it  may  be  substi- 
tuted by  morphia  administered  by  the  mouth  or  hypodermically.  With 
the  same  view,  food  is  to  be  allowed  in  small  quantities  only  at  a  time, 
and  of  a  character  capable  of  digestion  by  the  stomach.  A  light  poul- 
tice, or,  if  there  is  much  evidence  of  inflammation,  ice  should  be  applied 
to  the  abdomen.  It  has  been  recommended  also,  in  cases  in  which  the 
peritonitis  has  become  general,  to  apply  leeches  to  the  abdomen,  but  few 
patients  in  this  condition  will  readily  bear  the  loss  of  much  blood.  It  is 
very  important  not  to  interfere  with  the  constipation  which  results  from 
the  above  treatment,  and  which  it  is  one  of  its  objects  to  promote,  until 
all  inflammatory  symptoms  have  been  absent  for  at  least  a  week,  when 
a  simple  enema  may  be  administered.  Peritonitis  resulting  from  other 
causes  than  perforation  of  the  intestine  does  not  require  any  modification 
of  the  above  treatment. 

Severe  abdominal  pain,  when  it  occurs  independently  of  inflammation, 
is  best  treated  by  the  application  to  the  abdomen  of  light  poultices,  to 
which  two  or  three  teaspoonfuls  of  laudanum  may  be  added. 

Constipation  is  an  occasional  symptom,  but  it  rarely  calls  for  active 
interference.  When  it  is  present  so  early  in  the  course  of  the  disease  that 
the  diagnosis  is  still  uncertain,  and  has  continued  for  several  days,  it  is 
best  to  prescribe  a  small  dose  of  castor  oil ;  a  dessertspoonful  is  generally 
sufficient.  The  late  Dr.  Gerhard  was  in  the  habit  of  giving  a  table- 
spoonful  of  sweet  oil  in  this  condition.  The  inordinate  action  which 
frequently  follows  the  administration  of  these  mild  purgatives  will  often 
dispel  all  uncertainty  as  to  the  nature  of  the  disease  we  have  to  do  with. 
When  it  occurs  in  a  more  advanced  stage  of  the  disease  it  is  best  met 
by  the  administration  of  enemata,  which  may  contain,  if  there  is  much 
tympanites  present,  a  small  quantity  of  oil  of  turpentine.  Under  all 


334  TYPHOID  FEVER. 

circumstances  it  will  be  well  to  remember  the  advice  given  by  Baglivi 
two  centuries  ago,  to  avoid  the  use  of  active  cathartics  in  this  disease.1 

The  headache  which  is  sometimes  a  distressing  symptom  in  the  begin- 
ning of  the  disease  is  usually  relieved  by  the  application  to  the  head  of 
cloths  constantly  wet  with  ice-water  or  by  that  of  a  bladder  filled  with 
ice  and  lard.  If  it  is  very  severe  and  does  not  yield  to  these  remedies,  a 
few  leeches  applied  to  the  temples  often  have  a  very  happy  effect  in  mod- 
eratino-  the  pain.  Murchison  recommends  that  the  cold  affusion  should 
be  administered  by  simply  placing  the  patient's  head  over  a  basin  at 
the  edge  of  the  bed  and  pouring  water  on  it  from  a  height  of  two  or 
three  feet.  He  also  says  that  warm  fomentations  are  to  be  preferred  to 
cold  in  aged  and  infirm  persons  of  feeble  circulation.  Sleeplessness  will 
often  disappear  under  the  use  of  remedies  presented  for  the  relief  of  the 
headache  and  other  nervous  symptoms.  It  is  occasionally  so  persistent 
as  to  call  for  special  treatment.  If  it  occur  early  in  the  disease,  it  will 
generally  be  sufficient  to  prescribe  at  bedtime  ten  grains  each  of  potas- 
sium bromide  and  chloral,  repeated  once  or  twice  during  the  night. 
Later  in  the  disease  this  combination  ceases  to  produce  any  effect,  besides 
which  chloral  cannot  be  administered  with  safety  after  the  action  of  the 
heart  becomes  feeble.  It  is  therefore  necessary  to  have  recourse  to  opium 
in  some  form  or  other.  There  are,  it  is  true,  theoretical  objections  to  its 
use  in  typhoid  fever,  such  as  its  interference  with  digestion  and  its  tend- 
ency to  lock  up  the  secretions ;  but  these  will  hardly  weigh  in  the  bal- 
ance against  the  fact  that  the  patient  will  die  of  exhaustion  if  the  insom- 
nia is  allowed  to  continue,  and  that  under  certain  circumstances  opium  is 
the  only  drug  which  will  procure  the  needed  sleep.  The  form  in  which 
it  is  given  is  not  a  matter  of  much  importance.  1  prefer  the  deodorized 
tincture,  twenty  or  thirty  drops,  repeated  if  necessary  in  an  hour  or  two, 
but  I  have  seen  good  results  from  the  solid  opium  and  from  the  hypo- 
dermic injection  of  morphia.  When  the  insomnia  is  attended  by  much 
tremor  and  muttering  delirium,  camphor  may  be  added  to  the  opium,  and 
given  throughout  the  day  as  well  as  in  the  evening.  Violent  delirium 
is  sometimes  also  relieved  by  administration  of  opium  and  alcoholic 
stimulants,  and  by  the  application  of  cold  to  the  head.  It  is  also  much 
lessened  by  the  cold-water  treatment.  When  the  delirium  is  so  violent 
that  restraint  is  necessary,  it  is  better  that  this  should  be  mechanical  than 
that  it  should  be  left  wholly  in  the  hands  of  ignorant  and  untrained 
nurses.  A  folded  sheet  passed  over  the  chest  of  the  'patient  and  fastened 
to  the  sides  of  the  bed  is  frequently  all  that  is  needed.  Stupor  requires 
very  much  the  same  kind  of  treatment  as  that  suitable  for  the  other 
forms  of  nervous  derangement.  If  it  is  extreme,  counter-irritants  should 
be  applied  to  the  nape  of  the  neck  and  cold  to  the  head.  The  late  Dr. 
\\  «..M!  was  in  the  habit  of  shaving  the  hair  and  applying  a  blister  to  the 
scalp  of  a  patient  in  this  condition,  and  I  have  seen  good  in  more  than 
one  instance  result  from  this  treatment.  The  urine  should  also  be 
examined,  and  if  the  quantity  be  insufficient  diuretics  should  be  given, 
f  it  contain  albumen  or  blood,  counter-irritants  and  even  cut  cups  should 
be  applied  to  the  loins.  It  is  also  important,  if  the  patient  be  in  this 
condition,  that  the  physician  should  not  rest  satisfied  with  the  nurse's 
-8antia  tanqUam  P0616111"  O/>«™  Omnia  Medico- Practica  et  Anatomica,  Georgii 


TREATMENT  OF  COMPLICATIONS.— CONVALESCENCE.         335 

assurance  that  the  urine  is  passed  freely,  but  should  from  time  to  time 
examine  the  supra-pubic  region  himself.  It  is  not  infrequently  found 
under  these  circumstances  that  there  is  really  retention,  and  that  the 
wetting  of  the  bed  upon  which  the  nurse  has  based  her  assurances  is 
really  the  consequence  of  the  dribbling  of  urine  from  an  over-distended 
bladder.  I  have  known  of  serious  results,  such  as  cystitis,  paralysis  of 
the  bladder,  having  followed  the  neglect  of  this  very  simple  precaution. 
Convulsions  when  they  occur  are  to  be  treated  by  the  application  of  cold 
to  the  head  and  counter-irritants  to  other  parts  of  the  body. 

Epistaxis  is  rarely  so  severe  as  not  to  yield  to  the  use  of  simple  reme- 
dies, such  as  the  application  of  ice  to  the  forehead  or  back  of  the  neck, 
or  of  styptics  locally.  In  a  few  cases,  however,  it  is  profuse,  and  it  will 
then  be  necessary  to  have  recourse  to  hypodermic  injections  of  ergotin, 
as  in  the  case  of  hemorrhage  from  the  intestines,  or  to  plug  the  nostrils. 

TREATMENT  OF  COMPLICATIONS. — Hypostatic  congestion  of  the  lungs, 
as  it  is  usually  the  consequence  of  feeble  action  of  the  heart,  is  best  treated 
by  frequently  changing  the  position  of  the  patient,  and  by  remedies  cal- 
culated to  increase  the  power  of  the  organ,  such  as  alcoholic  stimulants, 
ammonium  carbonate,  oil  of  turpentine,  and  digitalis.  Recent  German 
authors,  however,  regard  digitalis  as  a  dangerous  remedy  when  the  heart 
has  undergone  the  granular  degeneration  peculiar  to  fevers.  It  had, 
therefore,  better  not  be  given  if  the  congestion  occurs  late  in  the  disease. 
I  have  myself  always  found  advantage  from  the  application  of  turpen- 
tine stupes  to  the  chest,  and  occasionally  from  the  application  of  dry  cups. 
Pneumonia  when  it  occurs  as  a  complication  does  not  render  necessary  a 
material  modification  of  the  above  treatment.  It  may  sometimes  be  well, 
if  it  occur  early  in  a  robust  subject,  to  take  blood  locally,  but  it  can 
rarely  be  justifiable  to  do  so  by  venesection. 

Bed-sores  may  generally  be  prevented  by  frequently  changing  the 
position  of  the  patient,  by  scrupulous  attention  to  cleanliness,  and  by 
bathing  prominent  parts  of  his  body  with  whiskey  and  alum.  These 
parts  should  also  be  protected  from  pressure  by  the  judicious  arrange- 
ment of  pillows  and  cushions.  When  redness  or  abrasions  appear  the 
part  should  be  covered  with  soap  plaster  smoothly  spread  upon  kid. 
This  application  may  be  continued  even  after  the  formation  of  sloughs. 
As  soon,  however,  as  these  show  a  tendency  to  suppurate  poultices  should 
be  applied,  and  the  resulting  ulcer  treated  as  if  occurring  under  other 
circumstances. 

Thrombosis  of  the  femoral  vein  is  best  treated  by  elevating  the  affected 
leg  and  enveloping  it  with  flannel  cloths  saturated  with  hot  vinegar  and 
water.  Thrombosis  of  other  veins  is  to  be  treated  on  the  same  general 
principles.  When  an  artery  becomes  obliterated,  whether  from  embolism 
or  thrombosis,  the  part  which  it  supplies  should  be  surrounded  with 
cotton  wool  and  every  effort  made  to  favor  the  establishment  of  the  col- 
lateral circulation.  If  sphacelus  occurs,  it  should  be  treated  on  general 
surgical  principles. 

TREATMENT  OF  CONVALESCENCE. — The  importance  of  a  strict  adher- 
ence to  a  liquid  diet  in  the  early  part  of  the  convalescence  of  typhoid  fever 
has  already  been  alluded  to.  The  ulcers  in  the  intestines  often  remain 
unhealed  for  some  time  after  the  subsidence  of  the  fever,  and  errors  in  diet 
may  therefore  readily  cause  recrudescences  of  fever,  if  not  true  relapses. 


336 


TYPHOID  FEVER. 


These  recrudescences  are  sometimes  produced  by  very  slight  causes.  1 
have  seen  them  follow  undue  mental  exercise  or  worry,  or  sitting  up  too 
early  or  too  long.  It  is  therefore  important  to  guard  our  patients  at  this 
stage  of  the  disease  from  undue  fatigue  or  excitement  of  any  kind.  _  Med- 
icines calculated  to  build  up  the  strength  and  to  improve  the  nutrition  are 
clearly  indicated  at  this  time.  If  the  diarrhoea  should  persist,  nitrate  or 
oxide  of  silver,  sulphate  of  copper,  and  subuitrate  of  bismuth  in  appro- 
priate doses,  given  with  a  little  opium,  will  all  be  found  to  be  useful 
remedies.  When,  on  the  contrary,  constipation  exists,  it  is  still  necessary 
to  avoid  the  use  of  drastic  cathartics  ;  indeed,  even  mild  laxatives  should 
be  given  by  the  mouth  only  after  euemata  have  failed  to  produce  a  move- 
ment of  the  bowel. 

SPECIFIC  TREATMENT. — The  search  for  a  specific  remedy  in  typhoid 
fever  is  not  new.  It  is  as  old  as  the  theory  that  the  disease  is  generated 
by  a  specific  cause.  The  hypothesis  that  this  is  an  alkaline  poison  led 
many  years  ago  to  the  use  of  the  mineral  acids,  and  it  was  only  after 
experience  had  shown  that  they  were  without  power  to  cut  the  disease 
short,  or  even  to  control  many  of  its  symptoms,  that  they  ceased  in  a 
measure  to  be  prescribed.  Calomel  also,  which  was  occasionally  resorted  to 
formerly  for  its  antiphlogistic  effects  upon  the  intestinal  lesions,  has  been 
lately  recommended  in  Germany  in  the  treatment  of  typhoid  fever  on 
account  of  its  supposed  antidotal  properties.  Seven  and  a  half  grains  of 
the  drug,  and  in  some  eases  a  much  larger  dose,  are  given  four  times  daily 
on  alternate  days  as  soon  as  the  nature  of  the  disease  is  fully  recognized. 
It  is  claimed  for  this  treatment  that  when  it  is  begun  early  the  rate  of 
mortality  and  the  duration  of  the  disease  are  much  less  under  it  than 
under  any  other.  Its  advocates  admit,  however,  that  the  latter  is  not 
always  the  case — a  variety  in  the  action  of  the  medicine  which  is  attrib- 
uted to  a  difference  in  the  way  in  which  the  poison  of  the  disease  has 
been  taken  into  the  body.  Salivation  is  rarely  produced  by  the  calomel. 
The  diarrhoea,  which  is  at  first  increased  by  it,  subsequently  diminishes, 
and  the  administration  of  each  dose  is  followed  by  a  decided  although 
temporary  reduction  of  temperature. 

A  diminution  in  the  rate  of  mortality  is  also  said  to  have  been  obtained 
by  the  administration  of  iodine  in  typhoid  fever,  although  the  results  of 
its  use  are  on  the  whole  less  favorable  than  those  of  calomel.  Lieber- 
meister  recommends  that  three  or  four  drops  of  a  solution  of  one  part  of 
iodine,  two  parts  of  iodide  of  potassium,  and  ten  parts  of  water  should 
be  given  every  two  hours  in  a  glass  of  water. 


Number  treated. 

Number  died. 

Percentage  of 
mortality. 

Non-specificaily  treated 

Q77 

en 

1  Q  q 

Treated  with  calomel 

223 

na 

H7 

Treated  with  iodine... 

239 

35 

14.6 

Total  

838 

130 

15.5 

The  preceding  table,  which  is  taken  from  Liebermeister's  article  on 
lever  in  Ziemssen's  Cyclopcedia,  is   based  upon  the  results  of 


SPECIFIC  TREATMENT.  337 

treatment  in  839  cases,  a  part  of  which  were  treated  with  iodine,  a  part 
with  calomel,  and  a  part  with  neither,  the  rest  of  the  treatment  being 
exactly  alike  in  all  of  them,  and  consisting  in  the  employment  of  a 
partial  antipyretic  method. 

James  C.  Wilson1  has  recently  used  with  great  success  in  the 
treatment  of  typhoid  fever  the  following  prescription,  which  was  orig- 
inally suggested  by  Roberts  Bartholow :  Ji.  Tinct.  lodinii  f  31). ;  Acid. 
Carbolici  liq.  f  3J. — M.  Of  this,  one,  two,  or  even  three  drops  is  given 
in  a  sherry-glassful  of  ice-water  after  food  every  two  or  three  hours 
during  the  day  and  night.  In  addition  to  this  prescription  his  patients 
were  given  a  dose  of  calomel  varying  in  amount  from  seven  and  a  half  to 
ten  grains,  which  was  repeated  on  every  alternate  night  until  three  or  four 
doses  had  been  administered  in  the  course  of  the  first  six  or  eight  days. 
Of  sixteen  cases  so  treated,  none  proved  fatal,  although  eight  of  them 
were  severe,  the  temperature  reaching  or  exceeding  104°  F.  Da  Costa2 
has  used  carbolic  acid  in  this  disease,  and  has  found  it  useful  in  control- 
ling the  diarrhoea  and  in  lowering  the  temperature,  but  suggests  the  use 
of  thymol  in  doses  of  from  half  a  grain  to  one  grain  as  a  substitute,  on 
account  of  its  greater  acceptability  to  the  stomach.  C.  G.  Rothe3  recom- 
mends a  mixture  of  carbolic  acid,  tincture  of  digitalis,  tincture  of  aconite, 
brandy,  and  tincture  of  iodine.  Its  use  causes  a  decided  fall  of  tempera- 
ture and  diminution  in  the  frequency  of  the  pulse. 

My  own  experience  does  not  enable  me  to  speak  with  positiveness  of 
the  value  of  this  plan  of  treatment.  Indeed,  it  has  been  used  in  so  few 
cases,  to  the  exclusion  of  all  other  remedies,  that  it  is  difficult  to  decide 
how  far  the  result  attained  in  cases  treated  by  them  is  due  to  them,  and 
how  far  to  the  other  therapeutic  means  employed.  With  the  testimony 
of  such  competent  observers  as  those  above  named  it  is  only  proper  that 
the  treatment  by  iodine  and  carbolic  acid  should  have  a  further  trial. 
More  caution,  it  seems  to  me,  is  required  in  the  use  of  calomel.  While  it 
is  probable  that  in  a  few  cases  the  intestinal  lesions  may  be  favorably 
modified  by  the  purgation  which  it  induces,  the  indiscriminate  use  of 
the  drug  is,  I  am  sure,  calculated  to  do  more  harm  than  good. 

1  Transactions  of  the  College  of  Physicians  of  Philadelphia,  3d  Series,  vol.  yi.,  Pliiladei 
phia,  1883,  p.  221. 

*Ibid.,  p.  234.  *  Deutsche  Med.  Wocheiisc.hr.,  1880. 

VOL.  T.— 22 


TYPHUS  FEVER. 

BY  JAMES  H.  HUTCHINSON,  M.  D. 


DEFINITION. — Typhus  fever  is  an  acute  contagious  disease,  usually 
occurring  epidemically,  lasting  from  ten  to  twenty  days,  and  characterized, 
among  other  symptoms,  by  an  abrupt  commencement,  great  prostration, 
profound  derangement  of  the  nervous  system,  and  a  peculiar  eruption 
which  appears  between  the  third  and  eighth  days,  and  which,  disappear- 
ing at  first  under  pressure,  soon  becomes  persistent,  and  in  severe  cases 
may  be  converted  into  and  be  associated  with  true  petechise.  When  it 
proves  fatal,  it  generally  does  so  at  or  near  the  end  of  the  second  week. 
The  lesions  found  after  death  are  not  specific  in  character,  and  consist 
mainly  of  a  marked  alteration  of  the  blood,  congestions  of  internal 
organs,  softening  of  the  heart,  and  atrophy  of  the  brain. 

SYNONYMS. — Petechial  Typhus,  Putrid  or  Malignant  Fever,  Camp, 
Jail,  Ship,  or  Hospital  Fever,  Spotted  Fever,  Irish  Ague,  Contagious 
Typhus,  Brain  Fever,  Adynamic  or  Ataxic  Fever,  Ochlotic  Fever, 
Catarrhal  Typhus. 

The  term  typhus  was  first  applied  by  Sauvages  in  1760,  and  after- 
ward by  Culleu,  to  certain  forms  of  fever,  characterized  by  marked 
prominence  of  the  nervous  symptoms,  to  distinguish  them  from  another 
group  of  cases  to  which  they  gave  the  name  synochus,  and  is  derived 
from  the  Greek  word  ry^oc,  which  literally  means  smoke,  and  which  is 
employed  in  the  treatise  on  internal  affections  attributed  to  Hippocrates 
for  a  similar  purpose.  According  to  Murchison,1  Hippocrates  used  the 
word  to  define  a  "  confused  state  of  the  intellect,  with  a  tendency  to 
stupor."  The  appellation  typhus,  therefore,  as  indicating  a  very  promi- 
nent symptom  of  the  disease  about  to  be  described,  is  perhaps  the  best 
that  could  be  given  to  it.  It  has  been  generally  adopted  by  the  physi- 
cians in  England  and  in  this  country  to  denote  this  disease,  but  on  the 
Continent,  and  especially  in  Germany,  it  is  applied  also  to  typhoid  fever, 
the  two  fevers  being  usually  designated  there  as  typhus  petechialis  and 
typhus  abdominalis,  respectively. 

ISIORY. — As  human  want  and  misery  and  the  evils  which  follow  in 

;  tram  of  war  have  never  been  wholly  absent  from  the  world,  and  as 

e  are  the  conditions  which  are  now  known  to  be  favorable  to  the 

ad,  if  not  to  the  generation,  of  typhus  fever,  it  is  highly  probable  that 

sease  was  the  cause  of  some  of  the  epidemics  to  which  allusion  is 

!  by  the  sacred  and  profane  writers  of  antiquity.     Yet  their  descrip- 

o  vague  to  justify  us  in  assuming  that  such  was  positively  the 

p^c071/*6  Conti»™d  Fevers  of  Great  Britain,  by  Charles  Murchison,  M.  D., 
K.  S.,  etc.,  second  edition,  London,  1873. 


338 


HISTORY.  339 

case.  The  records  of  the  first  fifteen  centuries  of  our  own  era  are 
similarly  wanting  in  details,  for,  with  the  exception  of  a  brief  notice  of 
an  outbreak  of  the  disease  in  the  monastery  of  La  Cava,  near  Salerno,  in 
the  year  1083,  by  Corradi l  it  may  be  said  to  have  been  practically  unde- 
scribed  before  the  year  1546,  when  Fracastorius 2  published  his  work,  De 
Contagionibus  et  Morbis  Contagiosis.  From  the  description  which  this  dis- 
tinguished physician  gives  there  of  the  epidemics  which  prevailed  in 
Verona  in  the  years  1505  and  1508,  there  can  be  no  doubt  that  the  dis- 
ease he  had  the  opportuity  of  observing  was  really  typhus  fever.  Npt 
only  are  the  principal  symptoms  succinctly  described,  but  its  contagious- 
ness and  tendency  to  early  prostration  fully  recognized.  We  learn  also, 
from  the  same  work,  that  the  disease,  although  previously  unknown  in 
Italy,  was  one  with  which  the  physicians  of  Cyprus  and  the  neighboring 
islands  were  perfectly  familiar.  According  to  the  same  authority,  it 
again  made  its  appearance  in  1528  in  Italy,  and  from  there  extended  to 
Germany. 

During  the  last  half  of  the  sixteenth  century  epidemics  of  typhus 
fever  would  seem  to  have  been  of  more  frequent  occurrence  than  before 
it,  since  many  of  the  medical  authors  of  this  period  not  only  refer  to  it 
very  fully,  but  also  give  accurate  descriptions  of  the  disease.  There  is 
also  abundant  evidence  of  the  same  kind  that  it  frequently  prevailed 
epidemically  in  almost  every  part  of  Europe  during  the  seventeenth  and 
eighteenth  centuries,  following  generally  in  the  wake  of  famine  and  of 
war,  and  often  attaining  a  high  degree  of  virulence  in  besieged  towns. 
The  histories  of  many  of  these  epidemics  are  exceedingly  interesting, 
especially  those  of  the  so-called  Black  Assizes  which  occurred  at  different 
times  in  several  of  the  towns  of  England,  and  which  derived  their  name 
from  the  fact  that  the  disease  was  communicated  from  the  prisoners  on 
trial  to  the  judges  and  other  persons  in  attendance  upon  the  court;  but 
to  give  these  in  detail  would  be  beyond  the  scope  of  this  article. 
Although  many  of  the  authors  of  these  two  centuries  boldly  advocated 
copious  venesection  as  the  only  rational  method  of  treating  the  disease, 
there  was  a  not  inconsiderable  number  who  recognized  its  essentially 
typhoid  nature,  its  tendency  to  early  prostration,  and  the  fact  that  patients 
suffering  from  it  bear  bleeding  badly,  as  fully  as  is  done  by  physicians 
of  the  present  day.  They  were  also  unquestionably  quite  aware  of  the 
circumstances  under  which  typhus  fever  generally  arises,  for  in  1735, 
Browne  Langrish 3  wrote  that  it  originated  from  "  the  effluvia  of  human 
live  bodies,"  and  that  its  principal  cause  was  overcrowding  with  deficient 
ventilation,  as  a  result  of  which  "  people  were  made  to  inhale  their  own 
steams ;"  and  a  similar  opinion  was  expressed  a  few  years  later  by  Sir 
John  Pringle,4  J.  Carmichael  Smyth,5  and  others. 

Epidemics  of  typhus  fever  have  frequently  occurred  in  various  parts 
of  Europe  during  the  present  century,  although  they  have,  on  the  whole, 
shown  a  greater  tendency  than  before  to  confine  themselves  to  the  place 
in  which  they  first  appeared.  The  most  severe  of  these  began  in  1846, 
and  after  committing  great  ravages  in  Ireland  extended  to  England,  and 

1  In  Chron.  Cavense  Annali,  p.  1,  101,  quoted  in  Handbuch  der  Histori&h-Geographischen 
Pathologic,  von  Dr.  August  Hirsch,  Stuttgart,  1881. 

2  Quoted  by  Murchison. 

8  The  Modern  Theory  and  Practice  of  Physics,  by  Browne  Langrish,  p.  354,  London, 
1764.  4  Observations  in  Diseases  of  the  Army,  London.  4  Quoted  by  Murchison. 


340  TYPHUS  FEVER. 

subsequently  to  the  Continent.  The  disease  proved  much  more  fatal 
than  the  sword  in  the  armies  of  Napoleon  in  the  towns  besieged  by 
him  in  the  early  part  of  this  century,  and  was  the  cause  of  an  immense 
loss  of  life  in  the  Russian  and  French  armies  in  the  Crimea  after  the 
fall  of  Sebastopol. 

In  our  own  country  typhus  fever  has  appeared  several  times  during 
the  present  century,  but  the  outbreaks  have  rarely  attained  the  magnitude 
of  epidemics,  such  as  are  seen  in  Europe,  and  have  usually  been  distinctly 
traceable  to  importation  from  abroad.  It  was  first  met  with,  according 
to  Wood,1  in  New  England  in  1807  and  in  Philadelphia  in  1812, 
continuing  to  lurk,  this  author  says,  in  the  lanes  and  alleys  of  that  city 
until  the  winter  of  1820-21,  when,  as  a  student  of  medicine,  he  had  an 
opportunity  of  studying  it.  Another  outbreak  of  the  disease  occurred 
in  the  same  city  in  1836,  and  is  the  subject  of  an  admirable  paper  by 
the  late  Win.  S.  Gerhard.2  Since  then  epidemics  of  moderate  sever- 
ity have  repeatedly  occurred  at  different  times  in  several  of  the  American 
cities,  and  have  been  described,  among  others,  by  Flint,  Da  Costa,3 
and  Loomis.  A  large  number  of  cases  of  typhus  fever  (1723),  with  572 
deaths,  were  reported  to  the  Surgeon-General's  office  during  the  late  Civil 
War,  but  doubt  has  been  thrown  upon  the  correctness  of  the  diagnosis 
of  many  of  these  cases  by  Clymer4  and  Woodward,5  and  by  other 
army  surgeons,  who,  as  the  result  of  their  investigations  of  this  subject, 
have  reached  the  conclusion  that  typhus  did  not  prevail  as  an  epidemic, 
however  limited,  among  our  soldiers  at  depots  for  returned  prisoners  of 
war.  A  like  immunity  from  this  scourge  may  be  assumed  to  have  been 
enjoyed  by  the  Confederate  forces,  since  Joseph  Jones,6  one  of  the  most 
eminent  of  their  medical  officers,  has  stated  positively  that  no  case 
of  true  typhus  fever  came  under  his  observation  during  the  war  in  any 
army,  in  any  field  hospital,  general  hospital,  or  military  prison,  and  that 
the  experience  of  all  of  his  associates  whose  opinions  on  this  question  he 
was  able  to  obtain,  either  personally  or  by  letter,  was  the  same.  It  is 
therefore  most  probable  that  the  cases  entered  upon  the  sick  reports  of 
both  armies  as  typhus  fever  were  in  almost  every  case,  if  not  in  all,  cases 
of  typhoid  fever  occurring  in  scorbutic  subjects. 

From  the  foregoing  sketch  of  its  histoiy  it  is  evident  that  typhus  fever 

has  prevailed  from  time  to  time  in  almost  all  the  countries  of  Europe. 

Indeed,  it  is  probable  that  no  one  of  them  has  wholly  escaped  its  ravages, 

while  in  others  —  as,  for  example,  Ireland  —  it  has  been  more  or  less  con- 

stantly present  until  within  the  last  few  years,  when  its  visitations  have 

been  less  frequent  as  well  as  less  severe.     Even  in  countries  which  are 

popularly  supposed  to  enjoy  an  immunity  from  it  there  is  evidence  of  an 

ncontrovertible  character  that  it  has  occasionally  occurred.     Such  an 

unity  has  been  claimed  for  France,  but  in  the  works  of  Riverius,7 

1  A  Treatise  on  the  Practice  of  Medicine,  by  George  B.  Wood,  M.  D.,  etc.,  Philada.,  1855, 

.  /ft,    T  ncaB  Jo*™*  of  the  Medical  Sciences,  February  and  August  1837. 
Jowl.,  January,  1866. 

by  wm    Aitken>  M-  D-  mi»-->  3d  Amer- 


rius,  Londo     1678 


0/  ^  Unit**  StateS  Armies>  by  JosePh  Janvier  Woodward,  M.  D.,  Phil- 
P?^  P?"?1'*81™''  Uenwirs-Medical,  p.  600,  New  York,  1867. 

g  7  &  Translation  of  the  Works  of  Lazarus  Kive- 


ETIOLOGY.— PREDISPOSING  CAUSES.  341 

Ambrose  Pare1,  and  others  will  be  found  descriptions  of  the  disease  which 
leave  no  doubt  upon  the  mind  of  their  entire  familiarity  with  it ;  and 
Hirsch,  in  his  work  on  Historico-  Geographical  Pathology,  is  able  to  give 
references  to  several  writers  who  describe  outbreaks  that  have  recently 
occurred  there.  The  disease  has  also  been  observed  in  Iceland.  Typhus 
fever  is  of  much  less  frequent  occurrence  in  the  other  divisions  of  the 
eastern  hemisphere  than  in  Europe.  According  to  Murchison,  there  are 
no  authentic  records  of  its  having  been  met  in  Africa,  or,  with  the  excep- 
tion of  India,  in  Asia,  such  as  it  is  seen  in  England  and  Ireland.  There 
are,  however,  reports  of  its  occurrence  in  Asia  Minor,  Syria,  Persia, 
Egypt,  Nubia,  Tunis,  and  Algeria,  which  Hirsch,2  on  the  other  hand, 
believes  place  the  occasional  presence  of  this  disease  in  these  countries 
beyond  doubt.  The  same  difference  of  opinion  exists  between  these  two 
distinguished  observers  in  regard  to  the  accounts  which  have  been  pub- 
lished of  typhus  fever  occurring  in  Mexico,  Central  America,  and  South 
America,  the  latter  holding  that  they  are  entirely  reliable,  the  former  that 
the  cases  described  in  them  were  really  cases  of  malarial  or  typhoid  fever. 
The  disease  lias  never  been  met  with  on  the  continent  of  Australia,  in 
New  Zealand,  or  in  the  valley  of  the  Mississippi  and  the  States  bordering 
on  the  Pacific  Ocean  in  our  own  country. 

While  Hirsch's  researches  go  to  show  that  the  tropical  zone  has  not 
been  so  wholly  exempt  from  the  visitation  of  typhus  fever  as  some 
authors  have  asserted,  they  establish  the  fact  that  it  is  of  much  less  fre- 
quent occurrence  there  than  in  the  colder  portions  of  the  temperate  zone, 
where  the  modes  of  life  are  certainly  much  more  favorable  to  its  exten- 
sion. Natives  of  warm  climates  are  as  liable  to  be  attacked  by  it  as 
others  upon  coming  to  places  where  it  is  prevailing,  and  in  the  Phila- 
delphia epidemic  of  1836,  which  Gerhard3  has  described,  negroes  and 
mulattoes  suffered  from  it  more  severely  than  the  whites. 

ETIOLOGY. — The  etiology  of  typhus  fever  will  be  best  studied  under 
the  heads  Predisposing  and  Exciting  Causes. 

PREDISPOSING  CAUSES. — It  may  be  stated,  generally,  that  whatever 
impairs  the  health  or  reduces  the  strength  of  an  individual,  even  tempor- 
arily, or  acts  depressingly  on  his  nervous  system,  predisposes  him  to 
typhus  fever.  But  there  are  among  the  predisposing  causes  some  which 
exert  a  more  special  influence  on  its  production  than  others.  Among  the 
more  powerful  of  these  is  the  overcrowding  of  human  beings,  with 
deficient  ventilation.  Indeed,  there  are  some  authors  who  consider  that 
this  has  been  in  many  cases  alone  sufficient  to  occasion  the  disease ;  and 
although  this  opinion,  as  it  involves  the  admission  that  it  may  be  generated 
de  novo,  is  contested  by  others,  there  is  great  unanimity  among  authors 
in  attaching  great  importance  to  it.  Of  the  patients  admitted  into  the 
London  Fever  Hospital  with  typhus  fever,  a  large  proportion  came  from 
the  more  crowded  districts  of  the  city.  The  disease  has  always  been 
most  prevalent  in  the  poorer  quarters  of  Glasgow,  Dublin,  and  Edin- 
burgh, and  when  epidemic  in  Philadelphia  in  1836  it  was  confined  to  a 
portion  of  the  town  which  has  always  been  noted  for  the  squalor  and 
misery  of  its  inhabitants.  Among  those  admitted  during  that  year  to 
the  Philadelphia  Hospital  were  seven  negroes,  said  by  Gerhard  to 

1  Traite  de  la  Pesle,  de  la  Petite  Verolle  el  Eougeolle,  par  Ambrose  Par£,  Paris,  1568. 
1  Loc.  cit.  3  Loc.  oil. 


342  TYPHUS  FEVER. 

be  "the  entire  population  of  a  cellar."  It  is  probably  largely  due  to 
the  fact  that  the  better  social  condition  of  the  poor  in  this  country  pre- 
vents the  degree  of  crowding  which  often  exists  in  European  cities  that 
the  disease  is  comparatively  rare  here.  The  effect  of  overcrowding  is  of 
course  much  increased  by  want  of  cleanliness,  either  of  the  person  or  of 
the  clothes. 

Poverty,  not  merely  from  its  own  depressing  influences,  but  also  from 
the  fact  that  it  leads  to  overcrowding,  is  a  powerful  predisposing  cause 
of  typhus  fever.  Insufficiency  of  food,  which  is  one  of  its  many  conse- 
quences, by  impairing  his  nutrition  and  thus  diminishing  his  vital  resist- 
ance, renders  the  individual  more  susceptible  to  the  action  of  the  specific 
cause.  Gerhard  says  that  of  the  patients  seen  by  him  in  1836  a  very  small 
proportion  came  from  the  better  class  of  mechanics,  and  Tweedie l  and  Sir 
William  Jenner2  state  that  it  is  rare  to  meet  with  instances  of  the  disease, 
except  in  the  case  of  medical  practitioners  and  students,  among  those  in 
comfortable  circumstances.  Bateman3  goes  so  far  as  to  assert  that 
"  deficiency  of  nutriment  is  the  principal  source  of  epidemic  fever ;"  and 
there  is  certainly  a  remarkable  coincidence  in  time  between  outbreaks 
of  this  fever  and  seasons  of  want  and  distress.  But,  as  Murchison  has 
shown,  destitution  is  not  essential  to  the  production  of  typhus,  for  the 
Dundee  epidemic  of  1865  was  due  to  overcrowding  of  the  town,  brought 
about  by  the  inhabitants  of  the  surrounding  country  flocking  into  it  in 
consequence  of  labor  being  unusually  abundant  and  wages  good. 

Similar  in  its  action  to  the  above  cause  is  intemperance.  Not  only  is 
the  habitual  drunkard  more  likely  to  suffer  from  typhus  fever  than  the 
temperate  man,  but  a  single  debauch  has  been  followed  by  an  attack  in 
individuals  who  had  previously  resisted  the  contagion.  On  the  other 
hand,  the  most  rigid  temperance  will  not  afford  in  all  cases  a  complete 
immunity  from  its  effects.  The  debility  left  by  an  illness  is  also  a  con- 
dition favoring  the  occurrence  of  an  attack  of  the  disease  in  those  who 
are  exposed  to  its  exciting  cause.  Fatigue  of  all  kinds  renders  the  body 
less  able  to  resist  the  causes  of  disease,  and  typhus  fever  is  not  an  excep- 
tion to  the  general  rule.  Overworked  nurses  are  specially  liable  to  con- 
tract it.  The  depressing  emotions  also  favor  its  occurrence.  It  has  been 
observed  during  epidemics  that  those  who  exhibit  an  excessive  fear  of 
the  contagion  are  much  more  likely  to  suffer  from  it  than  the  cheerful 
and  courageous. 

No  age  enjoys  an  immunity  from  the  disease.  In  fact,  it  is  probable 
that  all  ages  are  equally  liable  to  it.  Buchanan4  has  seen  it  at  the 
London  Fever  Hospital  in  an  infant  a  fortnight  old  and  in  a  man  of 
eighty,  and  attributes  the  prevailing  opinion  that  children  rarely  suffer 
from  it  to  the  fact  that  they  are  not  often  taken  to  hospitals,  but  are 
vtamed  in  their  own  homes  for  treatment.  Gerhard5  says  that  no 
m  the  asylum  attached  to  the  Philadelphia  Hospital  were 

1  Lectures  m  (fc  Distinctive  Character,  Pathology,  and  Treatment  of  Continued  Fevers,  by 
author"  London  1830  F' *'  S''  London> 1842  '•  and  Clinical  EePorts  m  Fever>  b?  s*me 

*  On  the  Identity ,or  Non-Identity  of  Typhoid  and  Typhus  Fevers,  by  William  Jenner, 
M.D    London  1880;  also  Lancet,  November  15,  1879 
M.D    FR"S    LonTon^lS"8  "  Conta9ious  Fever  °f  this  Country,  by  Thomas  Bateman, 

'  M-D-  F-K-°-P"' '•• 


EXCITING  CAUSE. 

attacked  with  the  disease  during  the  prevalence  of  the  epidemic  there, 
but  the  distance  of  the  asylum  from  the  wards  in  which  the  cases  were 
treated  was  probably  the  reason  of  their  escaping.  In  the  few  cases 
which  have  come  under  my  own  observation  the  patients  were  young 
men,  varying  in  age  from  twenty-five  to  thirty-five.  The  sexes  also 
suffer  from  it  equally.  In  some  epidemics  there  may  be  a  preponderance 
of  one  sex  over  the  other,  but  in  others  the  reverse  has  been  the  case. 

Occupation,  except  so  far  as  it  brings  the  individual  into  immediate 
contact  with  the  sick,  as  in  the  case  of  physicians,  nurses,  and  clergymen, 
does  not  predispose  to  the  disease.  There  would  seem  also  to  be  no  dif- 
ference in  the  susceptibility  of  the  different  races  to  the  contagion. 
Acclimatization  affords  no  protection  from  the  disease,  as  it  does  in  the 
case  of  typhoid  fever,  and  change  of  the  habits  of  life  does  not  appear  to 
exercise  any  influence  upon  the  liability  to  it.  On  the  other  hand,  the 
susceptibility  of  different  individuals,  and  of  the  same  individual  at  dif- 
ferent times,  varies  considerably.  Thus,  while  in  many  persons  a  single 
exposure  to  the  contagion  is  followed  by  an  attack,  in  the  case  of  an 
engineer  mentioned  by  Murchison  it  did  not  occur  until  after  fifteen 
years  of  continuous  service  at  the  London  Fever  Hospital.  A  person 
who  has  once  suffered  from  typhus  fever  is  not  likely  to  contract  it  again, 
but  this  protection  is  not  complete,  as  there  are  a  few  well-attested 
instances  of  a  second  attack  on  record. 

The  disease  prevails  most  frequently  during  the  winter  and .  early 
spring,  principally  because  the  cold  weather  of  these  seasons  leads  to  the 
closing  of  windows  and  all  other  avenues  of  ventilation,  thus  intensifying 
its  exciting  cause.  Still,  some  epidemics  of  great  severity  have  occurred 
in  the  warmer  months  of  the  year,  as,  for  instance,  the  one  described  by 
Gerhard.  It  is  also  doubtful  if  there  is  any  relation  between  varia- 
tions in  temperature  and  the  amount  of  moisture  in  the  air  and  the  prev- 
alence of  epidemics  of  typhus  fever,  although  Hirsch  regards  a  low  and 
damp  situation  as  powerfully  predisposing  to  the  endemic  and  epidemic 
prevalence  of  the  disease.  It  is  usually  met  with  in'  towns  on  the  sea- 
coast  or  on  navigable  rivers,  but  it  has  also  been  observed  frequently  in 
country  districts,  and  even  in  regions  at  a  considerable  elevation  above 
the  level  of  the  sea. 

EXCITING  CAUSE. — The  principal  if  not  the  only  exciting  cause  of 
typhus  fever  is  a  specific  contagion  developed  in  the  bodies  of  the  infected 
and  transmitted  from  them  to  the  healthy  by  actual  contact,  by  fomites, 
or  through  the  atmosphere.  The  nature  of  this  contagion  is  unknown. 
A  careful  study  of  its  peculiarities  seems  to  justify  the  opinion  that  it 
depends  upon  the  presence  of  a  minute  organism  in  the  emanations  given 
off  by  the  sick,  which  is  capable  of  indefinitely  multiplying  itself  in  the 
human  body.  But  this  is  only  an  hypothesis,  which  rests  principally  upon 
the  analogy  between  typhus  and  some  other  diseases,  as,  for  instance, 
relapsing  fever  and  diphtheria,  in  which  such  a  growth  is  thought  to 
have  been  discovered,  and  upon  the  fact  that  the  contagious  principle 
whatever  it  may  be,  is  destroyed  by  a  temperature  over  204°  F. 

The  evidence  in  favor  of  the  contagiousness  of  typhus  fever  is  conclu- 
sive, and  may  be  briefly  stated  as  follows :  When  it  breaks  out  in  a 
community  the  disease  not  only  attacks  those  persons  who  have  been 
subjected  to  the  same  influence  as  the  sick — as,  for  instance,  members  of 


344  TYPHUS  FEVER. 

their  own  families,  occupants  of  the  same  house,  etc. — but  also  those  who 
have  come  from  healthy  localities  to  visit  them.  In  fever  hospitals  it  is 
rare  for  any  member  of  the  household  who  has  not  already  had  the  fever 
to  escape  an  attack,  and  the  probability  of  his  suffering  is  in  direct  pro- 
portion to  the  intimacy  of  his  relations  with  the  patients.  Thus,  the 
nurses  are  far  more  likely  to  be  attacked  than  servants  whose  duties  do 
not  take  them  into  the  wards,  except  those  employed  in  the  laundry,  who 
are  so  often  affected  by  it  that  Murchison  says  it  is  difficult  to  find 
women  who  are  willing  to  take  the  position.  The  spread  of  the  disease 
may  often  be  promptly  arrested  by  the  complete  isolation  of  the  first  few 
cases,  while  free  intercourse  between  the  sick  and  the  well  is  invariably 
followed  by  its  extension,  not  only  in  the  locality  in  which  it  first  ap- 
peared, but  to  other  localities.  But  the  strongest  argument  in  favor  of 
its  contagiousness  is  found  in  the  fact  that  patients  taken  into  a  previously 
healthy  place  have  frequently  become  the  starting-point  of  an  epidemic.  In 
this  way  the  disease  has  often  been  introduced  by  Irish  immigrants  into 
the  cities  on  our  seaboard,  and  even  into  some  of  our  interior  towns. 

Actual  contact  is  not  necessary  for  the  communication  of  typhus  fever 
from  the  sick  to  the  well.  The  contagion  may  be  transmitted  through 
the  atmosphere.  How  far  it  will  be  transmitted  in  this  way  will  depend 
upon  many  circumstances.  In  a  spacious  and  well-ventilated  ward  it  is 
probable  that  the  presence  of  one  or  two  patients  with  this  disease  does 
not  seriously  endanger  the  safety  of  the  other  patients,  and  that  the 
only  persons  who  run  much  risk  of  contracting  it  are  the  physicians  and 
nurses,  who  are  often  compelled  in  the  performance  of  their  duties  to 
inhale  the  emanations  from  the  bodies  of  the  sick.  At  the  Pennsylvania 
Hospital,  where  cases  of  this  disease  are  occasionally  admitted,  it  has  been 
usual  to  isolate  them  by  placing  them  in  a  room  a  few  feet  distant  only 
from  the  dining-room  of  the  men's  medical  ward  and  separated  from  the 
ward  by  a  short  corridor.  The  steward  of  the  hospital  informs  me  that 
during  his  connection  with  it,  which  extends  over  a  period  of  more  than 
sixty  years,  he  has  never  known  the  disease  to  extend  to  other  persons,  except 
on  two  occasions.  One  of  these  was  during  the  epidemic  described  by  Da 
Costa,  when  an  unusual  number  of  cases  was  received,  and  when  one  resident 
physician  and  two  nurses  contracted  the  disease.  On  the  other  occasion, 
which  happened  during  my  own  term  of  service  in  the  spring  of  1881, 
a  young  Danish  sailor  appeared  to  have  taken  the  disease  from  two  Brit- 
ish seamen.  ^  As  it  was  ascertained  positively  that  he  had  not  entered  the 
room  in  which  these  two  seamen  were  isolated,  and  as  his  bed  in  the  ward 
was  one  of  the  farthest  removed  from  the  room,  and  he  had  not  therefore 
been  more  or  as  much  exposed  to  the  contagion  as  the  other  patients,  it 
was  difficult  to  understand  why  he  alone  of  all  of  them  should  have  suf- 
fered from  it.  The  explanation  was,  however,  found  in  the  fact  that  he 
had  been  taken  over  to  the  women's  ward  to  act  as  interpreter  for  a 
ntrywoman  who  was  not  known  at  the  time  to  be  suffering  from 
typhus  fever,  and  that  he  had  remained  there  some  time  in  conversation 
with  her.  Murchison  and  Buchanan  both  assert  also  that  typhus  fever 
has  never  extended  from  the  London  Fever  Hospital  to  the  inmates 
ot  adjacent  houses,  even  when  it  was  itself  one  of  a  row  of  houses, 
the  other  hand,  several  patients  with  typhus  fever  are  placed  in  a 
rowded  and  ill-ventilated  ward,  the  contagion  will  then  be  found  to  have 


EXCITING  CAUSE.  345 

acquired  so  much  more  virulence  that  few  of  the  other  patients  will  escape 
its  effects. 

There  is  also  no  question  that  typhus  fever  may  be  communicated  by 
fomites.  Numerous  instances  are  on  record  in  which  the  disease  has 
been  communicated  by  the  wearing  apparel  and  bed-clothes  of  patients, 
and  we  have  already  called  attention  to  the  frequency  with  which  laundry- 
women  in  fever  hospitals  are  attacked  by  it.  The  clothes  of  persons  who 
are  themselves  free  from  the  disease,  but  who  have  been  in  close  attend- 
ance upon  the  sick  for  some  time,  are  often  also  the  medium  of  communi- 
cation. Indeed,  Murchison  goes  so  far  as  to  say  that  men  who  have  not 
cl  anged  their  clothes  and  "  who  have  been  living  in  close,  ill-ventilated 
apartments  and  on  short  allowance,  may  at  length  have  their  garments 
so  impregnated  with  the  poison  of  typhus  as  to  communicate  it  to  others 
without  being  themselves  the  subjects  of  it,"  even  if  they  have  not  been 
brought  in  contact  with  fever  patients.  The  disease  was  communicated 
in  this  way,  he  thinks,  in  the  famous  Black  Assize  in  1750  by  several 
prisoners  to  the  court  that  tried  them,  although  they  were  themselves  free 
from  it.  On  the  other  hand,  with  proper  precautions  there  is  little 
dangei  of  the  disease  being  conveyed  by  physicians  to  their  own  families 
or  to  other  patients. 

Some  difference  of  opinion  exists  as  to  the  stage  at  which  typhus  is 
most  contagious.  Many  authors  believe  that  it  is  more  infectious  during 
convalescence  than  at  any  other  time,  and  base  this  opinion  upon  the  fact 
that  the  removal  of  fever  patients  to  the  convalescent  ward  is  very  often 
followed  by  the  occurrence  of  the  disease  among  its  other  occupants ;  but 
this  is  probably  due,  as  Murchison  suggests,  to  the  patients  being 
allowed  at  this  time  to  wear  their  own  clothing,  which  has  not  been 
thoroughly  disinfected.  It  is  much  more  likely  that  the  disease  is  more 
contagious  during  the  stage  when  the  febrile  symptoms  are  most  marked 
than  during  either  the  stage  of  convalescence  or  that  of  invasion.  It 
would  appear  also,  from  the  observations  of  Dr.  Gerhard  and  others, 
that  dead  bodies  do  not  readily  communicate  the  contagion  or  that  the 
contagious  principle  is  easily  counteracted  after  death.  Still,  there  are 
several  well-authenticated  cases  on  record  in  which  individuals  have 
unquestionably  contracted  the  disease  from  dissecting  the  bodies  of  patients 
dead  from  this  cause. 

A  question  of  great  interest  naturally  arises  here,  as  to  whether  or  not 
typhus  fever  ever  occurs  except  as  the  consequence  of  exposure  to  a  pre- 
vious case  of  the  disease.  Is  it,  in  other  words,  ever  generated  de  novo  ? 
Authorities  are  divided  upon  this  point,  many  contending  that  an  inde- 
pendent origin  is  impossible,  and  others  that  it  may  occasionally  arise  in 
this  way.  Among  the  latter  is  Murchison,  who  adduces  in  support  of 
the  position  he  takes  several  instances  in  which  poverty,  with  overcrowd- 
ing and  deficient  ventilation,  appears  to  have  been  the  only  cause  of  exten- 
sive outbreaks  of  the  disease,  as  in  the  case  of  the  Black  Assize  already 
alluded  to.  These  cases  the  opposite  party  explain  by  assuming  that  the 
germs  of  the  disease  are  capable  of  lying  dormant  for  a  long  time  until 
roused  into  activity  by  favoring  circumstances.  If  the  disease  is  caused, 
as  we  have  shown  there  is  good  reason  to  believe  it  is,  by  the  presence  of 
a  minute  organism,  this  view  does  not  seem  to  be  untenable.  Pasteur  has 
demonstrated  that  the  germs  of  the  splenic  fever  of  some  of  the  lower 


346  TYPHUS  FEVER. 

animals  may  be  deprived  of  their  virulence  by  cultivation  in  appropriate 
liquids.  If  their  virulence  is  diminished  under  certain  .circumstances, 
the  assumption  does  not  seem  unwarrantable  that  under  others  it  may  be 
increased,  and  if  we  may  draw  this  conclusion  in  regard  to  one  form  of 
microscopic  growth,  we  may  do  the  same  for  others ;  and  the  hypothesis 
is  therefore  not  an  unreasonable  one  that  the  typhus  germ  needs  the 
atmosphere  engendered  by  overcrowding  for  it  to  acquire  the  power  to 
produce  the  disease. 

PERIOD  OF  INCUBATION. — The  period  of  incubation  of  typhus  fever 
appears  to  vary  considerably  in  length,  but  is  usually  about  twelve  days. 
In  some  cases  the  interval  between  exposure  to  the  contagion  and  the 
occurrence  of  the  first  symptoms  of  the  disease  is  asserted  to  have  been 
considerably  longer,  and  in  one  instance  as  long  as  thirty-one  days ;  but 
it  is  probable  that  there  has  been  in  most,  if  not  in  all,  of  these  cases  a 
second  exposure  which  has  been  overlooked.  On  the  other  hand,  it  is 
said  to  have  followed  at  once  upon  exposure,  as  in  cases  reported  by 
Gerhard,  in  one  of  which  a  nurse  inhaled  the  breath  of  a  patient  whom 
he  was  shaving,  and  in  an  hour  afterward  was  taken  with  cephalalgia 
and  ringing  in  the  ears,  which  were  immediately  succeeded  by  the 
other  symptoms  of  typhus.  In  this  and  other  similar  cases  which  are  on 
record  it  is  difficult  to  exclude  the  possibility  of  a  previous  infection. 
In  a  case,  however,  reported  by  Murchison  there  would  seem  to  be  no 
reason  to  susj>ect  that  any  such  previous  infection  could  have  taken  place, 
as  the  patient,  the  matron  of  an  orphan  asylum  where  there  was  no 
typhus,  was  taken  ill  immediately  after  opening  a  bundle  of  clothes  which 
a  child  had  brought  with  her  from  a  fever  hospital,  and  which  had  not 
been  thoroughly  disinfected. 

^  SYMPTOMATOLOGY.— It  will  facilitate  the  study  of  typhus  fever  to 
give,  in  the  first  place,  as  most  of  the  systematic  writers  on  fever  have 
done,  a  brief  clinical  sketch  of  the  disease  as  it  ordinarly  occurs,  and 
then  afterward  to  consider  its  leading  symptoms  in  greater  detail. 

GENERAL  DESCRIPTION. — An  attack  of  typhus  fever  is  sometimes  pre- 
ceded for  a  few  days  by  prodromata,  such  as  a  feeling  of  malaise,  indis- 
position to  exertion,  pain  in  the  head  and  limbs,  anorexia,  and  vertigo  ; 
but  it  oftener  begins  abruptly  with  a  slight  chill,  or  more  rarely  with  a 
decided  rigor.  This  is  followed  in  a  short  time  by  headache,  by  a 
marked  rise  of  jtemperature,  and  by  an  increased  frequency  of  pulse  and 
respiration.  Nausea  is  also  occasionally  present,  and  less  frequently 
vomiting.  The  tongue  is  at  first  moist  and  covered  with  a  thin  whitish 
fur,  but  soon  becomes  dryish,  and  its  coating  is  apt  to  assume  a  brownish 
appearance  in  a  day  or  two.  With  these  symptoms  there  are  loss  of 
appetite,  great  thirst,  constipation,  a  dull,  heavy  expression  of  counte- 
nance, a  dark,  dusky  hue  of  the  face,  and  injection  of  the  conjunctiva. 

.ental  confusion  is  early  observed,  so  that,  although  the  patient  may  be 
•  answer  questions  correctly  when  thoroughly  roused,  it  is  readily 
:hat  his  mind  is  working  with  difficulty.     The  sleep  is  very  often 
disturbed  by  dreams,  so  that  he  awakes  from  it  unrefreshed.     Prostra- 
tion and  loss  of  muscular  power  are  so  decided  from  the  very  beginning 
hsease  that  the  patient  is  obliged  usually  to  take  to  his  bed  at 
: ;  is  much  rarer  to  meet  with  walking  cases  of  the  disease  than 
m  typhoid  fever.     The  urine  is  dense,  scanty,  and  hio-h-colored. 


DESCRIPTION  OF  SPECIAL  SYMPTOMS.  347 

Usually,  about  the  fourth  day  of  the  disease  the  characteristic  eruption 
of  typhus  fever  makes  its  appearance.  It  consists  of  numerous  spots  of 
irregular  form  with  ill-defined  margins  and  of  a  dark  red  or  purplish 
color,  occurring  singly  or  in  groups,  and  varying  in  size  from  that  of  a 
pin's  point  to  two  or  three  lines  in  diameter.  They  disappear  at  first 
under  pressure,  but  in  twenty-four  hours  becomes  persistent,  and  in 
severe  cases  may  be  converted  later  into  petechise.  Besides  this  eruption 
there  is  another  which  consists  of  a  faint,  irregular  dusky  red,  subcuticu- 
lar  mottling.  The  two  eruptions  together  constitute  the  mulberry  rash 
of  Jenner,  and  have  been  variously  described  by  different  authors  under 
the  name  of  measly  or  morbilliform  rash. 

As  the  disease  advances  the  prostration  becomes  greater  and  the  pulse 
grows  weaker.  The  tongue  becomes  dry  and  brown  and  trembles  when 
protruded.  Later,  it  is  so  dry  and  contracted  that  it  can  scarcely  be  put 
out  of  the  mouth.  Sordes  collect  about  the  teeth  and  lips,  and  the  sur- 
face exhales  a  peculiar  odor.  The  headache  grows  more  severe  or  gives 
place  to  delirium,  which  may  at  first  be  active  and  violent,  and  then  pass 
into  the  low  and  muttering  form,  or  the  delirium  may  be  of  the  latter 
variety  from  the  start.  The  sleeplessness  of  the  early  stages  may  con- 
tinue, and  the  condition  known  as  coma  vigil  not  infrequently  supervenes. 
The  delirium  is  usually  followed  by  stupor,  which  is  more  or  less  pro- 
found in  accordance  with  the  severity  of  the  case,  and  which  is  accom- 
panied by  all  the  symptoms  which  characterize  the  so-called  typhoid  state, 
such  as  subsultus  tendinum,  picking  at  the  bed-clothes,  slipping  down  in 
bed,  retention  or  incontinence  of  urine,  and  sloughing  of  the  parts 
exposed  to  pressure.  In  this  condition  the  temperature,  although 
usually  still  considerably  above  normal,  is  lower  than  during  the  first 
week  of  the  disease. 

Meanwhile,  the  issue  remains  in  doubt,  and  may  continue  uncertain 
for  several  days  before  any  improvement  in  the  symptoms  can  be  ob- 
served, or,  the  stupor  passing  into  coma,  the  case  may  speedily  terminate 
in  death.  When  death  is  the  result,  it  usually  takes  place  about  the 
close  of  the  second  week  or  a  little  later,  but  it  may  occur  earlier  in  con- 
sequence of  the  violence  of  the  fever,  or,  when  due  to  a  complication, 
may  be  postponed  until  after  the  end  of  the  third  week.  Fortunately, 
however,  recovery  is  the  rule  in  this  disease.  The  beginning  of  conva- 
lescence is  often  as  abrupt  as  that  of  the  attack  itself.  The  temperature 
will  often  be  found  to  have  fallen  to  the  normal  or  below  the  normal,  the 
pulse  and  respiration  to  have  returned  to  a  healthy  condition,  and  all 
confusion  of  the  intellect  to  have  disappeared  in  the  course  of  a  few 
hours.  Occasionally,  however,  its  approach  is  more  gradual,  and  a  slight 
fall  in  temperature  and  a  corresponding  improvement  in  the  other  symp- 
toms may  be  observed  before  it  actually  occurs.  Diarrhrea,  an  excessive 
secretion  of  urine,  with  a  tendency  to  the  deposition  of  urates,  and  mod- 
erate sweating,  often  take  place  simultaneously  with  the  cessation  of  the 
fever,  and  were  formerly  regarded  as  critical  discharges.  The  return  to 
health  is  usually  rapid,  and  very  rarely  retarded  by  the  occurrence  of 
complications  or  relapses,  as  in  typhoid  fever.  The  disease  itself  leaves 
no  tendency  to  any  other  disease. 

DESCRIPTION  OF  SPECIAL  SYMPTOMS. — The  appearance  of  a  patient 
with  typhus  fever  is  pathognomonic,  and  is  often  alone  sufficient  to  enable 


348  TYPHUS  FEVER. 

a  physician  or  nurse  familiar  with  it  to  recognize  the  disease  when  brought 
in  contact  with  it.  The  surface  generally  is  congested ;  the  face  is  flushed, 
and  in  bad  cases  dusky  red  or  even  livid  in  hue ;  the  expression  is  dull 
and  vacant,  except  during  delirium,  when  it  may  be  wild  or  even  fierce ; 
the  conjunctive  are  injected,  the  eyes  watery,  and  the  teeth  encrusted 
with  sordes.  The  skin  is  generally  hot  and  dry,  except  toward  the  close 
of  bad  cases,  when  it  may  be  cool  and  bathed  in  a  profuse  sweat. 

The  symptoms  connected  with  the  nervous  system  are  among  the  most 
characteristic  of  the  disease,  and  of  them  none  is  more  marked  than  pros- 
tration. It  shows  itself  early,  the  patient  usually  taking  to  his  bed 
immediately  after  his  seizure  or  within  a  few  days  of  it.  It  is  much 
rarer  than  in  typhoid  fever  to  meet  with  walking  cases  of  typhus,  but 
Buchanan l  mentions  that  patients  with  the  rash  already  out  upon  them 
do  occasionally  present  themselves  at  the  out-door  department  of 
the  London  Fever  Hospital.  It  generally  increases  as  the  disease  pro- 
gresses, and  is  often  accompanied  by  a  tendency  to  syncope.  It  may 
attain  such  a  degree  that  the  patient  is  unable  to  turn  himself  in  bed  or 
to  help  himself  in  any  way.  Among  the  most  distressing  sensatious 
which  attend  this  condition  of  excessive  feebleness  is  a  feeling  as  if  he 
were  sinking  into  the  earth  with  nothing  to  support  him.  Headache  is 
also  an  early  symptom.  It  is  often  observed  among  the  prodromata  of 
the  disease,  and  when  these  are  absent  supervenes  directly  after  the  chill. 
It  is  usually  frontal,  but  may  be  diffused.  It  is  generally  dull  and  heavy, 
but  is  sometimes  acute,  and  may  be  accompanied  by  a  tendency  to  vertigo, 
increased  by  sitting  up,  and  by  pains  in  the  back  and  limbs.  It  becomes 
more  severe  with  the  progress  of  the  disease  until  the  occurrence  of  delir- 
ium, when  it  is,  as  a  rule,  less  complained  of.  With  the  headache  there 
is  generally  some  dulness  of  intellect,  except  in  mild  cases.  This  may  be 
slight  at  first,  and  may  continue  so  throughout  the  whole  course  of  the 
attack,  exhibiting  itself  principally  in  some  confusion  as  to  dates.  In 
more  severe  cases  it  is  much  more  marked,  and  may  finally  pass  into  actual 
stupor.  On  the  other  hand,  it  may  be  entirely  absent,  even  in  severe 
attacks,  as  in  a  case  reported  by  Da  Costa  and  in  some  cases  recently 
observed  by  myself.  It  is  usually  soon  replaced  by  delirium,  which  may 
be  low  and  muttering  or  wild  and  noisy,  the  former  being  the  more 
common.  Delirium  is  said  to  occur  most  frequently  among  me  educated 
classes  and  those  oppressed  with  care  and  anxiety,  but  is  not  rare  among 
those  who  occupy  a  lower  position  in  the  social  scale,  especially  the  intem- 
perate. It  is,  as  a  rule,  most  marked  at  night,  and  in  mild  cases  may 
occur  only  at  that  time  or  upon  waking  iu  the  morning.  When  the 
delirium  is  active  the  patient  may  shout  and  scream,  or  leave  his  bed  and 
attempt  to  throw  himself  from  "the  window,  being  endowed  apparently 
for  the  moment  with  strength  sufficient  to  enable  him  to  commit  these 
acts  of  violence.  After  the  paroxysm  is  over  he  sinks  back  in  bed 
exhausted.  The  confusion  of  intellect  or  delirium  continues  in  bad 
cases  until  death  supervenes  or  until  the  establishment  of  convalescence. 
Indeed,  the  mental  disturbance  does  not  always  end  with  the  latter,  and 
t  is  not  rare  for  feebleness  of  intellect  to  persist  for  some  time  after  the 
patient  has  in  other  respects  regained  his  usual  health,  and  in  a  few  cases 
nty  has  followed  an  attack  of  typhus  fever.  Among  the  most  for- 

1  Loc.  cit. 


DESCRIPTION  OF  SPECIAL  SYMPTOMS.  349 

midable  of  the  symptoms  of  typhus  are  convulsions,  which  are  for- 
tunately of  infrequent  occurrence. 

The  patient  generally  suffers  from  wakefulness,  except  during  the  first 
few  days.  When  sleep  is  obtained  it  may  be  unrefreshing  or  broken  and 
disturbed  by  dreams.  In  other  cases  the  opposite  condition  of  somno- 
lence may  be  present.  Occasionally,  after  having  apparently  slept  for 
hours,  he  may  deny  having  been  asleep  at  all.  This  condition,  which 
constitutes  the  coma  vigil  of  Chomel,  is  entirely  distinct  from  that 
described  by  Jenner  under  the  same  name,  in  which  the  patient  lies 
with  his  eyes  wide  open,  gazing  into  vacuity,  his  mouth  only  partly 
closed,  his  face  pale  and  devoid  of  expression,  and  which  is  invariably 
fatal.  Muscular  tremor  is  more  or  less  present  in  all  cases  of  the  disease, 
and  in  bad  cases  may  be  a  prominent  symptom.  The  disease,  when  this 
symptom  is  marked,  especially  if  there  is  at  the  same  time  low,  mutter- 
ing delirium  and  a  moist  skin,  presents  a  considerable  degree  of  resem- 
blance to  delirium  tremens.  There  is  very  often  intolerance  of  light, 
tinnitus  aurium,  and  loss  or  perversion  of  the  senses  of  taste  and  smell. 
Deafness  is  also  not  uncommon,  and  is  regarded  by  many  authors  as  a 
favorable  symptom.  In  bad  cases,  in  addition  to  subsultus  tendinum, 
there  are  carphologia,  incontinence  or  retention  of  the  urine,  and  paral- 
ysis of  the  sphincter  ani. 

Some  discrepancy  is  found  to  exist  in  the  statements  of  different 
authors  in  regard  to  the  temperature  curves  of  typhus  fever.  They 
all  agree,  however,  in  assigning  them  certain  characters,  the  knowledge 
of  which  is  often  of  great  assistance  in  diagnosis.  One  of  these  is  a 
rapid  rise  of  temperature  immediately  after  the  invasion  of  the  disease. 
Wunderlich1  asserts  that  he  has  observed  a  temperature  of  104.9°  F.  on 
the  evening  of  the  first  day,  and  Lebert  has  found  it  as  high  as  106.4° 
F.  on  that  of  the  second.  Such  temperatures,  occurring  so  early  in  the 
disease,  must  be  infrequent,  as  Murchison  has  never  met  with  them. 
Usually,  the  temperature  attains  its  maximum  on  the  third  or  fourth 
day.  The  maximum  is  about  104°  or  105°  F.  Murchison  says  it 
scarcely  ever  reaches  106°,  except  in  children,  in  whom  it  rarely  is  as 
high  as  107°,  but  Lebert  states  that  he  has  known  it  to  be  as  high  as 
107.8°.  On  the  other  hand,  it  may  never  exceed  103°,  even  in  fatal 
cases.  When  the  maximum  is  attained  early  in  the  disease  there  may 
be  for  several  days,  or  until  defervescence  takes  place,  very  little 
variatioi  in  the  evening  temperatures,  but,  as  a  general  rule,  they  are 
slightly  less  elevated  in  the  second  than  in  the  first  week.  This  usually 
occurs  from  the  tenth  to  the  fourteenth  day,  but  it  may  be  postponed 
until  the  eighteenth,  or  even  until  much  later.  In  some  cases  on  the 
day  before  the  crisis  a  slight  fall,  and  in  others  a  considerable  fall  with 
a  subsequent  rise  of  temperature,  are  observed.  Defervescence  is  often 
very  rapid,  the  temperature  falling  five  or  six  degrees  in  the  course  of 
twelve  hours.  A  true  lysis  is  rarely  observed.  The  occurrence  of  a 
complication  in  the  course  of  a  disease  will  not  only  cause  a  decided  rise 
of  temperature  and  a  modification  of  the  temperature  curve,  but  may 
also  postpone  defervescence  beyond  the  usual  time.  Not  infrequently 
the  thermometer  indicates  subnormal  morning  temperatures  with  slight 
evening  rises  for  several  days  after  the  crisis,  unless  complications  arise, 
1  On  the  Temperature  in  Disease,  New  Sydenham  Society's  translation,  London,  1871. 


350  TYPHUS  FEVER. 

when  fever  of  the  hectic  type  may  occur.  A  very  slight  cause  will  also 
often  produce  a  considerable,  although  temporary,  elevation  of  tempera- 
ture in  this  condition.  The  morning  remissions  are  less  decided  than  in 
typhoid  fever,  especially  in  the  first  week.  As  a  rule,  they  do  not  exceed 
1°,  but  Lebert  lays  stress  upon  the  fact  that  in  the  same  curve  variations 
fro'm  0.3°  to  1.8°  and  from  0.6°  to  2.1°  often  occur.  Cases  which  termi- 
nate fatally  are  generally  characterized  by  high  fever,  with  absence  of 
the  morning  remissions,  which  may  continue  uninterruptedly  through 
the  second  and  even  the  third  week.  During  the  death-agony  there  is 
frequently  a  rise  of  temperature  of  two  or  more  degrees.  A  very  high 
temperature  in  the  first  week  is  often  the  forerunner  of  severe  cerebral 
symptoms  in  the  second,  and  a  fall  of  temperature  unaccompanied  by  an 
improvement  in  the  other  symptoms  is  not  always  indicative  of  the 
approach  of  convalescence. 

Anorexia  is  generally  present  in  typhus  fever  from  the  beginning  of 
the  attack,  and  may  persist  until  its  close.  It  is  not,  however,  usually 
attended  by  the  same  repugnance  for  food  as  in  other  fevers.  Patients 
can  generally  be  persuaded  at  first  to  take  nourishment.  Indeed,  Dr. 
Gerhard  asserts  that  the  negroes  who  fell  under  his  care  in  1832  fre- 
quently asked  for  solid  food.  Nausea  and  vomiting  are  rare  symptoms  ; 
the  latter  may  occur  late  in  the  disease,  and  then,  not  infrequently,  is 
caused  by  irritation  of  the  brain.  Thirst  is  present  in  all  cases.  In  the 
later  stages  of  the  disease,  when  tho  senses  are  blunted,  water  may  not 
be  asked  for,  although  urgently  called  for  by  the  condition  of  the  system. 
The  bowels  are,  as  a  rule,  constipated  in  this  disease.  The  exceptions  to 
this  rule  are,  however,  more  numerous  than  is  usually  thought.  Wood ! 
says  that  he  has  frequently  seen  diarrhoea  in  typhus  fever  when  it  occurs 
in  recently-arrived  immigrants.  Da  Costa2  mentions  that  it  has  occurred 
in  several  of  the  rases  which  have  come  under  his  care,  and  Buchanan3 
says  that  he  has  observed  it  'in  at  least  one-third  of  the  patients  admitted 
into  the  London  Fever  Hospital  in  recent  years.  When  there  is  no  diar- 
rhoea the  stools  are  of  normal  color  and  consistence.  When  it  exists  they 
are  watery  and  usually  dark  greenish  in  color,  and  never  present  the 
peculiar  ochrey-yellow  appearance  seen  in  typhoid  fever.  They  are  said 
to  be  alkaline  in  reaction.  Tympanites  is  rare  in  typhus  fever.  It  may 
be  present  in  cases  in  which  there  is  diarrhoea,  and  may  then  be  associ- 
ated with  gurgling  in  the  bowels,  but  rarely  attains  the  degree  common 
in  typhoid  fever.  Gurgling  when  present  is,  moreover,  not  confined  to 
the  right  ileo-ca?cal  region,  but  may  be  produced  in  different  parts  of  the 
abdomen  by  pressure.  There  may  also  be  tenderness  in  the  epigastric 
and  hepatic  regions,  but  the  enlargement  of  the  spleen  so  constantly 
observed  in  typhoid  is  generally  wholly  wanting  in  this  fever. 

The  tongue  in  the  beginning  of  the  disease  is  covered  with  a  thin 
whitish  fur  and  is  moist,  and  may  continue  so  throughout  in  mild 
attacks.  Generally,  however,  it  soon  becomes  dryish,  and  in  bad  cases 
absolutely  dry,  and  is  tremulous  when  put  out  of  the  mouth,  while  its 
coating  becomes  thicker  and  brownish,  and  finally  brown,  or  even  black 
and  cracked.  It  is  rare  to  see  the  tongue  itself  fissured  as  in  typhoid 
fever.  Less  frequently  it  remains  red,  smooth,  and  glazed  throughout 
the  attack.  Occasionally  the  tongue  is  contracted  in  bulk,  and  it  may 

2ioc.  cit.  *Loc.rit, 


DESCRIPTION  OF  SPECIAL  SYMPTOMS.  351 

then,  in  consequence  of  its  dryness  and  that  of  the  mouth,  be  impossible 
to  protrude  it.  Sordes  frequently  collect  about  the  gums  and  lips  in 
severe  cases. 

The  pulse  is  usually  increased  in  frequency  in  typhus  fever,  and  varies 
from  100  to  120,  but  in  many  cases  it  never  rises  above  90,  and  in  very 
severe  cases  it  may  be  as  high  as  150.  This  increase  is  observed  from 
the  beginning,  and  generally  bears  some  proportion  to  the  severity  of  the 
fever;  but  toward  the  close,  when  the  prostration  is  great,  the  pulse  may 
continue  frequent  even  after  a  fall  in  temperature  has  taken  place,  and  is 
always  more  frequent  when  the  patient  is  sitting  up  than  when  he  is 
lying  down.  Occasionally,  however,  a  very  slow  pulse  is  associated  with 
symptoms  of  great  severity.  When  this  association  occurs  the  prognosis 
is  grave.  In  the  young  and  robust  the  pulse  may  be  full  and  bounding, 
but  it  is  more  often  compressible  or  small  and  weak.  It  is  not  so  often 
dicrotic  as  in  typhoid  fever.  There  is  sometimes,  according  to  Lyons,  a 
singular  want  of  uniformity  in  the  force  and  volume  of  the  arterial  pulse 
in  different  parts  of  the  system,  and  there  may  be  but  one  pulsation  at 
the  wrist  for  two  of  the  heart.  A  very  sudden  fall  in  the  frequency  of 
the  pulse  without  an  improvement  in  the  other  symptoms  is  not  a  favor- 
able indication,  as  it  may  be  due  to  impaired  innervation  or  to  degenera- 
tive changes  in  the  muscular  tissue  of  the  heart.  Usually  the  beginning 
of  convalescence  is  marked  by  a  gradual  fall  of  the  pulse.  Later  it  may 
fall  to  50  or  below  it,  and  continue  slow  for  some  time,  just  as  it  does 
in  typhoid  fever. 

The  heart  shares  in  the  general  enfeeblement  of  the  system.  In  severe 
attacks  the  impulse  soon  becomes  weak  and  diffused,  and  may  be  entirely 
absent  for  some  time  even  in  cases  which  eventually  terminate  in  recov- 
ery. Stokes  long  ago  called  attention  to  an  alteration  in  the  systolic 
sound  of  the  heart  which  he  taught  indicated  the  urgent  necessity  for  the 
administration  of  stimulants.  This  sound  is  observed  in  the  progress  of 
the  disease  to  become  shorter  and  less  distinct,  and  finally  inaudible, 
while  the  second  sound  is  unaffected.  This  modification  of  the  heart- 
sounds  is  ahvays  an  accompaniment  of  great  prostration.  Occasionally 
the  first  sound  is  replaced  by  a  functional  murmur. 

The  characteristic  eruption  of  the  disease  is  generally  preceded  by  the 
fainter  subcuticular  mottling  already  alluded  to,  and  usually  appears 
between  the  fourth  and  seventh  days,  but  it  has  been  observed  as  early 
as  the  third  day,  and,  on  the  other  hand,  its  appearance  is  said  by 
Wood  to  have  been  delayed  until  the  thirteenth.  It  consists  of  minute 
spots  with  ill-defined  margins,  varying  in  size  from  that  of  the  point  of 
a  pin  to  two  or  three  lines  in  diameter,  irregular  in  shape,  slightly  ele- 
vated above  the  skin  at  first  only,  and  occurring  singly  or  in  groups. 
They  are  pinkish  in  color,  and  disappear  readily  under  pressure  when 
first  observed.  They  may  then,  as  Gerhard  and  others  have  pointed  out, 
present  a  considerable  resemblance  to  the  rose-colored  spots  of  typhoid 
fever.  In  the  course  of  twenty-four  hours  they  become  brownish,  and 
later,  when  the  attack  is  a  severe  one,  livid  in  color.  In  malignant  or 
even  severe  cases  they  are  frequently  converted  into  true  petechise.  They 
do  not  appear  in  successive  crops,  but  usually  require  a  couple  of  days 
for  their  full  development.  Their  duration  is  variable.  In  mild  attacks 
they  may  disappear  in  the  course  of  a  few  days,  but  in  bad  cases  often 


352  TYPHUS  FEVER. 

persist  until  after  convalescence,  and  are  recognizable  after  death.  They 
are  confined  to  no  part  of  the  body,  but  appear  usually  earliest  and  most 
abundantly  upon  the  folds  of  the  axilla  and  upon  the  abdomen^  Occa- 
sionally, however,  they  are  first  observed  upon  the  wrists,  and  in  some 
cases  are  more  numerous  upon  the  arms  and  legs  than  upon  the  body. 
They  are  rarely  found  upon  the  neck  and  face,  but  in  children  the  latter 
may  be  so  much  covered  by  them  that  the  disease  may  be  readily  mis- 
taken for  measles.  They  present  some  resemblance  to  flea-bites,  but  the 
latter  may  be  easily  distinguished  from  them  by  the  minute  discoloration 
in  the  centre  left  by  the  puncture  of  the  insect.  The  eruption  is  oftenest 
wanting  in  young  subjects.  It  is  usually,  but  not  invariably,  most  copi- 
ous in  severe  attacks,  but  cases  have  ended  fatally  in  which  it  was  wholly 
wanting  from  beginning  to  end.  Its  color  is  also  to  a  certain  extent  an 
index  of  the  severity  of  the  attack ;  the  darker  and  more  livid  it  is,  the 
graver  the  prognosis.  In  malignant  cases  or  those  complicated  by  scurvy, 
in  addition  to  the  petechiae  above  referred  to,  purpura  spots  and  vibices 
are  not  infrequently  observed.  Some  authors  assert  that  the  eruption  is 
followed  by  a  slight  desquamatiou  of  the  cuticle,  but  this  is  denied  by 
others.  Sudamina  occasionally  occur,  but  they  are  much  rarer  than  in 
typhoid  fever.  The  blue  spots  described  by  the  French  under  the  name 
of  taches  bleuatres  are  also  sometimes  met  with. 

A  very  disagreable  odor  is  exhaled  from  the  bodies  of  typhus-fever 
patients  after  the  first  week.  Although  readily  recognizable  by  those 
who  have  once  perceived  it,  it  is  difficult  to  describe.  Gerhard  spoke 
of  it  as  pungent,  ammoniacal,  and  offensive,  especially  in  fat,  plethoric 
individuals,  and  believed  that  those  patients  who  presented  this  symp- 
tom in  the  highest  degree  were  most  likely  to  communicate  the  disease 
to  others.  Murchison  has  also  expressed  the  opinion  that  the  typhus 
poison  is  associated  with  this  odoriferous  substance.  Others  have  com- 
pared the  odor  to  the  smell  given  off  by  rotten  straw,  the  urine  of  mice, 
and  various  other  substances.  Wood  says  that  he  has  often  per- 
ceived the  same  odor  in  badly-ventilated  rooms  in  which  a  number  of 
people  have  been  shut  up  together  for  some  time. 

The  sensibility  of  the  skin  in  cases  in  which  the  stupor  is  not  so  great 
as  to  render  the  patients  insensible  to  all  external  impressions  is  said  by 
some  writers  to  be  much  increased.  There  is  also  occasionally  so  much 
tenderness  in  the  epigastric  region  as  to  give  the  impression  at  first  to  the 
attendant  that  there  is  inflammation  of  the  stomach  or  liver. 

Pulmonary  complications  are  quite  frequent  in  typhus  fever,  and,  as 
they  often  come  on  insidiously  and  give  no  evidence  of  their  presence  by 
cough,  expectoration,  or  even  more  hurried  breathing,  that  is  often  seen 
in  uncomplicated  cases,  it  is  well  to  make  it  a  rule  to  examine  the  chest 
of  every  patient  with  this  disease.  To  do  this  thoroughly  it  is  not  neces- 
sary to  make  him  sit  up,  which,  where  great  prostration  exists,  is  often 
attended  with  danger.  If  he  be  turned  gently  upon  his  side  the  auscul- 
tator  will  usually  have  no  difficulty  in  ascertaining  the  precise  condition 
of  his  lungs. 

The  respiration  is  usually  much  more  frequent  in  this  disease  than  in 
ft  Even  in  cases  in  which  there  is  no  disease  of  the  lungs  it  is 

ten  as  high  as  30,  and  in  cases  in  which  there  is  such  a  complication 
it  may  be  60.  Its  frequency  is  generally  proportional  to  the  severity  of 


VARIETIES.  353 

the  fever.  On  the  other  hand,  in  grave  cases  in  which  cerebral  symp- 
toms are  predominant  it  may  be  reduced  in  frequency  much  below  the 
normal.  When  coma  or  profound  stupor  exists,  it  may  become  jerking 
and  spasmodic,  or  even  simulate  the  stertorous  respiration  of  apoplexy. 
Bronchitis,  if  not  of  such  constant  occurrence  as  in  typhoid  fever,  is  cer- 
tainly not  rare.  It  usually  occurs  early  in  the  attack,  and  makes  itself 
known  by  the  presence  of  sonorous  and  sibilant  rales,  which  give  place 
later  to  mucous  r£les.  Expectoration  is  often  absent  in  these  cases ;  where 
it  exists  the  sputa  are  either  mucous  or  muco-purulent.  In  mild  cases  no 
further  lesion  of  the  lungs  occurs.  When  the  attack  is  more  severe 
hypostatic  congestion  is  very  likely  to  supervene.  This  is  a  condition 
which  is  often  attended  with  danger,  and  which  frequently,  as  has  been 
said  already,  escapes  recognition  unless  the  chest  be  thoroughly  examined, 
when  dullness  on  percussion,  feeble  respiration,  and  subcrepitaut  rales 
may  readily  be  detected.  Occasionally  the  physical  signs  indicate  the 
existence  of  pneumonia.  This,  when  it  occurs  in  the  course  of  this  dis- 
ease, is  always  of  low  grade,  and  is  attended  by  the  expectoration  of 
mucus  streaked  with  blood. 

The  breath  of  the  typhus-fever  patient  has  a  very  disagreeable  odor, 
not  unlike  that  given  off  from  the  body,  and  is  said  by  Murchison  to  con- 
tain an  increased  amount  of  ammonia. 

According  to  Parkes,1  the  changes  in  the  urine  are  those  usual  in 
ordinary  pyrexia.  During  the  fever  it  is  generally  diminished  in  quantity, 
dark  in  color,  and  of  high  specific  gravity.  It  contains  an  increased 
amount  of  urea  and  of  uric  acid,  the  latter  of  which  is  not  infrequently 
spontaneously  precipitated.  Sulphuric  acid  is  also  in  excess.  On  the 
other  hand,  the  chlorides  are  diminished  in  amount  or  entirely  absent. 
This  diminution  cannot  be  ascribed  to  a  decrease  in  the  quantity  in- 
gested, for  when  they  are  administered  with  the  food  they  are  not  found 
to  be  eliminated  by  the  kidney.  The  amount  of  phosphoric  acid  does 
not  appear  to  be  affected  by  the  disease.  The  urine  is  acid  in  reaction  at 
first,  but  its  acidity  soon  diminishes,  and  it  may  become  alkaline  toward 
the  close  of  bad  cases.  It  may  also  contain  albumen,  or  even  blood,  the 
former  being  present  oftenest  in  cases  characterized  by  high  temperature. 
According  to  Da  Costa,  tube-casts  are  more  often  present  than  absent  in 
severe  cases.  Those  seen  by  this  observer  were  either  coated  with  rather 
opaque  epithelial  cells,  many  of  which  were  finely  granular  or  covered 
with  granules,  which,  when  tested  with  reagents,  were  sparingly  soluble 
in  acetic  acid,  and  which  with  very  high  magnifying  powers  did  not 
present  the  round  shape  of  oil,  and  were  probably  the  urinary  salts  col- 
lected in  the  tube-casts.  The  crisis  is  sometimes  marked  by  a  copious 
deposit  of  urates.  During  convalescence  the  mrine  is  usually  increased  in 
quantity,  is  pale  and  limpid,  and  of  low  specific  gravity,  and  is  found  to 
contain  the  chlorides  in  gradually  increasing  quantity. 

VARIETIES. — Many  of  the  varieties  of  typhus  fever  recognized  by 
authors — as,  for  example,  jail  fever,  ship  fever,  camp  fever,  and  hospital 
fever — really  differ  in  nothing  but  name  and  the  circumstances  under 
which  the  disease  has  arisen.     Others  are  mere  modifications  of  it,  due 
to  the  predominance  of  one  symptom  or  of  a  certain  set  of  symptoms  or 
to  the  intercurrence  of  a  particular  complication,  and  likewise  do  not 
1  The  Composition  oj  the  Urine,  etc.,  by  Edmund  A.  Parkes,  M.  D.,  London,  ]  SCO. 
VOL.  I.— 23 


354  TYPHUS  FEVER. 

need  a  full  description  here.  To  this  latter  class  belong  the  inflammatory 
typhus,  the  nervous  or  ataxic  typhus,  the  adynamic  typhus,  and  the 
ataxo-adynamic  typhus  of  Murchison.  The  first  variety  occurs  in 
young  and  robust  subjects,  and,  it  is  also  said,  in  persons  of  the  upper 
class.  It  is  characterized  by  high  fever,  intense  headache,  and  active 
delirium.  In  the  second  variety  the  nervous  symptoms,  such  as  delir- 
ium, somnolence,  stupor,  and  muscular  tremblings,  are  the  most  promi- 
nent. The  most  marked  feature  of  the  third  variety  is  the  excessive 
prostration,  which  is  shown  in  the  feebleness  of  the  heart's  action  and 
the  loss  of  muscular  strength  and  of  control  over  the  sphincters.  In 
this  form  the  eruption  is  dark  colored.  Purpura  spots  and  vibices  also  are 
very  apt  to  appear,  and  even  hemorrhages  from  the  gums,  nose,  or  other 
parts  to  occur.  In  the  ataxo-adynaniic  form  the  symptoms  of  the  ataxic 
and  those  of  the  adynamic  form  are  found  united.  In  addition  to  these 
there  are  certain  other  varieties,  arising  from  differences  in  degree. 
These  differences  are  sometimes  owing  to  diversities  in  the  constitution 
and  habits  of  the  patient,  sometimes  to  variations  in  the  character  of  the 
epidemic,  and  are  sometimes  not  readily  explainable.  One  of  these  is  the 
mild  form,  in  which  the  symptoms  are  those  of  moderate  fever,  and  in 
which  the  disease  may  run  its  course  in  seven  days.  In  this  form  the 
temperature  may  never  rise  above  102°  F.,  the  eruption  be  absent  or  very 
scanty,  and  the  characteristic  stupor  or  dulness  be  wholly  wanting. 
Unless  complications  arise  recovery  invariably  takes  place.  A  walking 
form  of  typhus  fever,  as  has  already  been  said,  is  much  rarer  than  of 
typhoid,  but  it  does  sometimes  occur,  Dr.  Buchanan  having  often  seen 
the  eruption  out  upon  patients  who  have  walked  to  the  London  Fever 
Hospital  to  seek  admission.  In  this  form  the  disease,  however,  does  not 
always  run  a  mild  course,  as  alarming  prostration  is  very  apt  to  come  on 
later  in  its  course.  Another  variety,  the  abortive  form,  has  been  described 
by  authors.  In  this  an  individual,  in  due  time  after  exposure  to  the 
contagion,  may  present  all  the  characteristic  symptoms  of  typhus  fever, 
but  the  disease,  instead  of  running  its  usual  course,  may  terminate 
abruptly  with  a  critical  discharge  of  some  kind.  This  form  occurs 
during  epidemics,  and  is  analogous  to  the  abortive  attack  of  scarlet 
fever  or  some  other  diseases  which  are  occasionally  met  with.  On  the 
Other  hand,  a  very  severe  form,  the  typhus  sideraus  of  authors,  also 
sometimes  occurs.  In  this  variety  the  temperature  rises  rapidly,  and 
soon  attains  its  maximum  ;  there  are  frequent  pulse  and  respiration,  severe 
headache,  and  early  delirium  and  stupor.  The  mortality  in  this  form  is 
very  great,  Very  frequently  death  takes  place  so  rapidly  as  often  to 
leave  the  physician  in  some  doubt  as  to  the  nature  of  the  disease  in  those 
cases  in  which  exposure  to  the  contagion  cannot  be  positively  traced. 

COMPLICATIONS  AND  SEQUELAE.— The  complications  of  typhus  fever 
men  exercise  a  decided  influence  upon  the  course  of  the  disease,  for  they 
not  only  retard  convalescence,  but  are  often  the  immediate  cause  of  death. 

icir  early  detection,  therefore,  becomes  a  matter  of  the  greatest  import- 
They  will  be  found  to  vary  in  different  years,  one  epidemic  being 
characterized  by  complications  which  are  entirely  wanting  in  the  next. 
Among  the  commonest  of  them  are  several  different  conditions  of  the 
respiratory  organs.  Bronchitis,  if  not  quite  so  frequent  as  in  typhoid 
lever,  occurs  in  a  large  number  of  cases.  It  may  come  on  at  any  stage 


COMPLICATIONS  AND  SEQUELAE.  355 

of  the  disease,  either  immediately  after  the  beginning  of  the  attack  or  in 
its  course,  or  not  until  convalescence.  In  cases  accompanied  by  prostra- 
tion mucus  may  accumulate  in  the  bronchial  tubes,  and  be  the  cause  of 
the  patient's  death  by  preventing  the  due  aeration  of  the  blood.  It  would 
seem  to  be  an  especially  frequent  complication  in  Ireland,  and  it  is  rather 
surprising  that  so  acute  an  observer  as  Graves  appears  not  to  have  been 
aware  of  its  real  relation  to  typhus,  and  speaks  of  it  as  if  it  were  a  pre- 
disposing cause.  "  Nothing  can  be  more  remarkable,"  he  says,  "  than 
the  facility  with  which  a  simple  cold,  which  in  England  would  be  per- 
fectly devoid  of  danger,  runs  into  maculated  typhus  in  Ireland,  and  that, 
too,  unde»  circumstances  quite  free  from  even  the  suspicion  of  contagion;  in 
truth,  except  when  fever  is  epidemic,  taking  cold  is  its  most  usual  cause." 
A  much  more  serious  complication  than  bronchitis  is  the  form  of  pneu- 
monia already  alluded  to  as  liable  to  occur  in  the  course  of  typhus.  This 
may  often  occur  so  insidiously  that  it  may  be  considerably  advanced 
before  its  presence  is  even  suspected ;  hence  the  necessity  for  examining 
carefully  the  lungs  of  every  patient  with  this  disease  who  comes  under 
our  care.  Generally,  however,  it  makes  itself  known  by  giving  rise  to 
rapid  breathing  and  great  lividity  of  the  surface,  but,  as  has  already  been 
said,  both  of  these  symptoms  may  exist  in  cases  in  which  there  is  no 
chest  complication.  This  pneumonia,  if  it  does  not  immediately  prove 
fatal,  may,  by  becoming  chronic,  retard  the  convalescence.  It  occasion- 
ally is  followed  by  gangrene,  and  sometimes  by  phthisis,  which  may  then 
run  a  very  rapid  course.  Phthisis  is,  however,  a  much  less  frequent 
sequela  of  typhus  than  of  typhoid  fever.  Pleurisy  may  also  complicate 
typhus  fever,  but  it  is  much  more  rarely  met  with  than  pneumonia. 

Perhaps  next  in  frequency  to  pneumonia  and  bronchitis  are  diseases 
of  the  kidneys.  These  are  very  serious  complications,  whether  they 
antedate  the  fever  or  have  occurred  in  its  course.  Careful  examination 
of  the  urine  will  generally  lead  to  the  discovery  of  a  small  amount  of 
albuminuria  in  bad  cases,  but  this  is  fortunately,  in  the  majority  of  them, 
only  temporary.  The  urine  should,  however,  always  be  re-examined 
before  the  discharge  of  the  patient,  as  there  is  good  reason  to  believe  that 
many  otherwise  inexplicable  cases  of  chronic  albumiuuria  have  originated 
in  an  attack  of  typhus.  The  presence  of  albumen  and  of  casts  in  the 
urine  of  a  patient  apparently  convalescent  from  this  disease  should  there- 
fore make  us  careful  in  our  prognosis  as  to  his  future  health.  The  occur- 
rence of  diarrhoea  may  also  very  seriously  affect  the  patient's  chances  of 
recovery.  Dysentery  has  also  been  observed  in  certain  epidemics  in  Ire- 
land, and  is  not  infrequent  when  the  disease  breaks  out  in  besieged  towns 
or  when  it  occurs  in  summer.  In  grave  cases  or  those  complicated  with 
scurvy  the  blood  may  be  so  broken  down  as  to  escape  readily  from  the 
vessels.  Under  these  circumstances,  in  addition  to  the  purpura  spots 
beneath  the  skin,  we  may  have  epistaxis,  haemoptysis,  hsematemesis,  intes- 
tinal hemorrhage,  or  hemorrhage  from  any  other  part.  Erysipelas,  too, 
may  be  a  troublesome  complication,  for  not  only  does  it  exhaust  the 
strength,  but,  when  it  invades  the  mucous  membrane  of  the  larynx,  as 
it  sometimes  does,  it  may  prove  rapidly  fatal  by  producing  oedema  of  the 
glottis.  Degeneration  of  the  muscular  structure  of  the  heart  may  also 
take  place.  This  gives  rise  to  a  slow  and  feeble  pulse  and  to  a  disposition 
to  syncope.  Bed-sores  are  not  so  frequent  as  in  typhoid  fever.  They 


356  TYPHUS  FEVER. 

do,  however,  sometimes  occur,  as  does  also  gangrene  of  the  toes  and  of 
other  parts  not  subjected  to  pressure. 

Less  common  complications  are  jaundice,  pen-  and  endo-carditis,  men- 
incitis,  local  and  general  paralyses,  cancrum  oris,  a  diffuse  cellular 
inflammation  ending  in  purulent  infiltration,  and  inflammatory  swell- 
ings of  the  glands,  or  buboes.  The  salivary  glands — and  especially  the 
parotid  gland — are  very  apt  to  be  affected  by  this  inflammatory  swelling. 
This  occurs  rapidly,  is  very  tender,  and  in  most  cases  soon  runs  on  to 
suppuration,  although  it  occasionally  in  children  spontaneously  subsides. 
It  may  occur  at  any  time  during  the  course  of  the  fever,  or  not  until 
convalescence,  and  sometimes  affects  the  glands  of  both  sides  o£  the  face. 
These  buboes  form  a  connecting  link  between  typhus  fever  and  the 
Oriental  plague,  and  Murchison  says  that  the  distinguished  Egyptian 
physician  Clot  Bey,  on  seeing  some  cases  of  the  former  disease  compli- 
cated with  parotid  swellings,  declared  that  in  Egypt  they  would  be 
regarded  as  examples  of  the  latter. 

Many  of  the  above-named  complications  may  occur  also  as  sequela?, 
and  in  addition  to  these  we  may  have  pyaemia,  giving  rise  to  purulent 
collections  in  the  joints  and  phlegmasia  alba  dolens.  The  last  named 
is  not  in  itself  serious.  Its  chief  danger  is  from  the  breaking  down 
of  the  clot  and  the  subsequent  occurrence  of  embolism. 

Menstruation  is  said  not  to  be  uncommon  in  the  early  stages  of  typhus 
fever,  and  may  be  so  profuse  as  to  greatly  increase  the  prostration  or  even 
to  cause  death.  According  to  Murchisou,  miscarriage  does  not  inevitably 
occur  when  pregnant  women  are  attacked  with  the  disease,  and  if  it  does 
occur  it  is  not  necessarily  fatal  to  either  mother  or  child. 

POST-MORTEM  APPEARANCES. — Emaciation  when  death  has  occurred 
early  in  the  course  of  the  disease,  and  is  due  solely  to  the  violence  of  the 
fever,  is  usually  not  well  marked,  but  in  those  cases  which  have  been 
protracted  through  the  iutercurrence  of  complications  it  may  sometimes 
reach  an  extreme  degree.  Bed-sores,  except  under  the  circumstances  just 
mentioned,  are  also  rare.  Iligor  mortis  is  generally  not  well  developed, 
and  is  of  short  duration.  lu  a  few  cases  it  would  seem,  however,  to 
have  been  well  marked.  The  typhus  maculae  are  persistent  after  death, 
and  so  are  any  purpura  spots  and  vibices  which  may  have  been  present 
during  life,  but  the  subcuticular  mottling  usually  disappears.  The  skin 
of  the  dependent  portions  of  the  body  is  discolored  by  the  settling  of 
blood  in  it,  and  putrefactive  changes  are  apt  to  set  in  rapidly. 

The  only  constant  lesion  observed  is  a  profound  alteration  of  the  blood, 
which  is  darker  in  color  and  abnormally  fluid.  If  clots  are  found  at 
all;  they  are  large,  soft,  and  friable.  The  fibrin  is  diminished  in  amount. 
In  the  early  part  of  the  disease  the  red  blood-corpuscles  are  said  to  be 
slightly  increased  in  number,  but  later  they  are  diminished,  and  under 
the  microscope  are  observed  to  be  crenated  and  not  to  form  themselves 
readily  into  rouleaux.  The  white  corpuscles  are  increased  in  number. 
.No  accurate  chemical  examination  of  the  blood  appears  to  have  been 
made.  Many  of  the  post-mortem  appearances  which  have  been  described 
as  characteristics  of  typhus  fever  are  really  the  consequence  of  this 
abnormal  condition  of  the  blood. 

The  respiratory  organs  generally  present  evidences  of  disease;    the 

nons  of  laryngitis,  bronchitis,  pneumonia,  hypostatic  congestion  of  the 


POST-MORTEM  APPEARANCES.  357 

lungs,  and  pleurisy  have  all  been  observed  after  death  from  typhus  fever. 
Usually,  the  traces  of  previous  inflammation  of  the  larynx  are  but  slight; 
in  a  few  cases,  however,  ulceratiou  has  been  found,  but  the  ulcers  are 
stated  to  be  always  minute  and  superficial.  Ulcers  are  also  occasionally 
found  in  the  bronchi,  and  frequently  indicate  by  their  appearance  the  pre- 
existence  of  a  much  higher  grade  of  inflammation.  The  bronchial  mucous 
membrane  is,  however,  ofteuer  merely  reddened  and  softened  and  covered 
with  a  tenacious  frothy  secretion.  True  pneumonia  is  of  infrequent 
occurrence  as  compared  with  that  of  hypostatic  congestiv»n  of  the  lungs, 
but  it  nevertheless  does  occur,  and  may  be  of  either  the  catarrahal  or 
croupous  variety.  When  pleurisy  exists,  it  is  usually  accompanied, 
according  to  Murchison,  by  purulent  effusion  into  the  pleura]  cavity. 
On  'the  other  hand,  Lebert  says  the  variety  of  inflammation  of  the  pleura 
oftenest  met  with  is  the  plastic.  The  intestines  present  no  constant  lesion. 
Gerhard  says  that  in  fifty  examinations  there  was  but  in  one  case,  and 
that  doubtful  in  diagnosis,  the  slightest  deviation  from  the  natural  appear- 
ance of  the  glands  of  Peyer.  In  a  few  cases  the  Peyer' s  patches  have  been 
found  more  prominent  than  usual,  but  not  more  so  than  they  are  in  measles 
and  in  some  other  diseases.  Lebert  alone  of  recent  authors  makes  a  con- 
trary statement.  In  an  epidemic  at  Breslau,  he  says,  the  solitary  glands, 
as  well  as  the  patches  of  Peyer,  were  the  seat  of  small,  isolated,  and  super- 
ficial ulcers,  which  were  usually  situated  in  the  vicinity  of  the  ileo-csecal 
valve.  The  mesenteric  glands  are  generally  unaffected,  but  in  the  Breslau 
epidemic  just  referred  to  they  were  not  infrequently  found  moderately 
swollen.  In  cases  in  which  dysentery  has  occurred  as  a  complication  the 
characteristic  appearances  of  the  disease  will  of  course  be  observed,  as 
well  as  those  of  typhus  fever.  The  spleen  is  generally  softened  and 
slightly  enlarged.  The  enlargement  is  not,  however,  always  present, 
as  Gerhard  found  it  in  one  only  out  of  every  five  or  six  of  the  cases 
which  he  examined.  Extravasations  of  blood  into  its  structure  are  occa- 
sionally met  with.  The  liver  is  usually  congested,  somewhat  enlarged,  and 
frequently  under  the  microscope  presents  the  appearances  of  commencing 
fatty  degeneration.  The  kidneys  often  present  unmistakable  signs  of 
renal  disease  in  the  swollen  granular  and  more  or  less  fatty  condition  of 
their  gland-cells  according  to  the  duration  of  the  disease.  The  muscles 
are  darker  in  color  than  in  health.  Under  the  microscope  they  are  found 
to  have  undergone  the  peculiar  granular  or  waxy  degeneration  described 
by  Zenker,  and  which  have  been  fully  referred  to  in  the  article  on  typhoid 
fever.  Extravasations  of  blood  are  occasionally  found  in  them,  which  may 
soften  and  form  pseudo-abscesses. 

Other  post-mortem  appearances  which  are  met  with  less  frequently 
than  those  above  detailed  are  inflammation,  and  even  ulceration,  of  the 
mucous  membrane,  of  the  bladder,  inflammation  of  the  salivary  gland, 
peritonitis,  and  congestion  of  the  pancreas  and  of  the  stomach. 

The  muscular  tissue  of  the  heart  is  generally  softened  and  easily  torn. 
It  is  not,  however,  as  stated  by  some  authors,  invariably  so,  for  in  several 
cases  in  which  it  was  examined  by  Da  Costa  it  had  undergone  this  change 
in  one  case  only,  in  which  there  was  no  reason  to  suspect  previous  disease 
of  the  heart.  The  alteration  is  similar  in  kind  to  that  which  takes  place 
in  the  voluntary  muscles.  An  effusion  of  serum,  which  may  be  of  a  deep- 
red  color  from  the  trausudatiun  of  the  coloring  matter  of  the  blood,  is 


358 


TYPHUS  FEVER. 


sometimes  found  in  the  periairdial  sac,  as  are  ecchymotic  patches  upon 
the  surface  of  the  heart.  The  endocardium  may  be  stained  from  the 
imbibition  of  blood.  On  the'  other  hand,  endo-  and  pericarditis  are 

excessively  rare.  . 

Notwithstanding  the  severity  of  the  cerebral  symptoms  in  typhus 
fever,  there  are  few  or  no  important  changes  found  in  the  brain  or  its 
membranes  after  death.  The  sinuses  are  occasionally  filled  with  dark 
fluid  blood,  and'  the  appearances  of  congestion  of  _the  brain  are  some- 
times present,  In  other  cases  there  may  be  an  increased  amount  of 
serum  beneath  the  arachnoid  and  into  the  lateral  ventricles,  but  not  more 
than  is  often  seen  after  death  from  other  causes.  Very  rarely  a  slight 
film  of  hemorrhage  has  been  found  in  the  cavity  of  the  arachnoid,  ^and 
sometimes  also  the  evidences  of  non-inflammatory  softening  of  the  brain. 
Actual  inflammation  of  the  meninges  has  only  been  detected  in  a  very 
few  cases.  There  may  also  be  congestion  of  the  spinal  membranes, 
increase  of  the  spinal  fluid,  and  softening  of  the  cord  itself.  The  ganglia 
of  the  sympathetic  system  appear  to  undergo  a  form  of  granular  degen- 
eration. 

DIAGNOSIS. — The  diseases  which  most  closely  resemble  typhus  fever 
are  typhoid  fever,  measles,  meningitis,  and  typhoid  pneumonia, 

The  circumstances  under  which  typhoid  and  typhus  fever  occur  are 
different.  Typhoid  is  never  generated  by  overcrowding,  and  if  conta- 
gious at  all  is  much  less  so  than  typhus.  Prostration  occurs  much  earlier 
and  is  usually  much  more  marked  in  the  latter.  The  eruption  in  the 
former  does  not  appear  until  the  eighth  day,  and  comes  out  in  successive 
crops,  and  usually  disappears  under  pressure  as  long  as  it  lasts,  and  there- 
fore may  be  easily  distinguished  from  that  of  the  latter.  The  duration 
of  typhus  is  from  ten  to  twenty  days ;  that  of  typhoid  is  rarely  less  than 
twenty-one.  Nevertheless,  cases  are  occasionally  met  with  in  which  it  is 
impossible  to  arrive  at  a  correct  conclusion  as  to  their  nature  unless  some 
light  is  thrown  upon  it  by  the  existence  of  other  and  more  characteristic 
cases  in  the  same  house  or  neighborhood.  I  have  recently  had  under  my 
care  a  case  which  eventually  proved  to  be  typhoid  fever,  but  which  I  and 
many  others  who  saw  it  at  first  believed  to  be  typhus  in  consequence  of 
the  presence  of  an  abundant  eruption,  which  did  not  disappear  under 
pressure,  and  was  finally  converted  into  petechiae. 

The  eruption  of  typhus  is  sometimes  found  upon  the  face,  especially  in 
children,  and  then  presents  a  considerable  similarity  to  that  of  measles, 
which,  however,  usually  appears  a  little  earlier.  There  is,  moreover, 
rarely  the  same  amount  of  prostration  or  stupor  in  the  latter  disease, 
which  is  also  attended  by  coryza  and  more  bronchial  catarrh  than  is 
often  present  in  the  former.  The  eruptions  in  the  two  diseases  differ. 
In  measles  it^  is  crcsceutic  in  shape,  and  is  more  elevated  than  in  typhus. 
It  is  also  brighter  in  color,  disappears  under  pressure,  except  in  malig- 
nant cases,  ^as  long  as  it  lasts,  and  is  followed  by  free  desquamation  of  the 
cuticle,  which  is  not  often  observed  in  typhus.  The  temperature  may  be 
high  in  the  former,  but  it  usually  falls  upon  the  sixth  day. 

In  meningitis  the  headache  is  much  more  severe,  and  does  not  disap- 
pear upon  the  occurrence  of  delirium.  It  may  be  so  severe  as  to  cause 

ie  patient  ^to  cry  out.  The  senses  are  painfully  acute.  There  are  intol- 
erance of  light  and  sound,  and  some  hypersensitiveness  of  the  surface, 


PEOGNOSJS.  359 

strabismus,  inequality  of  the  pupils  or  some  other  local  paralysis,  and 
retraction  of  the  head.  Nausea  and  vomiting  are  more  common  than  iu 
typhus,  while  the  utter  prostration  of  the  latter  disease  is  wholly  want- 
ing, and  so  is  of  course  the  characteristic  eruption.  The  tache  menin- 
gitique  is  wanting  in  the  latter,  but  too  much  reliance  should  not  be 
placed  upon  either  the  presence  or  absence  of  this  sign.  The  diagnosis 
is  only  likely  to  be  difficult  in  those  cases  of  typhus  in  which  the  delir- 
ium is  active.  In  that  form  of  typhus  in  which  the  symptoms  simulate 
those  of  delirium  tremens  some  difficulty  may  also  be  experienced  in 
making  a  diagnosis,  especially  if  the  patient  be  a  drunkard.  In  delirium 
tremens  it  will  be  remembered,  however,  that  there  is  little  or  no  eleva- 
tion of  temperature,  that  the  skin  is  bathed  in  perspiration,  the  tongue 
moist,  and  the  characteristic  eruption  absent.  Typhoid  pneumonia  can 
be  distinguished  from  pneumonia  complicating  typhus  fever  by  the 
presence  of  the  eruption  in  the  latter. 

Other  diseases  which  have  occasionally  been  mistaken  for  typhus  fever 
are  remittent  fever,  Bright's  disease,  giving  rise  to  uremia  and  purpura. 
It  does  not  seem  likely  that  even  the  severest  forms  of  malarial  fever 
should  ever  present  such  a  resemblance  to  typhus  fever  as  to  make  the 
differential  diagnosis  a  matter  of  difficulty ;  but  it  would  appear  from 
the  history  of  the  latter  disease  given  by  Murchison  that  such  a  mistake 
has  occurred  in  some  of  the  Spanish  American  countries.  The  enlarge- 
ment of  the  spleen  and  liver  is  much  less  marked  than  in  remit- 
tent fever,  and  the  remissions  of  temperature  are  much  less  decided. 
Uraemia  may  at  times  present  a  good  deal  of  resemblance  to  the  condi- 
tion often  seen  in  typhus  fever  after  the  supervention  of  coma  or  stupor, 
but  the  history  of  the  case,  the  absence  of  fever  and  of  eruption  in  the 
former,  will  generally  enable  us  to  distinguish  between  the  two  condi- 
tions. It  should  be  remembered,  however,  that  Bright's  disease  may 
occur  in  the  course  of  typhus  fever.  Purpura  may  generally  be  recog- 
nized by  the  absence  of  fever  and  by  the  occurrence  of  hemorrhages  from 
the  nose,  gums,  and  bowels. 

PROGNOSIS. — The  age,  habits  of  life,  and  previous  condition  of  health, 
as  well  as  the  character  of  the  prevailing  epidemic,  must  all  be  fully 
considered  before  making  a  prognosis  in  any  special  case.  The  -disease 
usually  runs  a  much  milder  course  in  children  and  young  people  than  in 
adults  past  thirty  years  of  age.  After  this  age  the  mortality  progres- 
sively increases,  and  in  advanced  life  it  becomes  very  high,  being  often 
as  much  as  50  per  cent,  or  over.  Sex  does  not  of  itself  exercise  much 
influence  upon  the  course  of  typhus  fever,  for,  although  a  few  more  men 
than  women  die  of  it,  this  appears  to  be  attributable  to  the  greater  preva- 
lence of  drinking  among  the  former.  Previous  intemperance  acts  unfa- 
vorably by  producing  a  degeneration  of  the  tissues  of  the  body,  thus 
rendering  the  patient  less  able  to  withstand  the  effects  of  the  disease. 
Drunkards  have  therefore  always  furnished  a  large  proportion  of  the 
fatal  cases.  The  mortality  among  patients  who  are  unfortunate  enough 
to  take  typhus  fever  as  they  are  convalescing  from  other  diseases  is 
usually  also  very  great.  This  has  often  been  observed  in  general  hospi- 
tals in  which  cases  of  fever  as  well  as  those  of  other  forms  of  disease 
are  admitted.  Fat,  lymphatic,  or  muscular  people  more  frequently  die  of 
it  than  those  of  a  different  conformation.  Gerhard  found  it  especially 


360  TYPHUS  FEVER. 

fatal  among  negroes  in  the  epidemic  of  1836,  and  Buchanan  seems  to 
have  had  a  similar  experience  at  the  London  Fever  Hospital.  It  is  a 
fact  noticed  by  English  writers  that  people  of  the  better  class,  although 
seldom  attacked  by  typhus,  often  suffer  severely  from  it.  The  mortality 
is  always  high  among  those  patients  Avho  previously  to  contracting  the 
disease  have  been  for  some  time  deprived  of  sufficient  food,  or  have  beeu 
overworked,  or  who  have  been  the  subjects  of  mental  anxiety,  worry,  or 
any  other  depressing  emotion.  It  is  high  also  among  those  who  in  the 
beginning  of  the  disease  have  exhausted  their  strength  in  the  vain  effort 
to  resist  the  disposition  to  go  to  bed.  The  chances  of  recovery  are,  on 
the  other  hand,  very  much  improved  by  the  removal  of  patients  from 
crowded,  ill- ventilated  houses  to  the  wards  of  a  spacious,  airy  hos- 
pital. 

Unfavorable  symptoms  arc  a  profuse  dark-colored  eruption  associated 
with  purpura  spots  and  vibices,  general  lividity  of  the  surface,  great 
injection  of  the  pupils,  and  a  dusky  hue  of  the  countenance ;  extreme 
prostration  ;  an  excessively  frequent  and  feeble  pulse,  especially  if  it  is 
at  the  same  time  irregular  or  intermittent ;  absence  of  the  cardiac  impulse 
and  of  the  systolic  sound ;  hurried  and  spasmodic  or  abnormally  slow 
respiration  ;  great  dryness  and  retraction  of  the  tongue  ;  excessive  promi- 
nence of  the  nervous  symptoms,  such  as  headache,  delirium,  whether  active 
or  muttering ;  unequal  or  pin-hole  contraction  of  the  pupils  ;  strabismus 
or  other  local  paralysis ;  sleeplessness ;  muscular  tremblings/;  subsultus 
tendinum ;  carphology ;  protracted  hiccough,  retention  of  the  urine ; 
relaxation  of  the  sphincters  of  the  bladder  and  rectum  ;  coma  and  espe- 
cially coma  vigil,  and  convulsions;  continued  high  temperature,  rising 
instead  of  falling  after  the  tenth  day,  especially  if  it  is  associated  with 
coldness  of  the  extremities  and  of  the  breath ;  a  profuse  perspiration 
without  a  general  improvement  in  the  symptoms;  diminution  in  the 
quantity  of  the  urine,  or  the  presence  in  it"  of  albumen,  blood,  or  casts ; 
vomiting ;  and  diarrhoea.  Hope,  however,  should  never  be  abandoned 
even  in  the  most  unfavorable  cases,  as  recovery  has  sometimes  occurred 
when  the  patient  seemed  almost  in  articulo  mortis.  Convulsions  are  said 
to  be  in  variably  followed  by  death,  and  Graves  regarded  the  presence  of 
the  pin-hole  contraction  of  the  pupils  as  of  very  grave  import. 

Favorable  symptoms  are— reduction  of  the  "frequency  of  the  pulse,  a 
fall  of  temperature,  a  diminution  of  the  stupor  or  a  resumption  of  cou- 
sciousneas,  and  a  return  of  appetite  and  of  moisture  to  the  tongue. 
When  the  patient  begins  to  improve  he  will  often  without  assistance  turn 
upon  his  side  after  having  lain  for  a  long  time  upon  his  back,  and  this 
change  of  position  is  sometimes  the  first  indication  of  the  approach  of 
convalescence. 

The  mortality  varies  of  course  in  different  epidemics.    The  cases  which 
have  come  under  my  own  care  being  too  few  in  number  to  draw  deduc- 
tions from  on  this  point,  I  must  rely  upon  the  experience  of  those  whose 
>f  observation  has  been  more  extended  than  my  own.     According 
tfurchison,  out  of  18,268  cases  of  typhus  fever  admitted   into  the 
*ever  Hospital  during  twenty-three  years,  3457  proved  fatal, 
king  a  mortality  of  18.92  per  cent,,  or  1  in  5.28.     Deducting  686 
es  fetal  within  forty-eight  hours,  the  mortality  falls  to  15.76  per  cent, 
b.<34.     Included  among  the  fatal  cases  is  a  large  number  in  which 


TREATMENT.  361 

the  disease  had  run  its  course  to  a  favorable  termination,  and  in  which 
death  was  really  due  to  sequelae,  such  as  pneumonia,  erysipelas,  etc. 
Moreover,  the  death-rate  in  the  hospital  is  greater  than  in  the  commu- 
nity, because  children,  who  rarely  die  of  typhus  fever,  are  seldom  brought 
to  it;  while,  on  the  other  hand,  it  receives  a  large  number  of  the  infirm 
and  aged  inmates  of  the  metropolitan  workhouses.  Making  allowance 
for  these  sources  of  fallacy,  Murchison  believes  that  the  actual  mortality 
of  typhus  is  not  more  than  10  per  cent.  In  Gerhard's  cases  the  propor- 
tion of  deaths  amongst  the  black  was  much  greater  than  amongst  the 
white  men ;  thus,  of  the  whites  1  died  in  4f ,  of  the  blacks  1  in 
2^|.  Amongst  the  women  the  reverse  was  true;  thus,  1  white  woman 
died  in  4|,  but  only  1  colored  woman  in  6  J,  nearly.  Da  Costa  lost  6 
out  of  39  cases.  In  one  of  the  fatal  cases  the  diagnosis  was  doubtful ; 
in  another  there  was  a  great  deal  of  previous  disease ;  in  two  others  death 
was  due  to  complications — so  that  there  were  but  two  in  which  the  fatal 
result  could  fairly  be  attributed  to  the  disease  itself. 

TREATMENT. — Typhus  fever  is  an  eminently  preventible  disease.  It 
is  therefore  proper  that  the  description  of  its  curative  treatment  should  be 
preceded  by  a  few  words  in  regard  to  its  prophylaxis. 

It  is  still  an  unsettled  question  whether  or  not  typhus  fever  ever  occurs 
de  novo,  and  although  the  recent  discovery  by  Klcbs  and  others  of  bacil- 
lus peculiar  to  typhoid  fever  (the  bacillus  typhosus),  and  of  special 
bacilli  in  other  analogous  diseases,  renders  it  highly  probable  that  typhus 
fever  has  also  its  own  bacillus,  and  that  therefore  it  is  not  likely  to  arise 
except  as  the  result  of  infection,  it  must  be  admitted  that  it  has  often  pre- 
vailed in  localities  into  which  it  has  not  been  possible  to  trace  its 
importation.  Under  these  circumstances  it  will  be  well  to  refer  to  those 
conditions  which  are  asserted  by  some  authors  to  favor  its  spontaneous 
generation,  especially  as  these  same  conditions  are  certainly  known  to 
favor  its  propagation.  It  will  not  be  necessary  to  do  this  at  any  great 
length,  as  they  have  all  been  fully  described  in  discussing  the  etiology  of 
the  disease.  The  most  important  of  them  is  the  overcrowding  of  human 
beings,  especially  when  combined  with  deficient  ventilation,  destitution, 
and  want  of  personal  cleanliness.  The  knowledge  of  the  laws  of  hygiene 
is  now  so  universally  diffused  that  this  combination  of  conditions  never 
occurs  at  the  present  time  to  anything  like  the  degree  it  often  existed  in 
the  eighteenth  century,  and  consequently  epidemics  of  this  disease  are 
not  only  less  frequent,  but  are  also  much  milder  in  character,  than  for- 
merly. Much  work,  however,  still  remains  for  sanitarians  in  the  im- 
provement of  the  homes  of  the  poor,  which  even  in  this  country  are  too 
often  overcrowded  and  ill-ventilated. 

The  extension  of  the  disease  in  a  community  will  almost  always  be 
prevented  by  the  prompt  isolation  of  the  first  few  cases.  This  can  often 
be  thoroughly  done,  if  the  patient  is  in  easy  circumstances,  by  placing 
him  in  an  upper  room,  which  should  be  stripped  of  its  carpets,  curtains, 
and  other  unnecessary  furniture;  by  cutting  off  all  communication 
between  him  and  his  attendants  and  the  rest  of  the  household ;  and 
by  the  free  use  of  disinfectants.  The  room  should  be  airy,  and  to 
ensure  good  ventilation  a  window  should  be  left  partly  open.  This 
may  be  done  during  the  febrile  stage,  even  in  winter,  without  the  risk 
of  any  injury  to  the  patient.  Among  the  poorer  classes,  however,  isola- 


362  TYPHUS  FEVER. 

tion  can  rarely  be  effectually  carried  out,  and  it  is  therefore  much  better 
to  remove  the  patient  to  a  hospital.  Upon  the  admission  of  such  a  patient 
to  an  institution  of  this  character  his  clothes  should  be  at  once  disinfected. 
This  may  be  done  by  washing  the  underclothing  in  a  disinfecting  fluid, 
and  then  exposing  them  to  a  free  current  of  air,  and  by  subjecting  the 
outer  clothing  to  a  very  high  temperature  in  an  oven  or  to  the  fumes  of 
burning  sulphur.  Murchison  believes  that  a  neglect  of  this  precaution 
has  often  been  the  cause  of  the  extension  of  the  disease  to  other  inmates 
of  the  hospital,  especially  when  the  patient  resumes  during  his  convales- 
cence the  same  clothing  he  wore  upon  admission.  If  the  hospital  is  a 
general  one,  he  should  be  placed,  whenever  practicable,  in  a  well-venti- 
lated ward  by  himself  or  with  other  patients  suffering  from  the  same 
disease.  As  this  is  not  always  possible,  the  number  of  the  other  occu- 
pants of  the  ward  should  be  reduced  and  their  beds  placed  as  far  away 
as  possible  from  his.  As  the  infectiousness  of  typhus  fever  is  very  much 
lessened  by  free  ventilation,  this  precaution  is  often  alone  sufficient  to 
prevent  its  extension  to  them.  It  is  also  well,  however,  to  supplement  it 
by  the  use  of  disinfectants.  The  diffusion  of  a  solution  of  carbolic  acid 
in  the  atmosphere  of  the  ward  by  means  of  the  steam  atomizer  has  not 
only  rendered  the  odor  emanating  from  the  patient  less  perceptible,  but 
has  also  appeared  to  diminish  decidedly  the  risk  of  infection.  As  a  still 
further  precaution  the  patient  may  be  sponged  with  a  weak  solution  of 
carbolic  acid  or  some  other  disinfectant.  His  nurses  should  be  selected, 
whenever  practicable,  from  among  those  who  have  had  the  disease  them- 
selves. They  should  never  sleep  in  the  sick  room,  lounge  about  the 
patient's  bed,  or  inhale  his  breath.  They  should  be  allowed  a  certain 
amount  of  time  every  day  for  rest  and  recreation  in  the  fresh  air,  and 
should  have  a  full  supply  of  nourishing  food.  On  the  other  hand,  they 
should  be  warned  against  the  danger  of  over-stimulation,  which  is  often 
resorted  to  in  the  hope  of  warding  off  the  disease,  and  should  be  relieved 
as  far  as  possible  from  attendance  upon  other  patients.  It  may  be  well 
here  to  say  that  the  nursing  of  a  case  of  typhus  fever  should  never  be 
undertaken  by  the  relatives  or  friends  of  the  patient,  except  as  a  matter 
of  necessity.  Not  only  do  the  anxiety  and  distress  they  naturally  feel 
unnerve  them  and  render  them  unfit  to  carry  out  the  directions  of  the 
physician,  but  they  can  rarely  execute  the  many  offices  required  in  the 
sick  room  with  half  the  skill  of  a  trained  nurse  or  with  so  little  annoy- 
ance to  the  patient. 

Before  the  patient  is  allowed  to  leave  his  ward  he  should  have  a  warm 

bath.     If  the  disease  has  occurred  in  a  private  house,  the  room  which  he 

has  occupied  should  be  thoroughly  disinfected.     This  is  best  done  by 

rep  astering,  repapering,  and  repainting  it.     In  many  cases,  however,  it 

be  sufficient  to  fumigate  it  with  burning  sulphur,  and  then  to  air  it 

several  days.     The  bed  and  bedding  should  also  be  disinfected,  and, 

whore  this  cannot  be  thoroughly  done,  the  latter  had  better  be  destroyed. 

f  primary  importance  in  the  treatment  of  typhus  fever  is  the  regula- 

of  the  diet.     Although  there  are  no  ulcers  in  the  bowels  in  this  as 

fever,  and    although,  consequently,  there    is  not  the  same 

necessity  in  this  as  in  the  latter  disease  to  restrict  the  patient 

1  articles  of  food,  experience  has  shown  that  such  articles  are 

much   more  readily  digested   and   assimilated   than   solids.      The   diet 


TREATMENT.  363 

should  consist,  therefore,  of  milk,  beef-tea,  and  chicken  or  mutton  broth. 
Of  all  of  these,  milk  is  incomparably  the  best,  and  it  should  form,  unless 
the  patient  manifest  an  unconquerable. repugnance  to  its  use,  a  large  part 
of  the  nourishment  in  every  case.  Farinaceous  articles  of  food  are  gen- 
erally not  well  borne  in  this  fever,  because  the  diminution  in  the  secretion 
of  the  salivary  glands  which  almost  always  exists  prevents  their  proper 
digestion.  After  the  third  or  fourth  day  nourishment  should  be  given  in 
small  quantities  at  short  intervals,  as  every  two  hours,  every  hour,  or 
even  every  half  hour  when  the  prostration  is  extreme.  It  should  be  the 
aim  of  the  physician  to  give  an  adult  at  least  two  quarts  of  milk  or  their 
equivalent  daily. 

It  is  sometimes  necessary  to  put  a  delirious  patient  under  some  restraint 
to  prevent  him  from  leaving  his  bed  or  doing  some  other  act  of  violence. 
Frequently  a  judicious  nurse  will  be  able  to  accomplish  this  without  the 
use  of  an  undue  amount  of  force,  but  at  other  times  it  will  be  necessary 
to  have  recourse  to  mechanical  means  of  restraint.  Usually,  all  that  is 
necessary  is  to  pass  a  folded  sheet  across  the  patient's  chest,  the  ends  of 
which  are  fastened  to  the  sides  of  his  bed. 

It  is  now  a  universally  accepted  axiom  among  physicians  that  typhus 
fever  is  a  self-limited  disease,  and  that  any  attempts  to  cut  it  short  is 
worse  than  useless.  Not  only  do  remedies  which  are  employed  for  this 
purpose  often  produce  alarming  prostration,  but  there  can  be  no  doubt 
that  they  have  in  some  cases  been  the  cause  of  a  fatal  termination,  which 
under  another  plan  of  treatment  would  have  been  averted.  During  the 
last  century  it  was  not  uncommon  to  bleed,  and  to  bleed  largely,  in  the 
beginning  of  an  attack  of  typhus  fever,  but  even  then  there  were  physi- 
cians— as,  for  instance,  O'Connell,  Rogers,1  Pringle,2  and  Rutty 3 — who 
raised  a  warning  voice  against  the  practice.  Sir  John  Pringle  goes  so 
far  as  to  say  that  "  many  have  recovered  without  bleeding,  but  few  who 
have  lost  much  blood."  A  very  similar  opinion  was  also  expressed  by 
Baron  Larrey  in  the  early  part  of  this  century.  Indeed,  it  is  very  evi- 
dent that  the  same  difference  of  opinion  existed  as  to  the  employment  of 
venesection  in  the  treatment  of  acute  affections  when  these  authors  wrote 
as  prevailed  in  England  and  this  country  until  within  the  last  thirty 
years,  and  that  the  disastrous  results  which  occasionally  follow  the 
abstraction  of  large  amounts  of  blood  from  patients  affected  with  fevers 
and  inflammations  were  as  fully  recognized  then  as  now  by  many  physi- 
cians. This  would  seem  effectually  to  dispose  of  the  change-of-type-in- 
disease  theory  which  was  generally  accepted  in  the  first  half  of  this  cen- 
tury as  sufficient  to  explain  the  fact  which  could  no  longer  be  overlooked 
that  this  class  of  patients  did  much  better  under  a  supporting  than  a 
depleting  plan  of  treatment.  Purgatives  were  also  at  one  time  freely 
given  for  the  purpose  of  arresting  the  disease,  but  the  results  obtained 
from  their  use  were  scarcely  less  unfavorable,  and  they  are  now  never 
employed  with  this  view.  The  use  of  quinia  in  large  doses  has  also 
been  advocated  for  the  same  purpose,  but  experience,  while  it  has  shown 
that  it  is  a  valuable  remedy,  has  demonstrated  also  that  it  does  not  possess 

1  An  Essay  on  Epidemic  Diseases,  p.  60,  by  Joseph  Rogers,  M.  D.,  Dublin,  1734. 
3  Loc..  cit. 

8  A  Chronological  History  of  the  Weather  and  Seasons,  and  the  Prevailing  Diseases,  in  Dub- 
lin during  the  Space  of  Forty  Years,  by  John  Rutty,  M.  D.,  London,  1770. 


364  TYPHUS  FEVER. 

this  power.  Exactly  the  same  thing  may  be  said  of  the  cold-water  treat- 
ment of  typhus  fever.  There  is  no  evidence  that  it  has  ever  shortened 
the  duration  of  the  disease. 

If  the  physician  is  called  to  a  case  of  typhus  fever  during  the  chill, 
before  reaction  has  taken  place,  he  will  of  course  have  recourse  to  diffusi- 
ble stimulants  and  external  warmth  to  aid  in  the  establishment  of  this 
process.     More  frequently  he  is  not  sent  for  until  after  the  chill  has  been 
succeeded  by  fever.     His  treatment  will  then,  of  course,  vary  with  the 
condition  of  the  patient.     If  his  stomach  is  loaded  with  food,  an  emetic 
should  be  administered  to  him.   If  the  bowels  are  constipated,  a  mild  cathar- 
tic will  often  be  of  service,  but  after  the  bowels  have  been  once  well  moved 
it  is  generally  unnecessary  to  disturb  them  further.     During  the  first  day 
or  two,  while  the  fever  is  still  moderate  in  degree,  and  during  the  uncer- 
tainty which  then  usually  exists  as  to  the  diagnosis,  it  will  be  sufficient  to 
prescribe  the  neutral  mixture  or  the  spirit  of  Miudererus  in  tablespoonful 
doses  every  two  or  three  hours.     Upon  the  third  day  more  active  reme- 
dies will  generally  be  required  to  reduce  the  temperature.     This  is  best 
done  by  the  cold-water  treatment  in  some  form  or  other,  or  by  the  inter- 
nal administration  of  antipyretic  doses  of  quiuia.     The  manner  in  which 
the  cold  water  is  to  be  used  and  the  cases  to  which  it  is  applicable  must 
be  left  in  a  great  measure  to  the  judgment  of  the  physician.      In  the 
form  of  the  cold  affusion,  it  is  now  rarely  resorted  to,  although  Currie l 
obtained  most  excellent  results  with  it.     It   is   calculated,  however,  to 
alarm  a  timid  patient,  and  it  is  probably  owing  largely  to  this  fact  that 
it  has  fallen  into  disuse.     The  cold  bath,  packing  in  a  cold  wet  sheet, 
and  sponging  with  cold  water  are  the  more  usual  means  of  employing 
cold  in  the  treatment  of  typhus  fever  at  the  present  day.     The  .cold  bath 
is  much  used^  in  Germany  in  the  treatment  of  different  forms  of  fever, 
and  even  of  inflammation.     It  is  also  resorted  to  in  this  country,  but  it 
has  never  attained  the  same  popularity  here  as  abroad.     The  best  way  of 
using  it  is  as  follows  :    The  patient  as  soon  as  his  temperature  rises  above 
r.  should  be  placed  in  a  bath  having  a  temperature  between  80° 
and  !  0°,  and  which,  whenever  practicable,  should  be  brought  to  his  bed- 
side, as  when  he  has  to  be  carried  to  the  bathroom  he  is  sometimes  not 
only  alarmed  and   rendered  very  nervous   by  the   operation,  but   may 
exhaust  himself  in  his  struggles  to  free  himself  from   his    attendants. 
After  his  immersion  cold  wafer   should    be    gradually  added  until  the 
temperature  of  the  bath  is  between  60°  and  70°  F.     The  length  of  time 
he  should  be  allowed  to  remain  in  the  bath  will  of  course  depend  upon 
circumstances.     If  shivering  is  produced   by  it,  he  should   be  at  once 
noved  from  it  and  thoroughly  dried  and  put  back  to  bed.     If  no  such 
mptoms  are  observed,  he  may  be  allowed  to  remain  in  it  longer.     As  a 
neral  rule,  a  half  hour  is  as  long  as  will  be  necessary  or  safe  for  him  to 
jue  immersed  at  any  one  time.    His  temperature  will  usually  continue 
some  time  after  his  removal  from  the  bath,  but  in  the  course  of 
t  will  be  found  to  have  risen  again  to  103°  or  over,  when  he 
Id .have  another  bath.     In  this  way  it  may  be  necessary  to  repeat  the 
from  eight  to  twelve  times  a  day.     Some  authors  recommend  that  the 
I  be  placed  at  once  in  a  bath  having  a  temperature  of  50°  F., 


TREATMENT.  365 

but  this  method  of  applying  cold  possesses  no  advantage  over  that  above 
described,  and  is,  like  the  cold  affusion,  very  apt  to  excite  alarm  in  the 
patient.  The  cold  bath  is  not,  however,  well  borne  by  all  persons,  and 
alarming  symptoms,  and  even  fatal  collapse,  have  followed  its  use  in  the 
old  and  feeble.  It  is  also  contraindicated  when  the  skin  is  covered  with 
a  profuse  sweat  or  when  the  disease  is  complicated  by  an  internal  inflam- 
mation. When  the  means  of  giving  a  cold  bath  are  not  at  hand,  the 
cold  pack  will  often  be  found  a  very  efficient  substitute  for  it.  Sponging 
with  cold  water,  although  not  so  efficacious  in  reducing  the  temperature, 
has  advantages  over  either  of  these  methods  of  applying  cold.  In  the  first 
place,  it  is  more  agreeable  to  most  patients  and  less  calculated  to  excite 
alarm  in  those  who  are  timid.  Again,  it  may  be  more  frequently 
repeated,  and  may  be  used  in  cases  in  which  the  cold  bath  is  contra- 
indicated.  Occasionally  alcohol  or  vinegar  may  be  added  with  advantage 
to  the  water,  with  the  view  of  increasing  its  refrigerant  effects. 

When  quinia  is  given  for  the  purpose  of  reducing  the  temperature  in 
the  treatment  of  typhus  fever,  it  must  be  used  in  large  doses,  as  much  as 
ten  or  fifteen  grains  repeated  once  or  twice  in  the  course  of  twenty-four 
hours  being  required  for  this  purpose.  When  given  in  these  quantities 
it  has  the  disadvantage  of  producing  deafness  and  occasionally  of  increas- 
ing the  headache.  I  have  therefore  contented  myself  in  the  cases  which 
have  fallen  under  my  own  care  with  giving  it  in  more  moderate  quanti- 
ties, in  combination  with  one  of  the  mineral  acids,  as,  for  instance,  a  couple 
of  grains  of  quinia  in  solution  with  from  eight  to  ten  drops  of  dilute 
muriatic  acid,  repeated  from  four  to  six  times  a  day.  The  mineral  acids 
were  originally  recommended  in  the  treatment  of  typhus  fever  in  the 
belief  that  they  neutralized  the  poison  which  caused  the  fever,  and  which 
was  supposed  to  be  ammonia  or  some  of  its  compounds.  Although  this 
theory  is  now  no  longer  entertained,  there  can  be  no  doubt  that  the 
tendency  in  this  disease  to  the  accumulation  of  ammonia  in  the  blood 
is  prevented  by  their  administration.  Digitalis,  aconite,  or  veratrum 
viride  may  also  be  given  in  appropriate  doses  if  with  a  high  temperature 
there  coexists  great  frequency  of  the  pulse.  The  first-named  remedy  is 
especially  indicated  if  there  is  at  the  same  time  diminution  of  the  secre- 
tion of  urine. 

As  the  disease  progresses  other  symptoms  present  themselves  for  treat- 
ment. One  of  the  most  urgent  of  these  is  the  prostration.  This  not 
only  appears  early,  but  is  often  extreme,  and  if  not  met  by  appropriate 
remedies  will  often  of  itself  be  sufficient  to  cause  the  death  of  the  patient. 
As  soon  as  it  makes  itself  manifest  stimulants  must  be  prescribed. 
These  are,  however,  not  to  be  resorted  to  simply  because  the  patient 
has  typhus  fever.  Many  cases  do  perfectly  well  without  them.  In  the 
young  and  robust  it  is  often  unnecessary  to  have  recourse  to  them. 
On  the  other  hand,  in  the  old,  the  feeble,  and  the  intemperate  they 
should  be  employed  early.  The  rule  laid  down  by  Stokes,  that  they 
should  be  administered  as  soon  as  the  first  sound  of  the  heart  becomes 
indistinct  and  inaudible,  may  be  adopted  for  our  guidance  in  this  respect. 
At  first  they  should  be  given  tentatively.  If  the  delirium,  headache,  and 
other  nervous  symptoms  are  increased  after  their  administration,  it  is  best 
to  withhold  them.  They  should  be  continued,  on  the  other  hand,  when 
under  their  use  the  delirium  ceases  or  grows  milder,  the  other  nervous 


366  TYPHUS  FEVER. 

symptoms  subside,  and  the  patient  falls  into  a  refreshing  sleep.  The 
amount  required  to  prevent  fatal  prostration  will  of  course  vary  in  each 
case.  I  have  rarely  myself  found  it  necessary  to  prescribe  more  than 
half  an  ounce  of  whiskey  or  brandy  every  two  hours,  and  frequently  a 
very  much  smaller  quantity  has  been  found  sufficient.  Cases  are,  how- 
ever, reported  in  which  from  twenty  to  twenty-four  ounces  daily  have 
been  given  with  asserted  advantage. 

Another  symptom  which  often  demands  prompt  relief  is  the  headache. 
When  not  severe,  it  may  be  relieved  by  the  application  of  cold  to  the 
head,  either  in  the  form  of  the  ice-cap  or  by  means  of  cloths  frequently 
wrung  out  of  cold  water,  and  by  the  administration  of  moderate  doses 
of  potassium  bromide ;  but  when  intense  it  requires  more  active  treat- 
ment for  its  removal,  such  as  the  application  of  cups  to  the  back  of  the 
neck  or  of  leeches  to  the  temples.  General  bleeding  will  accomplish  the 
same  result,  but  the  good  which  is  done  by  it  is  often  more  than  counter- 
balanced by  the  prostration  it  induces.  Sleeplessness  is  also  sometimes 
the  cause  of  a  good  deal  of  distress  to  the  patient.  When  it  occurs 
early  in  the  disease  and  is  caused  by  the  headache,  it  will  generally  sub- 
side under  the  use  of  the  remedies  which  are  employed  for  the  relief  of 
the  latter  symptom  ;  but  when  it  comes  on  at  a  later  period,  it  will  often 
require  special  treatment.  There  is  some  doubt  as  to  the  propriety  of 
giving  opium  under  these  circumstances,  but  Murchison,  Gerhard,  and 
others  assert  that  it  may  be  given  not  only  without  injury,  but  with 
positive  advantage  to  the  patient.  Graves  was  in  the  habit  of  combining 
it  with  a  small  quantity  of  tartar  emetic  in  the  condition  in  which  the 
sleeplessness  is  associated  with  active  delirium.  If,  on  the  other  hand, 
the  delirium  is  of  a  low  muttering  character,  it  should  be  given  with  a 
diffusible  stimulant. 

In  this  condition  I  have  often  found  a  pill  containing  a  small  quantity 
each  of  opium  and  camphor,  frequently  repeated,  to  answer  an  admirable 
purpose,  not  only  in  procuring  for  the  patient  the  needed  repose,  but  also 
in  diminishing  the  restlessness,  jactitation,  and  subsultus  tendinum. 
Opium  should,  however,  not  be  used  at  all  or  used  very  carefully  in  cases 
in  which  there  is  congestion  of  the  lungs  or  disease  of  the  kidneys.  The 
existence  of  the  pin-hole  pupil  is  also  a  contraindication  to  its  employ- 
ment. In  young  and  robust  patients,  if  the  insommia  is  attended  by 
active  delirium,  chloral  in  twenty-grain  doses,  repeated  if  necessary,  may 
often  be  given  with  advantage,  but  it  should  never  be  prescribed  in  cases 
in  which  the  action  of  the  heart  is  feeble.  Other  remedies  which  have 
been  recommended  in  the  treatment  of  this  condition  are  belladonna, 
hyoscyamus,  musk,  chloroform,  and  caunabis  indica.  Potassium  bromide 
appears  to  have  no  po\yer  to  relieve  it.  No  special  modification  of  the 
above  treatment  is  needed  when  delirium  occurs  independently  of  sleep- 
lessness aud  headache.  When  the  stupor  is  profound,  eiforts  should  be 
made  to  rouse  the  patient  by  the  use  of  counter-irritants  to  the  shaven 
scalp  or  to  the  nape  of  the  neck.  Murchison  speaks  well  of  the  adminis- 
tration of  strong  coffee  under  these  circumstances.  If  there  is  at  the 
s;im<>  time  suppression  or  diminution  of  urine,  diuretics  should  be  admiii- 
rsteral^  m  the  hope  of  stimulating  the  kidneys  to  increased  secretion. 

ictention  of  the  urine  is  not  an  infrequent  occurrence  in  this  condition, 
and  the  physician  ought  never,  therefore,  to  accept  the  assertions  of  the 


TREATMENT.  367 

nurse  or  friends  of  the  patient  that  the  latter  has  passed  water,  but  should 
satisfy  himself  by  an  examination  in  regard  to  the  condition  of  the 
bladder  at  every  visit.  He  will  often  find  that  the  apparent  passage  of 
urine  is  nothing  more  than  the  dribbling  due  to  an  over-distension  of  this 
organ.  Neglect  of  this  precaution  has  occasionally  been  the  cause  of 
much  subsequent  distress  to  the  patient,  as  cystitis  is  sometimes  set  up  as 
a  consequence  of  it.  In  one  case  which  came  under  my  observation, 
and  in  which  this  precaution  had  been  neglected,  the  patient  suffered  from 
incontinence  of  urine  for  some  time  after  his  recovery  from  the  fever. 
Thirst  is  a  symptom  which  is  always  present  and  complained  of  at  the 
beginning  of  the  fever,  and  usually  bears  some  proportion  to  the  severity 
of  this  process.  Weak  tea,  an  infusion  of  cascarilla-bark,  and  camphor- 
water  have  all  been  recommended  by  different  authors  for  its  relief,  but 
it  is  probable  that  no  one  of  them  possesses  any  superiority  over  water. 
If  the  stomach  is  irritable  and  water  is  not  retained,  small  pieces  of  ice 
should  be  allowed  to  dissolve  in  the  patient's  mouth.  Later,  when  the 
stage  of  stupor  supervenes,  it  is  very  important  to  see  that  the  patient 
obtains  a  full  supply  of  water.  In  this  condition  he  will  not  call  for  it, 
although  it  is  even  more  urgently  required  than  before. 

Vomiting  may  occur  at  any  time  in  the  course  of  typhus  fever.  If  it 
is  observed  at  the  very  beginning  of  an  attack,  an  emetic  will  often  arrest 
it,  but  when  it  supervenes  at  a  later  period,  it  is  generally  of  cerebral 
origin,  and  will  usually  subside  under  the  use  of  the  remedies  already 
referred  to  which  are  prescribed  for  the  relief  of  the  nervous  symptoms. 
In  addition  to  these,  sinapisms  may  be  applied  to  the  epigastrium,  and 
champagne,  when  the  circumstances  of  the  patient  will  permit  it,  should 
be  given  in  the  place  of  whiskey  or  brandy.  When  everything  is  rejected 
by  the  stomach,  recourse  must  be  had  to  nutritious  enemata.  Constipa- 
tion is  to  be  overcome  by  gentle  purgatives,  as  the  use  of  powerful  cathar- 
tics is  very  apt  to  be  followed  by  troublesome  diarrhoea.  If  this  should 
come  on,  it  is  best  treated  by  small  doses  of  opium  in  combination  with 
a  mineral  or  vegetable  astringent.  When  these  fail,  it  may  sometimes  be 
relieved  by  a  prescription  containing  sulphuric  acid  and  morphia,  and  at 
others  by  euemata  of  from  twenty  to  thirty  drops  of  laudanum  in  warm 
water.  When  glandular  swelling  occurs  in  the  parotid  region  or  in  other 
parts  of  the  body,  an  eifort  should  be  made  to  promote  resolution  by 
painting  them  with  tincture  of  iodine.  Blisters  have  also  been  recom- 
mended for  the  same  purpose,  but  they  should  be  used  carefully,  as  in 
low  conditions  of  the  system  they  are  sometimes  followed  by  sloughing 
of  the  integuments.  If  these  remedies  fail,  poultices  should  be  applied. 
As  soon  as  pus  has  formed  it  should  be  evacuated  by  one  or  more  free 
incisions. 

Very  few  attacks  of  typhus  fever  run  their  course  without  the  occur- 
rence of  some  pulmonary  complication.  When  this  is  slight  it  demands 
no  special  modification  of  the  previous  treatment,  and  it  is  sufficient  to 
apply  mustard  poultices  or  stimulating  liniments  to  the  chest.  But  in 
cases  of  greater  gravity,  it  matters  not  whether  the  complication  is  bron- 
chitis, congestion  of  the  lungs,  or  pneumonia,  a  more  active  treatment  is 
required.  Under  these  circumstances  the  ammonium  carbonate  in  five- 
grain  doses,  given  in  mucilage  of  acacia,  frequently  repeated,  or  from 
thirty  minims  to  a  teaspoonful  of  the  aromatic  spirit  of  ammonia  every 


3(J8  TYPHUS  FEVER. 

two  hours,  sufficiently  diluted,  may  be  prescribed  with  great  advantage. 
"When  gangrene  supervenes  the  prognosis  is  almost  hopeless,  but  an  effort 
should  be  made  to  save  the  patient's  life  by  the  administration  of  potas- 
sium chlorate  and  of  an  increased  amount  of  stimulus.  Murchison 
also  speaks  well  of  the  inhalation  of  tar  vapor  and  of  carbolic  acid. 

As  the  other  complications  of  typhus  are  at  least  of  as  common  occur- 
rence in  typhoid  fever,  it  will  avoid  a  good  deal  of  useless  repetition  to 
refer  the  reader  to  the  article  on  the  latter  disease  for  a  description  of  the 
treatment  which  they  render  necessary. 

The  patient  should  be  kept  in  bed  for  some  time  after  the  subsidence 
of  fever.  Although  relapses  are  rare  in  this  disease,  recrudescences  of 
fever  not  infrequently  occur  as  a  consequence  of  undue  exertion  in  the 
early  part  of  convalescence.  Syncope  is  also  not  infrequently  produced 
by  the  patient's  sitting  up  too  soon.  The  diet  should  be  carefully  regu- 
lated until  the  recovery  is  complete.  It  should  at  first  consist  wholly  of 
liquid  or  semi-liquid  articles  of  food,  but  later  meat  in  some  digestible 
form  may  be  allowed.  Stimulants  are  often  as  urgently  demanded  at 
this  time  as  during  the  fever  itself.  They  should  be  given  as  the  strength 
returns  in  gradually  diminishing  quantities.  The  length  of  time  during 
which  it  is  necessary  to  continue  them  will  depend  in  great  measure  upon 
the  previous  habits  of  the  patient.  As  a  general  rule,  their  use  should 
not  be  abandoned  until  he  is  able  to  leave  his  bed,  and  they  may  often  be 
continued  after  this  with  benefit  to  him.  As  convalescence  progresses  it 
will  be  well  to  substitute  ale  or  porter  for  the  brandy  or  whiskey  the 
patient  had  previously  taken.  A  return  to  health  will  also  be  promoted 
by  the  judicious  use  of  tonics,  such  as  iron,  quiuia,  Huxham's  tincture, 
tincture  of  nux  vomica,  the  mineral  acids,  and  even  cod-liver  oil  in  some 


RELAPSING  FEVER. 

BY  WILLIAM  PEPPER,   M.D.,  LL.D. 


SYNONYMS.  —  Febris  recidiva,  vel  recurrens ;  Fievre  a  rechutes ;. 
Fi&vre  recurrente ;  Typhus  icterodes,  vel  recurrens ;  Bilious  Typhoid; 
Fever;  Riickfall's  Typhus;  Tifo  recidivo;  Famine  Fever,  Hunger- 
pest,  Armentyphus,  Hunger-typhus,  Spirillum  Fever. 

DEFINITION. — Relapsing  fever  is  an  epidemic  contagious  disease,  the 
specific  cause  of  which  is  not  certainly  known,  although  a  peculiar  spi- 
rillum appears  to  be  constantly  present  in  the  blood.  It  occurs  chiefly 
among  the  over-crowded  and  destitute,  but  may  spread  widely  when 
introduced  among  more  favorably  situated  populations.  Its  invasion 
is  abrupt,  and  is  marked  by  a  distinct  chill  or  rigor,  followed  quickly  by 
high  fever  (101°  to  106°),  with  severe  headache  and  pains  in  the  back 
and  limbs.  Delirium  is  comparatively  rare.  The  tongue  is  heavily 
coated,  and  there  are  epigastric  tenderness,  vomiting,  constipation,  andi 
enlargement  of  the  liver  and  spleen,  with  frequent  jaundice.  There  is 
no  characteristic  eruption.  These  symptoms  cease  abruptly  from  the 
fifth  to  the  seventh  day,  with  copious  sweating ;  but  after  an  apyretic 
interval  of  about  a  week's  duration  a  relapse  occurs  similar  to  the  first 
attack,  but  of  less  duration  (three  to  five  days).  Second,  third,  or  even 
more  numerous  relapses  may  subsequently  occur  at  less  regular  intervals. 
One  attack  does  not  protect  against  a  second  one  to  the  same  extent  as 
with  other  contagious  diseases.  The  mortality  is  usually  small. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — It  is  not  important 
to  consider  here  at  any  length  the  history  of  this  disease.  Allusions  to  it 
were  made  by  Strother,  1729,  and  by  Huxham,  1752,  but  the  first  reliable 
account  on  record  is  the  description  of  an  epidemic  in  the  year  1739 
by  John  Rutty.1  Relapsing  fever  undoubtedly  occurred  at  diiferent 
times  and  at  various  places  during  the  next  hundred  years,  although  the 
records  of  it  are  scanty,  and  for  the  most  part  imperfect,  owing  chiefly  to 
the  want  of  a  clear  recognition  of  its  essential  difference  from  typhus  and 
typhoid  fevers. 

During  the  decade  from  1842  to  1852  relapsing  fever  prevailed  in  a 
very  active  and  widespread  form.  Epidemics  occurred  in  England, 
Scotland,  and  Ireland,  in  various  parts  of  Germany,  and  it  was  during 
this  time  that  it  was  first  observed  and  described  in  America.  In  June, 
1844,  an  emigrant  ship  from  Liverpool  came  to  America  with  eighteen 
cases  on  board,  which  were  taken  to  the  Philadelphia  and  Pennsylvania 

1 A  Chronological  History  of  the  Weather  and  Seasons,  etc.,  London,  1770,  pp.  75-90. 
VOL.  I.— 24,  369 


370  RELAPSING  FEVER. 

Hospitals.     In  1848  a  few  cases  were  imported  by  emigrants  to  New 
York,  and  in  1850  to  Buffalo  in  the  same  way.1 

The  next  great  outbreak  of  relapsing  fever  began  in  Ode?«a  in  1863 
and  lasted  uutil  1872.  It  prevailed  in  various  parts  of  Russia,  in  Ger- 
many, France,  and  Great  Britain,  and  for  the  first  time  occurred  exten- 
sively in  the  United  States,  especially  in  Philadelphia  and  New  York. 
The  present  article  is  based  largely  on  a  study  of  this  epidemic  as  it  pre- 
sented itself  in  Philadelphia  during  the  years  1869-70,  when  the  writer, 
in  conjunction  with  the  late  Edward  Ehoads,  had  the  opportunity  of 
observing  about  two  hundred  cases,  in  the  wards  of  the  Philadelphia 
Hospital.  An  admirable  article  on  the  same  epidemic  appeared  from  the 
pen  of  the  late  John  S.  Parry,  in  the  Amer.  Jour.  Med.  Sciences,  N.  S., 
vol.  lx.,  Oct.,  1870,  p.  336. 

Between  the  years  1877  and  1880  relapsing  fever  occurred  quite 
extensively  at  Bombay,  and  was  there  studied  by  Carter2  and  Lewis ; 
and  during  1879-80  it  prevailed  in  Konigsberg,  an  account  of  which 
epidemic  has  been  published  by  Meschede.3 

The  geographical  distribution  of  relapsing  fever  is  seen,  therefore,  to 
have  been  very  extensive ;  and  not  only  has  it  occurred  in  the  above- 
mentioned  localities,  but  there  have  also  been  less  extensive  outbreaks  in 
France,  India,  Egypt,  Algeria,  South  America,  and  elsewhere. 

CAUSES. — In  all  probability  the  essential  cause  of  relapsing  fever  is  a 
specific  poison,  but  we  know  nothing  of  its  real  nature  nor  of  the  pre- 
cise conditions  under  which  it  originates.  Recent  investigations  have 
shown  that  the  spirillum  discovered  by  Obermeier  is  constantly  present 
during  the  febrile  stages  of  relapsing  fever,  but  it  cannot  yet  be  decided 
whether  this  minute  organism  is  the  actual  cause  or  only  an  invariable 
accompaniment  of  the  disease. 

It  appears  that  conditions  of  destitution,  filth,  and  intemperance 
amongst  an  overcrowded  population  favor  the  development  of  the 
virus,  and  hence  the  epidemics  have,  as  a  rule,  begun  in  towns,  such 
as  Dublin,  Glasgow,  Odessa,  St.  Petersburg,  Breslau,  etc.,  where  such 
conditions  prevail.  Great  importance  has  been  attached,  in  particular, 
to  the  scarcity  of  food  and  to  destitution  as  powerful  factors  in  favoring 
the  production  of  the  disease.  Some  of  its  names  (hunger-pest,  hunger 
typhus,  famine  fever)  have  been  given  with  reference  to  this,  and  in  the 
case  of  several  outbreaks  a  careful  comparison  has  been  made  of  the 
decrease  of  the  food-supply  and  the  consequent  advance  in  price  of  the 
staple  commodities  with  the  development  and  progress  of  the  disease. 
Although  this  is  in  all  probability  true  of  those  centres  where  relapsing 
fever  originates,  it  has  but  a  partial  application  to  the  secondary  centres 
where  the  disease  is  imported  and  develops. 

>  The  presence  of  destitution  and  filth,  enfeebling  the  vitality  of  a  sco- 
rn of  the  community,  would  favor  the  spread  of  this  as  of  any  other 
fever,  but  there  is  considerable  evidence  to  favor  the  view  that 
1 1 H-  importance  of  starvation  as  a  cause  of  the  fever  has  been  exaggerated, 
s  was  strongly  urged  by  Parry4  as  the  result  of  his  study  of  the 


CAUSES  37] 

Philadelphia  epidemic  of  1870,  and  our  own  more  extended  observation 
showed  that  the  vast  majority  of  the  patients  appeared  to  be  well  fed. 
On  the  other  hand,  the  influence  of  overcrowding  as  favoring  the  devel- 
opment and  spread  of  relapsing  fever  has  been  clearly  established  by  the 
study  of  many  epidemics,  as  in  the  Breslau  attack  of  1868,  reported  by 
Wyss  and  Bock,  where  single  tenement-houses  furnished  as  many  as 
seventy-one  cases;  in  the  Edinburgh  epidemic  of  1869  and  1870,  where 
Muirhead  found  the  breathing-space  allotted  to  each  individual  in  the 
affected  houses  to  vary  from  250  to  400  cubic  feet ;  and  in  the  Phila- 
delphia epidemic,  where  the  observations  of  Parry  and  ourselves  showed 
the  presence  of  an  extreme  degree  of  overcrowding  in  most  of  the  houses 
where  the  disease  broke  out. 

No  age  is  exempt,  but  neither  can  it  be  said  that  age  exerts  any  influ- 
ence upon  the  occurrence  or  frequency  of  relapsing  fever.  Of  1164  cases 
in  the  Philadelphia  epidemic  of  1869-70  in  which  the  age  was  noted, 
the  result  was  as  follows : 

Males.  Females. 

Under  20 149  76 

From  20  to  30 220  140 

From  30  to  40 143  101 

From  40  to  50 135  67 

From  50  to  60 60  34 

From  60  to  70 20  6 

From  70  to  90 6  7 

Total 733  431  =  1164 

The  youngest  cases  were  in  children  two  or  three  years  old  ;  the  oldest 
patients  were  women  over  eighty-five  years  old. 

Sex  exerts  no  influence,  though,  on  account  of  the  larger  propor- 
tion of  males  likely  to  be  exposed  to  the  specific  cause,  the  results  of 
nearly  all  epidemics  show  a  preponderance  of  male  patients  in  the  pro- 
portion of  33  per  cent.,  66  per  cent.,  or  even  85  per  cent.  (Meschede). 

Nationality  does  not  act  as  a  predisposing  cause,1  except  in  so  far 
as  certain  countries  may  present  more  frequently  than  others  the  con- 
ditions favorable  for  the  development  of  this  disease.  Of  1170  cases 
in  Philadelphia  in  which  the  nativity  was  noted,  219  were  Irish,  61 
English,  161  German,  729  American.  Of  the  latter  729,  about  one- 
half,  or  nearly  28  per  cent,  of  the  whole  number,  were  negroes,  while  the 
negro  population  of  Philadelphia  was  only  about  3.3  per  cent,  of  the 
total.  This  excessive  proportion  of  cases  among  the  negroes  was  undoubt- 
edly due  in  large  part  to  the  fact  that  in  Philadelphia  overcrowding  is 
notoriously  more  common  and  extreme  among  them  than  in  any  other 
portion  of  the  population,  although  it  is  also  likely  that  they  present  an 
excessive  susceptibility  to  the  virus  of  this  as  of  many  other  specific 
diseases. 

Attempts  have  been  made  to  show  some  connection  between  the 
period  of  the  year  or  the  atmospheric  conditions  and  the  rise  and 
spread  of  epidemics  of  relapsing  fever;  but,  as  Murchison  clearly 
showed,  these  epidemics  are  wholly  independent  of  such  influences. 
In  Philadelphia,  of  1176  cases  in  which  the  date  of  occurrence  is 
known,  there  occurred  in  September,  1869,  4  cases ;  December,  1869, 
6  cases;  January,  1870,  5  cases;  February,  1870,  13  cases;  March, 
1  Hirsch's  Oeog.  and  Hist.  Pathology,  New  Syd.  Soc.  ed.,  1883,  vol.  i.  p.  615. 


372  RELAPSING  FEVER. 

1870,  124  cases;  April,  1870,  209  cases;  May,  325  cases;  June,  293 
cases;  July,  115  cases;  August,  19  cases;  September,  28  cases;  October, 
15  cases;  November,  1  case;  December,  2  cases;  January,  1881,  2 
cases ;  February,  1  case ;  March,  2  cases ;  May,  7  cases ;  June,  2  cases ; 
September,  2  cases ;  October,  2  cases. 

Occupation  exerts  no  predisposing  influence,  but  in  all  epidemics  the 
great  majority  of  cases  occur  among  the  vagrant  classes,  who  lead 
a  precarious  life  and  commonly  sleep  in  foul,  overcrowded  lodgings. 
Murchison  noted  that  in  the  London  epidemics  a  considerable  propor- 
tion of  cases  occurred  among  recent  residents,  but  he  attributed  this, 
correctly,  not  to  any  special  local  cause,  but  merely  to  the  fact  that  this 
floating  population  is  largely  of  the  vagrant  type.  In  Philadelphia 
a  careful  inquiry  showed  that  recent  residence  produced  no  special  pre- 
disposing influence,  and  a  study  of  other  epidemics  confirms  this  view. 

Contagion  is,  however,  the  essential  cause  of  the  spread  of  relapsing 
fever  when  the  virus  has  once  been  developed.  It  seems  clear  from 
the  distinct  periods  and  from  the  widely-separated  localities  in  which 
different  outbreaks  of  relapsing  fever  have  occurred  that  its  special 
poison  is  capable  of  being  called  into  existence  or  activity  by  favor- 
ing conditions.  Murchison  held  the  belief  that  it  was  veiy  inti- 
mately connected  with,  if  not  generated  by,  destitution,  and,  as  already 
stated,  much  evidence  exists  to  show  that  the  disease  is  most  apt  to  break 
out  after  periods  of  scarcity ;  but  no  just  and  convincing  proof  exists  that 
destitution,  any  more  than  over-crowding  and  other  depressing  influences, 
can  actually  engender  a  specific  contagium  capable  of  being  transported 
to  great  distances  and  of  originating  widespread  outbreaks  of  the  specific 
tli.-case  among  differently  situated  populations.  It  appears  necessary  to 
ii—unie  the  existence  of  some  unknown  special  virus  which  finds  its  suit- 
able nidus  for  development  in  the  conditions  attendant  on  filth  and  over- 
crowding, and  which  attacks  with  greatest  facility  the  systems  of  those 
who  are  enfeebled  by  want  and  depressed  by  vitiated  air.  When  once 
this  specific  poison  has  been  called  into  active  existence,  however,  there 
can  be  no  doubt  as  to  the  fact  that  it  can  be  carried  by  fomites,  and  that 
it  is  given  off  from  the  bodies  of  relapsing-fever  patients  so  as  to  affect 
any  who  may  approach.  Although  a  few  observers  have  doubted  this 
contagiousness  of  relapsing  fever,  the  evidence  in  its  favor  is  overwhelm- 
ing. In  many  epidemics,  as  in  Philadelphia  in  1869,  its  contagiousness 
is  at  least  as  intense  as  that  of  typhus  fever.  A  single  case  may,  indeed, 
be  admitted  to  a  healthy  family  among  the  better  classes  or  into  the  wards 
of  a  well-ventilated  hospital  without  propagating  the  disease,  although 
striking  cases  of  contagion  are  on  record  where  a  patient  has  communi- 
cated the  disease  to  all  the  members  of  a  family  favorably  situated  and 
living  at  a  distance  from  any  other  possible  source  of  contagion.  On  the 
)ther  hand,  if  admitted  to  an  overcroAvded  and  filthy  lodging  the  disease 
i  apt  to  spread  rapidly.  Wyss  and  Bock  report  seventy-one  cases  as 

ring  occurred  in  a  single  lodging-house  during  the  course  of  the 
u  epidemic  of  1868,  and  in  Philadelphia  single  houses  in  several 
5  furnished  more  than  a  score  of  cases,  and  several  short  streets 
more  than  one  hundred  cases  each. 

In  the  Philadelphia  Hospital  twenty-three  persons  lying  sick  in  the 
s  with  other  affections  contracted  relapsing  fever  from  the  patients 


CA  USES.  373 

admitted  with  that  disease ;  two  of  the  visiting  staff,  five  resident  physi- 
cians, and  nine  nurses  also  suffered  attacks  of  varying  severity.  This 
corresponds  with  the  general  experience  of  those  connected  with  fever 
hospitals  during  the  prevalence  of  relapsing  fever. 

As  in  the  case  of  typhus  and  other  contagious  diseases,  the  distance 
at  which  relapsing  fever  can  be  contracted  by  direct  contagion  through 
the  atmosphere  is  a  very  short  one,  not  exceeding  a  few  feet  at  most. 

The  poison  may  be  carried  by  fomites.  Instances  are  on  record  where 
persons  having  visited  infected  districts  have  conveyed  the  disease  to 
others  at  a  distance  without  contracting  it  themselves. 

^Yhen  rooms  which  have  been  occupied  by  relapsing-fever  patients  are 
subsequently  occupied  by  other  persons,  these  are  very  liable  to  acquire 
the  disease.  Parry  relates  two  remarkable  cases  in  which  relapsing  fever 
was  transported  to  a  distance  by  infected  clothes ;  and  it  has  been  more 
than  once  observed  that  during  epidemics  of  this  disease  laundry-women 
engaged  in  washing  the  clothes  of  fever  patients,  but  without  any  means 
of  more  direct  communication  with  the  sick,  were  frequently  attacked 
(Cormack,  Wyss  and  Bock). 

In  connection  with  the  etiology  of  relapsing  fever  it  is  necessary  to 
consider  the  role  played  by  a  minute  organism  which  has  been  frequently 
detected  in  the  blood  of  patients  suffering  with  this  disease.  This  spiro- 
bacterium  was  first  observed  in  relapsing  fever  by  Obermeier1  in  1873, 
and  has  since  been  identified  as  a  spirillum  or  spiroechete.  .The  very 
numerous  observations  of  Obermeier,  Albrecht,  H.  V .  Carter,  Motschut- 
koffsky,  Koch,  Cohen,  Holsti,  Enke,  Meschede,  and  others  leave  no 
doubt  that  this  peculiar  parasite  does  occur  at  least  very  frequently  in 
the  blood  of  patients  with  this  disease.  The  failure  to  detect  it,  which 
has  been  reported  by  several  good  observers,  may  readily  have  been  due 
to  the  extreme  delicacy  of  the  organism,  or  to  the  neglect  of  the  proper 
method  of  preparing  the  slides  of  blood  for  examination,  or  to  delaying 
the  examination  of  the  blood  until  after  death,  when  it  rapidly  disap- 
pears. Thus  no  value  can  be  attached  to  the  negative  observations  of 
Rhoads  and  myself,  made  prior  to  Obermeier's  discovery,  since  our 
method  of  examination  was  not  sufficiently  exact. 

The  following  description  of  the  mode  of  examining  the  blood,  and  of 
the  spirillum,  is  condensed  from  H.  V.  Carter's  account :  It  is  necessary 
to  employ  magnifying  powers  of  not  less  than  500  diameters.  The  fresh 
blood  may  be  examined  immediately  after  obtaining  it  by  pricking  the 
washed  finger  of  the  patient.  For  preservation  dried  specimens  are 
needed:  a  very  thin  layer  of  fresh  blood  is  evenly  spread  with  the 
needle  over  the  glass  cover,  exposed  to  the  weak  fumes  of  a  solution 
of  osmic  acid,  and  allowed  to  dry  under  protection  from  ^dust ;  the 
dried  film  of  blood  may  then  be  treated  with  glacial  acetic  acid  or  may 
be  stained. 

The  spirillum  [See  Fig.  19]  is  a  colorless,  slender,  twisted  filament, 
which  when  quiescent  has  a  length  of  2.66  times  the  diameter  of  a  blood- 
disc  (j  5\  0  to  ^  inch  =  0.01 2  to  0.043  millimetre).  When  unfolded 
they  become  distinctly  elongated.  They  are  very  narrow  (not  more  than 
.^^  inch),  and  present  four  to  ten  spiral  turns ;  when  fresh  they  are  in 
active  movement  and  unfold  in  part,  becoming  wavy  or  bent.  They 
1  Centmlbl.f.  die  med.  Wissensch.,  1873,  No.  10. 


374 


RELAPSING  FEVER. 


FIG.  19. 


Spirillum  from  the  blood  in  a  case  of  relapsing  fever,  X  700  (Koch). 


resist  the  action  of  concentrated  acetic  acid,  and  are  readily  stained  by 
certain  dyes.  In  number,  five  or  ten  may  be  visible  in  a  field  or  they 
nuiv  be  too  numerous  to  count.  They  have  not  been  detected  either  in 

the  secretions  or  in  the 
evacuations.  Both  Koch 
and  Carter  have  suc- 
ceeded  in  cultivating  this 
special  form  of  bacteria 
outside  of  the  body. 

To  judge  from  the  ob- 
servations thus  far  made 
on  this  difficult  question, 
the  parasite  is  found  first 
toward  the  close  of  the 

^   -v  —        ^-\^s      •     -^         \          period  of  inoculation  or 

Uv~vV-^r-"'~'  \/*  soon  after  the  beginning 

of  the  fever,  or  it  may 
be  detected  throughout 
the  febrile  stage ;  but 
shortly  before  the  ces- 
sation of  the  fever  it 
quickly  disappears,  to 
reappear  at  the  time  of  the  relapse.  There  would  seem,  therefore,  to  be 
some  close  connection  between  the  febrile  paroxysms  and  this  organism, 
and  it  is  not  remarkable  that  many  observers  have  concluded  that  this 
spirillum  is  the  essential  and  specific  cause  of  the  fever,  and  that  it  is 
impossible  to  have  this  disease  present  without  the  appearance  of  the 
parasite  in  the  blood;  nor  that  the  name  spirillum  fever  has  been  ap- 
plied to  the  disease  by  Carter. 

Such  conclusions  appear  to  be  premature,  however,  and  we  prefer  to 
regard  the  undoubted  existence  of  the  spirillum  in  the  blood  of  relapsing- 
Icver  patients  as  at  present  only  an  important  aid  in  diagnosis,  and  to 
await  the  occurrence  of  other  epidemics  and  the  repetition  of  careful 
studies  upon  this  organism,  both  within  and  without  the  human  system, 
before  venturing  to  decide  whether  it  is  merely  one  of  the  phenomena  of 
the  disease  or  whether  it  is  its  true  cause  and  specific  contagious  principle. 
It  must  be  added  that  both  Carter  and  Koch  have  succeeded  in  inocu- 
lating monkeys  with  relapsing  fever,  and  Motschutkoffsky1  of  Odessa,  who 
had  the  opportunity  of  inoculating  a  human  being,  asserts  that  he  suc- 
ceeded in  producing  the  disease,  and  found  the  incubation  period  to  be 
not  less  than  five  nor  more  than  eight  days.  Carter  also  gives  an 
interoBtingtable1  of  six  instances  of  inoculation,  four  of  them  by  cuts 
while  making  autopsies,  with  consequent  development  of  relapsing  fever 
in  each  instance.  Some  allowance  must  be  made  for  the  fact  that  in  all 
the  instances  of  this  series  there  had  been  exposure  to  contagion  by  close 
communication  with  fever  patients,  though  this  exposure  had  existed  for 
several  months  previously  without  leading  to  the  development  of  relaps- 
ing fever. 

GENERAL  CLINICAL  DESCRIPTION. — After  a  period  of  not  less  than 
live  or  six  days  from  the  reception  of  the  contagion  the  disease  begins 

1  Centnilbhttf.  d.  med.  Wissenschaftm,  1876,  No.  11,  p.  194.  a  Op.  clt.,  p.  403. 


GENERAL  CLINICAL  DESCRIPTION,  375 

abruptly  with  a  chill  of  variable  severity,  accompanied  by  headache  and 
aching  pains  in  the  back  and  limbs.  The  patient  feels  weak  and  is  often 
giddy,  but  is  not  always  obliged  to  go  to  bed  the  first  day.  Nausea  and 
vomiting  are  among  the  earliest  symptoms,  and  distress  at  the  epigastrium, 
with  tenderness,  may  attend  or  even  precede  the  chill.  Fever  quickly 
follows  ;  the  pulse  runs  up  from  110  to  130  in  a  few  hours ;  the  tempera- 
ture reaches  from  103.5°  to  106°  by  the  end  of  twenty-four  hours;  the 
pains  increase,  and  there  are  insomnia  and  great  restlessness ;  appetite  fails ; 
thirst  is  extreme;  the  tongue  is  moist  and  furred,  and  the  bowels  quiet. 
During  the  subsequent  six  days  these  symptoms  persist.  The  tempera- 
ture presents  a  daily  remission  at  some  period  of  the  twenty-four  hours 
amounting  to  one  or  two  degrees,  the  maximum  reached  in  fully-devel- 
oped cases  varying  from  104°  to  108°.  The  pulse  continues  very  rapid, 
and  not  rarely  exceeds  140 ;  the  respirations  are  hurried  and  rapid,  and 
cough  attends  many  cases.  Delirium  is  rare,  but  insomnia,  restlessness, 
headache,  and  rheumatic  pains  in  the  back  and  limbs  may  prove  constantly 
annoying.  Appetite  is  variable,  more  frequently  lost ;  nausea  and  vomit- 
ing are  common  ;  thirst  is  very  troublesome ;  and  the  bowels  are  consti- 
pated or  loose.  No  characteristic  eruption  appears,  but  sudamiiia  are 
frequently  present,  since  in  a  large  proportion  of  cases  there  is  more  or 
less  sweating,  even  during  the  continuance  of  high  fever.  Abdominal 
pain,  tenderness  in  the  epigastrium  and  hypochondria,  and  demonstrable 
enlargement  of  the  liver  and  spleen  are  almost  invariable.  The  urine  is 
concentrated  and  dark  or  bile-stained.  Jaundice  is  a  common  symptom, 
though  its  frequency  varies  greatly  in  different  epidemics.  The  same  may 
be  said  of  epistaxis. 

While  these  symptoms  are  at  their  height  and  the  patient  is  suffering 
severely  the  paroxysm  suddenly  ceases,  and  in  a  few  hours  he  is  entirely 
relieved.  This  remarkable  crisis  occurs  usually  at  the  close  of  the  seventh 
day,  but  may  occur  as  early  as  the  third  or  as  late  as  the  fifteenth  day. 
ft  is  attended  with  a  critical  discharge,  copious  sweating  being  by  far  the 
most  common,  though  diarrhoea,  free  epistaxis,  or  hemorrhage  from 
some  other  surface  may  replace  it.  The  patient  feels  weak  and  languid ; 
the  temperature  and  pulse  have  fallen  below  the  normal,  and  remain  so 
for  a  day  or  two.  Soon  there  is  a  rapid  improvement  in  the  appetite  and 
the  appearance  of  the  tongue,  and  the  patient  regains  strength  day  by  day, 
and  often  feels  so  well  that  it  is  difficult  to  persuade  him  that  he  must 
avoid  exertion  and  exposure.  The  enlargement  of  the  spleen  subsides 
rapidly,  that  of  the  liver  more  gradually ;  epigastric  tenderness  subsides, 
but  in  many  cases  some  degree  of  it  persists  for  several  days.  This 
interval  or  apyretic  period  lasts  about  a  week,  when,  again  without  warn- 
ing or  provocation,  the  patient  relapses,  and  is  seized  abruptly  with  the 
same  set  of  symptoms  which  attended  the  first  attack.  This  relapse 
does  not  usually  last  more  than  three  days  (one  to  five  are  the  limits),  and 
is  terminated  by  a  similar  crisis,  after  which  a  slow  convalescence  is 
entered  upon,  or  else  after  an  apyretic  interval  of  some  days'  duration  a 
second  relapse  ensues,  and  this  may,  in  rare  cases,  be  in  turn  followed  by 
a  third,  fourth,  fifth,  or  even  sixth  similar  relapse.  In  addition,  it  must 
be  noted  that  many  serious  complications  are  liable  to  occur.  The  total 
duration  of  the  disease  thus  varies  from  eighteen  to  ninety  days.  Con- 
valescence is  often  tedious,  and  there  are  many  troublesome  sequelae. 


376  RELAPSING  FEVER. 

The  mortality,  however,  is  not  great,  averaging  5  or  6  per  cent.  Death 
may  occur  suddenly  from  collapse  at  the  close  of  the  first  paroxysm  or 
from  heart-clot ;  it  may  be  produced  by  exhaustion  in  protracted  cases ;  or 
be  hastened  by  any  serious  complication ;  or  the  patient  may  sink  into  a 
typhoid  condition,  with  low  delirium,  coma,  and  suppression  of  urine  for 
several  days  before  the  fatal  termination. 

DETAILED  STUDY  OF  SPECIAL  CONDITIONS. — It  is  usually  difficult 
to  determine  the  period  of  incubation.  In  the  unique  case  in  which 
Motsclmtkoffsky  is  said  to  have  produced  relapsing  fever  by  inoculation 
the  initial  symptoms  occurred  seven  days  after  the  inoculation.  Wyss 
and  Bock  had  several  good  opportunities  of  determining  the  minimum 
period  of  incubation,  and  found  it  to  be  six  days.  We  may  assume  that 
the  ordinary  period  is  six  to  eight  days,  but  that  it  varies,  in  accordance 
with  the  virulence  of  the  virus  or  the  susceptibility  of  the  system,  from 
four  to  fourteen  days.  During  this  time  the  patient  feels  as  well  as  usual, 
or  at  most  suffers  for  a  day  or  two  from  slight  malaise,  with  vague  rheu- 
matoid pains,  headache,  giddiness,  and  anorexia.  In  only  13  out  of  181 
of  our  cases  in  which  this  point  is  noted  was  the  invasion  gradual.  Ex  • 
amination  of  the  blood  prior  to  the  invasion  does  not  discover  any  spirilla. 

The  invasion  is  usually  abrupt  and  during  the  daytime ;  the  patient 
can  often  fix  the  very  hour  of  its  occurrence,  a  severe  chill  attacking  him 
while  at  work  or  at  meal-time.  This  is  the  most  common  initial  symptom 
(138  out  of  168  our  cases  of  sudden  invasion);  less  commonly,  obstinate 
vomiting  and  nausea  or  sudden  vertigo  are  the  first  symptoms  (each  8 
times  out  of  168),  or  violent  headache  (14  times  out  of  168),  or  sharp 
epigastric  pain.  Parry  also  observed  that  the  occurrence  of  obstinate 
and  profuse  vomiting  as  the  initial  symptom  was  especially  frequent  in 
children. 

The  physiognomy  is  carefully  noted  in  one  hundred  and  seventy  of 
our  records.  The  countenance  is  often  flushed,  with  watery  eyes  and 
anxious,  suffering  expression.  The  flush  is  less  dingy  and  dull  than  in 
typhus  ;  the  eye  is  comparatively  rarely  injected ;  and  the  expression  is 
much  less  dull  and  stupid  than  in  that  disease.  In  cases  where  grave 
nervous  symptoms  supervene  and  the  typhoid  condition  is  developed  the 
facies  assumes  all  the  characteristics  of  that  state. 

The  livid  bronzing  of  the  face,  described  by  Cormack  in  1843  and  by 
Carter  (Bombay  epidemic  of  1877),  was  noticed  in  a  moderate  degree  in 
only  nine  of  our  cases,  and  seems  to  be  of  infrequent  occurrence.  When 
we  observed  it  it  seemed  due  to  an  admixture  of  a  faint  jaundice  tinge 
with  a  deep  flush.  Jaundice,  as  already  stated,  is  of  common  occurrence, 
though  its  frequency  varies  greatly  in  different  epidemics.  It  was  present 
in  25  per  cent,  of  our  cases,  rather  more  frequently  in  the  negro  patients 
than  in  whites,  and  in  degree  varied  from  a  slight  tinge  of  the  conjunc- 
tiva and  skin  to  the  deepest  staining  of  the  entire  body.  The  presence 
of  jaundice  in  combination  with  the  general  features  of  high  fever  imparts 
a  most  peculiar  and  alarming  appearance  to  such  patients. 

With  the  occurrence  of  the  crisis  the  flush  rapidly  subsides  and  the 
face  becomes  pale,  or,  if  the  discharges  have  been  profuse,  it  may  appear 
sunken,  haggard,  and  almost  choleraic.  Parry  described  a  peculiar  puffed, 
velvety  look  at  this  stage,  as  though  the  skin  had  been  much  thickened 
and  softened  at  the  same  time. 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  377 

There  is  no  characteristic  eruption  in  relapsing  fever.  In  150  out 
of  180  cases  where  the  condition  of  the  skin  was  carefully  noted  there 
was  no  eruption  of  any  kind ;  in  4  cases  there  were  small  roseolar 
spots,  with  peculiar  subcuticular  mottling,  which  resembled  the  early 
stages  of  typhus  eruption,  but  soon  faded  away  without  becoming  petechial. 
A  similar  eruption  was  noticed  by  Murchison  in  8  out  of  600  cases.  It 
appears  from  the  third  to  the  seventh  day  of  the  first  paroxysm ;  it  may 
or  may  not  recur  in  the  relapse,  or  it  may  occur  then  only.  Eruptions 
apparently  similar  to  this  have  been  described  by  others  as  quite  common 
in  certain  epidemics.  Carter  describes  minutely  an  eruption  which  was 
noted  in  at  least  10  per  cent,  of  his  Bombay  cases,  the  spots  of  which 
were  at  first  small,  slightly  raised,  and  pinkish  or  rose-colored,  and  which 
either  faded  away  soon  or  changed  into  purplish,  more  persistent  stains. 
In  a  valuable  report  on  the  Konigsberg  epidemic  of  1879—80,  Meschede1 
remarks  that  roseola  was  observed  in  cases  complicated  by  exanthematio 
typhus,  which  prevailed  simultaneously,  but  in  no  case  of  uncomplicated 
relapsing  fever.  While,  however,  this  suggestion  may  apply  to  some  few 
of  the  cases  of  eruption  observed  by  others,  it  is  certainly  inapplicable  to 
the  vast  majority  of  them.  We  also  noticed  an  eruption  of  pale-reddish, 
slightly  elevated  papules  in  seven  cases.  It  must  be  borne  in  mind  that 
persons  of  such  a  low  class  as  are  the  great  majority  of  relapsing-fever 
patients  would  naturally  be  expected  to  present  a  variety  of  cutaneous 
eruptions  from  filth  or  vermin,  and  that  in  consequence  some  of  the 
appearances  above  described  may  have  been  of  such  origin.  It  is  certain 
that  the  bites  of  either  mosquitoes,  fleas,  or  bedbugs  may  in  this  disease 
be  followed  by  persistent  reddish  papules  passing  into  petechiae.  Apart 
from  this,  however,  true  petechise  have  been  quite  common  in  some  epi- 
demics, while  very  rare  in  others.  Parry  saw  "  small  spots  of  purpura  " 
once  only,  in  a  delicate  girl ;  and  we  did  not  observe  petechise  once  in 
several  hundred  cases,  many  of  which  had  extensive  internal  ecchymoses. 
On  the  other  hand,  they  have  been  found  in  as  much  as  30  per  cent,  of 
all  cases  (314  out  of  1000  cases,  Smith  at  Glasgow).  They  do  not  appear 
on  any  fixed  day,  but  are  more  common  in  the  first  paroxysm  than  in  the 
relapses ;  and  although  sometimes  associated  with  a  tendency  to  hemor- 
rhages from  other  surfaces,  they  have  been  so  often  observed  in  cases  of 
ordinary  severity  that  scarce  any  unfavorable  prognostic  value  can  be 
attached  to  them. 

Vibices  and  extensive  ecchymoses  of  the  surface  are  of  much  more 
grave  import,  and  in  cases  where  fatal  sinking  is  threatened  they  may 
appear  accompanying  a  purplish  lividity  of  the  countenance. 

Herpetic  eruptions  about  the  mouth  or  nostrils  were  observed  in  20  out 
of  181  of  our  cases  in  which  this  point  is  noted.  They  appeared  usually 
toward  the  close  of  the  febrile  stage,  and  their  development  was  found  to 
have  value  in  determining  the  approach  of  the  crisis.  Barensprung  men- 
tions especially  the  occurrence  of  herpes  labialis  in  cases  of  irregular 
relapsing  fever  which  bore  considerable  resemblance  to  typhus.  Suda- 
mina  are,  as  might  be  expected  in  a  disease  attended  with  so  much  sweat- 
ing, of  quite  common  occurrence,  though  much  more  so  in  some  epidemics 
than  in  others,  unless  searched  for  with  greater  care  by  the  one  set  of 
observers.  Desquamation  was  noted  in  42  out  of  181  of  our  cases,  and 
1  Virchow's  Arch.,  Bd.  Ixxxvii.,  p.  405. 


378  RELAPSING  FEVER. 

invariably  at  the  close  of  the  relapse.  It  was  usually  confined  to  the  hands 
and  face,  and  occurred  in  the  form  of  comparatively  small  flakes.  This  is 
more  frequent  than  has  been  the  case  in  most  epidemics.  Murchison  quotes 
a  case  in  which  a  piece  of  epidermis  ten  inches  square  separated  from  the 
body  of  a  lad  convalescent  from  relapsing  fever. 

A  peculiar  odor  exhaling  from  patients  with  relapsing  fever  has  been 
repeatedly  noticed.  A  description  of  this  unpleasant  symptom,  given  by 
Kelly,  as  quoted  by  Murchison,1  accords  closely  with  what  was  frequently 
manifest  in  our  own  cases  :  "  The  smell  was  peculiar,  not  fetid  or  heavy, 
but  somewhat  like  burning  straw  with  a  musty  odor."  Carter,  in  describ- 
ing a  similar  odor  in  some  of  his  cases,  notes  that  the  skin  was  not  in 
these  instances  in  a  particularly  foul  state. 

From  what  has  already  been  said,  it  will  be  anticipated  that  the  varia- 
tions of  the  temperature  in  relapsing  fever  constitute  the  most  peculiar  and 
characteristic  feature  of  that  disease.  A  careful  study  of  the  accompany- 
ing charts  will  convey  a  more  accurate  impression  than  can  be  given  by  any 
description.  The  temperature  begins  to  rise  before  the  chill  is  fully  devel- 
oped, and  when  there  is  no  initial  chill  the  patient  may  be  found  within  a 
few  hours  of  the  appearance  of  giddiness  and  headache  with  a  temperature 
of  102.5°  to  103.5°.  Before  twenty-four  hours  have  passed  it  has  risen  to 
from  104°  to  106°.  During  the  paroxysm  the  febrile  movement  is  con- 
tinued, presenting  merely  a  diurnal  variation  of  one  to  two  degrees,  some- 
times attended  with  sweating  and  partial  relief  of  distressing  symptoms, 
the  minimum  being  observed  at  different  hours  in  different  cases,  or  even 
in  the  same  case,  though  more  frequently  it  occurs  in  the  morning. 

In  a  case  reported  by  Parry  a  chill  recurred  at  the  same  morning  hour 
on  three  successive  days.  Wyss  and  Bock  report  some  unusual  cases  in 
which  a  brief  intermission  occurred,  with  a  fall  of  pulse  and  temperature 
to  the  normal,  most  frequently  on  the  day  before  the  real  termination  of 
the  paroxysm.  The  highest  temperature  varies  from  104.5°  to  108.75°  ; 
in  our  cases  the  highest  observed  was  107.5°.  This  occurs,  as  a  rule,  on 
the  last  day  or  the  day  before  the  last  of  the  initial  paroxysm,  and  Ober- 
meier  has  observed  a  sudden  rise  of  four  degrees  in '  half  an  hour  just 
'before  the  crisis.  Meschede,2  however,  found  the  highest  temperature  on 
the  corresponding  days  of  the  first  relapse. 

The  duration  of  the  primary  paroxysm  is  usually  six  or  seven  days ; 
but  this  is  subject  to  considerable  variations,  as  will  be  seen  from  the 
following  table  of  160  cases  in  which  the  duration  was  accurately  ascer- 
tained :  Initial  paroxysm  lasted — 2  days  in  !•  case ;  3  days  in  2  cases ; 
4  days  in  10  cases;  5  days  in  19  cases;  6  days  in  40  cases;  7  days  in 
58  cases ;  8  days  in  18  cases ;  9  days  in  2  cases ;  10  days  in  5  cases ;  11 
days  in  2  cases;  14  days  in  2  cases;  15  days  in  1  case;  and  Parry, 
observing  the  same  epidemic,  found  the  duration  of  the  first  paroxysm 
to  vary  from  4  to  11  days.  It  is,  however,  rare  for  the  duration  to  exceed 
ten  days  unless  some  complication  be  present. 

"With  the  beginning  of  the  crisis  there  is  a  prodigious  and  sudden  fall 
of  temperature,  unequalled  in  any  other  condition  of  disease.  Within  a 
few  hours  it  may  fall  six  or  eight  degrees  (going  clown  at  the  rate  of  1.5° 
or  2°  an  hour) ;  and  falls  of  12°,  13°,  or  even  14.4°  (Murchison),  in  the 
course  of  twelve  hours  have  been  noted.  In  our  own  cases  the  greatest 

1  Op.  eU.,  p.  3-16.  *  Loc.  cit. 


379 


380 


RELAPSING  FEVER. 


fall  was  from  107.2°  to  95°,  or  12.2° ;  and  this  is  as  low  a  poiut  as  is 
usually  reached,  though  temperatures  of  94°,  93°,  or  even  92°,  have 
repeatedly  been  observed.  Murchison  refers  to  one  case  in  which  co]  lapse 
supervened,  where  the  rectal  temperature  was  90.6°.  In  nearly  all  of 


FIG.  21. 


Typical  case  of  relapsing  fever  (Mary  Collins,  aged  32),  terminating  in  recovery.    One  relapse, 
with  slight  post-critical  rise  of  temperature. 

our  cases  a  subnormal  temperature  occurred  at  the  crisis,  and  lasted  for 
a  day  or  two  subsequently,  when  it  gradually  rose  and  remained  normal 
until  the  relapse,  unless  some  transient  complication  caused  a  temporary 
rise  in  the  interval. 

Occasionally,  there  is  no  relapse  whatever,  but  convalescence  follows 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS. 


381 


the  initial  paroxysm.  This  occurred  in  10  out  of  181  of  our  cases,  and 
Murchison  found  that  of  2425  cases  reported  by  various  authors  no 
relapses  occurred  in  about  30  per  cent.  Carter  describes  these  under  the 
name  of  the  abortive  form,  and  found  them  to  constitute  23.8  per  cent, 
of  all  his  cases.  It  is  probable,  however,  that  in  many  cases  so  regarded 
either  a  relapse  of  very  transient  duration  has  been  overlooked,  or  else 
that  an  attack  of  ephemeral  fever  has  been  regarded  as  of  specific  nature. 
In  ordinary  cases  the  duration  of  the  intermission  averages  six  or  seven 
days,  but  here,  again,  considerable  variation  occurs.  In  139  of  our  cases 
where  its  duration  could  be  accurately  determined  it  was  as  follows : 


3  days  in    4  cases. 

4  "       "3      " 

5  "       "    12      " 

6  "      "    12      " 


7  days  in  64  cases. 

8  "  "    22      " 

9  "  "9      " 
10    "  "     9      " 


11  days  in  1  case. 

12  "       "  1      " 

13  "      "  1      " 
20     "       "  1      " 


Despite  these  variations  in  the  duration  of  the  initial  paroxysm  and  of 
the  first  intermission,  the  average  date  of  the  occurrence  of  the  relapse  in 
any  large  series  of  cases  is  about  the  twelfth  day  from  the  primary  chill. 

The  relapse  is  ushered  in  with  the  same  striking  abruptness  as  the 
initial  attack.  The  temperature  again  rises  rapidly  to  104°  or  106°, 
and  then  pursues  a  continuous  course  resembling  ordinarily  that  of  the 
primary  paroxysm.  The  difference  between  the  maximum  of  the  two 
paroxysms  is  rarely  more  than  1.5°  or  2°,  though  either  may  be  much 
milder  than  the  other ;  as  a  rule,  the  highest  temperature  is  attained  on 
the  last  or  penultimate  day  of  the  first  attack.  The  duration  of  the 
relapse  averages  three  or  four  days,  though  it  may  last  but  a  few  hours 
or  a  single  day,  and  yet  exhibit  a  rise  of  5°,  6°,  or  7° ;  or,  on  the  other 
hand,  it  may  be  prolonged  to  six,  seven,  or  even  more  days.  Lyons, 
observing  the  disease  in  the  Crimea,  reports  some  relapses  as  having 
lasted  twenty-one  days,  though  it  is  improbable  that  a  greater  duration 
than  seven  days  occurs  without  the  presence  of  some  complication.  The 
relapse  usually  terminates  by  crisis,  with  an  abrupt  fall  to  an  abnormally 
low  temperature ;  though  we  observed  at  this  time,  much  more  fre- 
quently than  at  the  close  of  the  first  paroxysm,  a  gradual  subsidence  of 
fever,  or  lysis.  Again  the  patient  regains  strength  and  appetite,  but  in 
a  considerable  proportion  of  cases  subsequent  relapses  ensue.  As  a  rule, 
the  second,  third,  and  later  relapses  are  attended  with  a  febrile  movement 
of  shorter  duration  and  of  less  severity  than  the  first  two  paroxysms, 
and  are  also  separated  by  intermissions  of  increasing  length.  Meschede1 
found  from  a  study  of  360  cases  that  the  average  duration  was  for  the 
first  paroxysm  six  or  seven  days ;  second  paroxysm,  four  or  five  days ; 
third  paroxysm,  three  or  four  days  ;  fourth  paroxysm,  one  or  two  days  ; 
fifth  paroxysm,  one  day. 

In  a  remarkable  case  given  in  full  at  page  394,  the  duration  of  th< 
paroxysms  and  intermissions  were  as  follows  : 


X    J.AOL     L/«*\/«a 

Second 

5     "      second 

1 

f  ' 

Third 

1 

third 

6 

1 

Fourth 

/» 

'      fourth 

8 

i 

Fifth 

5 

'      fifth 

9 

1 

Sixth 

4 

'      sixth 

10 

' 

Seventh 

3 

'      seventh 

11 

1 

Eighth 

3 

'      followed  by  convalescence. 

1  Loc.  cit. 


382  RELAPSING  FEVER. 

The  proportion  of  cases  in  which  more  than  a  single  relapse  occurs 
appears  to  vary  in  different  epidemics.  Mnrchison  found  that  in  1500 
cases  reported  by  various  authors  a  second  relapse  occurred  109  times  (1 
out  of  14) ;  a  third  relapse,  9  times  (1  out  of  166);  and  a  fourth  relapse, 
once.  Of  182  cases  noted  carefully  by  ourselves,  a  second  relapse 
occurred  24  times  (1  out  of  7£) ;  a  third  relapse,  5  times  (1  out  of 
36);  a  fourth  relapse,  once;  and  in  the  above-mentioned  case  six  or 
seven  relapses. 

It  follows  that  the  total  duration  of  the  morbid  process  varies  from  the 
average  of  about  eighteen  or  twenty  days,  in  cases  with  a  single  relapse, 
to  forty,  sixty,  or  even  ninety  days.  Of  course  the  occurrence  of  compli- 
cations may  lead  to  very  great  modifications  of  the  febrile  movement  and 
of  the  total  duration  of  the  disease. 

There  are  several  additional  points  about  the  febrile  process  requiring 
mention.  In  all  the  paroxysms  there  is  a  greater  tendency  to  local  or 
general  perspirations  than  is  met  with  in  other  continued  fevers,  and 
occasionally  there  are  rigors  or  slight  chills  about  the  same  hour  on 
several  days  after  the  invasion  or  on  the  day  preceding  the  crisis.  It 
has  been  noted  also  that,  even  when  the  temperature  is  very  high,  the 
quality  of  the  heat,  as  judged  by  the  feeling  of  the  skin,  is  different  from 
that  in  typhus  fever,  and  that  the  peculiar  pungent  irritating  sensation 
known  as  calor  mordax  is  rarely  marked.  But  a  more  important  pecu- 
liarity is  the  fact  that  the  extreme  temperatures  (106°,  107°,  or  108°) 
that  are  frequently  observed  in  relapsing  fever  for  several  days  in  suc- 
cession do  not  appear  to  involve  any  great  increase  of  danger,  and  in  par- 
ticular are  not  attended  with  the  production  of  the  grave  nervous  symptoms 
so  often  met  with  in  connection  with  hypei'pyrexia  in  typhus  and  typhoid, 
and  often  regarded  as  the  direct  result  of  the  exalted  temperature  itself. 
This  striking  fact  is  of  much  interest  in  its  bearing  on  the  theory  of 
livperpyrexia,  and  may  possibly  be  explained  by  some  marked  difference 
in  the  conditions  of  heat-dispersion  in  these  different  diseases. 

The  pulse  in  relapsing  fever  is  very  rapid,  and  on  the  whole  the 
rate  corresponds  with  the  movement  o'f  the  temperature.  It  usually 
rises  above  110,  the  limits  being  90  and  140,  the  lower  rate  being 
noticed  in  the  milder  and  uncomplicated  cases  and  in  subjects  of 
phlegmatic  constitution.  The  pulse  rises  rapidly  at  the  invasion, 
and  may  reach  120  in  the  course  of  a  few  hours.  Its  maximum 
is  usually  noticed  when  the  temperature  is  highest,  shortly  before 
the  crisis;  'and  when  this  actually  begins  the  pulse  may  fall  with  a 
rapidity  as  remarkable  as  that  of  the  decline  of  the  temperature.  Thus, 
within  twenty-four  hours  it  may  fall  from  152  to  80,  or  in  even  a  shorter 
time  from  140  to  54,  or  even  as  low  as  48  (Obermeier)  or  44  (Muirheid), 
or  even  30  (Stille).  While  this  great  fall  is  often  noted,  it  is  by  no 
means  constant.  In  our  own  cases  it  was  frequently  observed  that  the 
critical  fall  in  temperature  was  not  accompanied  by  a  commensurate  foil 
in  pulse.  Thus,  at  the  close  of  a  very  severe  initial  paroxysm  lasting 
nine  days  the  temperature  was  107°,  and  fell  in  the  course  of  twenty- 
four  hours  to  99°,  and  in  twenty-four  hours  more  to  96° ;  during  the  first 
day  of  this  fall  the  pulse  was  from  96  to  100,  and  durino-  the  second  it 
fell  to  76. 

This  want  of  correspondence  was  more  marked  at  the  close  of  the 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  383 

relapse  than  of  the  primary  attack ;  thus,  in  a  well-marked  case,  where 
the  maximum  temperature  (105.4°)  occurred  eighteen  hours  before  the 
crisis  of  relapse,  the  temperature  fell  in  four  hours  from  104.4°  to  96.2°, 
while  the  pulse,  which  was  130,  fell  in  twelve  hours  to  108,  and  in  twelve 
more  to  92.  In  another  case,  in  a  man  aged  twenty,  the  temperature  at 
the  close  of  the  second  relapse  was  106.4°,  with  a  pulse  of  only  100 ; 
after  the  crisis,  as  the  temperature  fell,  the  pulse  rose  to  120,  and  did  not 
descend  until  the  end  of  twenty-four  hours ;  and  later,  at  the  close  of 
thirty-six  hours,  the  temperature  was  98°  and  the  pulse  72,  lower  than 
which  it  did  not  go.  Carter l  states  that  in  the  Bombay  epidemic  it  was 
invariably  the  case  that  the  pulse  did  not  decline  to  an  extent  correspond- 
ing with  the  temperature. 

During  the  remainder  of  the  intermission  the  pulse  may  be  normal, 
or  it  may  continue  accelerated  in  consequence  of  some  irritative  condition  ; 
as  the  time  for  the  relapse  approaches  it  frequently  again  becomes  abnor- 
mally slow.  In  either  event  it  is  found  that  any  muscular  exertion 
causes  marked  acceleration  of  the  pulse. 

During  the  paroxysm  the  character  of  the  pulse  is  full  and  bounding, 
and  there  is  considerable  arterial  tension.  This  is  well  shown  in  some 
of  the  sphygmographic  tracings  by  Carter  ;2  while  in  one  of  our 
tracings  from  the  right  radial  of  a  man  set.  32,  taken  on  the  fourth  day 
of  a  severe  initial  paroxysm,  the  line  of  ascent  is  steep  and  the  summit 
sharp.  During  the  crisis,  and  for  a  day  or  two  thereafter,  the  pulse 
may  be  weak,  compressible,  and  dicrotic,  and  occasionally  irregular. 

The  sounds  of  the  heart  and  its  impulse  are  weakened,  except  possibly 
during  the  first  few  days  of  the  primary  paroxysm.  Blood-murmurs 
over  the  base  of  the  heart  and  along  the  great  vessels  in  relapsing  fever 
were  first  noticed  by  Stokes,  and  have  been  frequently  observed  in  subse- 
quent epidemics.  They  were  found  in  a  large  proportion  of  our  cases, 
not  rarely  in  both  paroxysms,  and  during  the  early  stage  of  convalescence 
when  anaemia  was  marked ;  but  during  the  intermissions  they  are  rarely 
audible,  and  when  the  action  of  the  heart  was  slow  they  were  replaced  by 
prolongation  of  the  first  sound. 

It  must  be  further  noted  that  the  pulse-rate  is  not  a  reliable  indication 
of  the  danger  in  this  disease,  since,  just  as  is  the  case  with  the  hyper- 
pyrexia,  extreme  rapidity  of  pulse  may  be  present  when  the  general 
symptoms  denote  no  unusual  danger,  and  when  the  patient  ultimately 
recovers  most  satisfactorily. 

There  is  a  remarkable  disproportion  and  dissimilarity  between  the 
cerebral  and  peripheral  nervous  phenomena  in  relapsing  fever  and 
those  familiar  to  us  in  typhus  and  typhoid  fevers.  We  have  seen  that 
patients  almost  invariably  complain  of  headache.  When  prodromes  are 
present  it  is  commonly  among  them,  and  it  may  be  the  initial  symptom 
to  usher  in  each  paroxysm.  When  the  attack  is  fully  developed  head- 
ache is  usually  very  severe,  and  no  symptom  is  more  bitterly  complained 
of.  It  varies  in  seat  and  character.  More  commonly  it  is  frontal  or 
general ;  occasionally  we  found  it  occipital,  and  still  more  rarely  it  was 
unilateral,  constituting  hemicrania.  It  rarely  continues  during  the  relapse. 
Headache  of  an  equally  acute  and  violent  character  may  be  present  in 
typhoid,  but  the  headache  of  typhus  is  much  more  dull  and  coutusive. 

1  Op.  cit.,  p.  140.  '  Op.  tit.,  p.  103. 


384  RELAPSING  FEVER. 

The  mental  condition  is  only-  exceptionally  affected,  a  circumstance 
which  greatly  increases  the  patient's  perception  of  his  sufferings.  Delir- 
ium is  not  'present  in  ordinary  cases,  even  though  very  severe  and 
attended  with  hyperpyrexia ;  or  if  present  is  limited  to  the  period 
immediately  preceding  the  crisis,  when  there  may  be  violent  and  noisy 
delirium  of  transient  character.  In  some  of  our  cases  forcible  restraint 
was  necessary  under  these  circumstances. 

There  are  numerous  instances  on  record  showing  the  abruptness  with 
which  noisy,  demonstrative,  or  even  destructive  delirium  may  appear, 
and  the  equal  suddenness  with  which  in  the  course  of  a  few  hours,  or 
even  of  fifteen  minutes,  the  patient  may  become  rational  and  composed. 
Such  attacks  resemble  hysteroidal  spells,  and  probably  occur  more  readily 
in  patients  of  a  nervous  or  hysterical  temperament.  They  were  certainly 
more  common  when  the  patients  had  been  of  intemperate  habits ;  and, 
further,  we  had  opportunities  of  noting  that  the  occurrence  of  relapses 
in  habitual  drunkards  who  had  previously  suffered  with  delirium  tre- 
mens  was  apt  to  develop  a  form  of  delirium  which  was  to  all  appearance 
of  that  nature. 

Delirium  of  a  different  and  much  more  grave  type  may  appear  in  con- 
nection with  the  symptoms  of  the  typhoid  state.  In  some  cases  this 
results  from  the  presence  of  serious  complications  which  induce  a  state 
of  great  prostration,  while  in  others  it  is  associated  with  great  diminution 
or  entire  suppression  of  urine.  The  delirium  under  these  circumstances 
is  apt  to  be  low  and  muttering,  with  a  tendency  to  pass  into  stupor  or 
profound  coma. 

Vertigo  is  present  more  frequently  and  in  a  more  persistent  form  than 
in  any  other  febrile  disease.  It  was  noticed  as  among  the  occasional 
prodromes,  and  was  especially  severe  for  the  first  few  days  of  the  initial 
paroxysm,  though  it  often  continued  throughout  this  stage  and  recurred 
with  the  relapse.  Occasionally  it  was  complained  of  in  the  recumbent 
position,  but  usually  it  was  excited  only  by  a  change  of  position. 

Wakefulness  was  one  of  the  most  distressing  symptoms  in  all  cases, 
and  appears  to  have  been  noted  in  all  epidemics.  Although  the  severity 
of  the  pain  in  various  parts  of  the  body  and  the  absence  of  blunting  of 
the  perceptions  would  naturally  cause  much  loss  of  sleep,  the  degree  of  the 
insomnia  and  the  obstinate  resistance  it  offers  to  the  action  of  anodynes 
are  apparently  far  in  excess  of  what  could  thus  be  accounted  for.  Parry 
found  that  several  of  his  patients  could  take  as  much  as  three  grains  of 
opium  every  second  hour  throughout  the  afternoon  and  night  without 
either  inducing  sleep  or  causing  contraction  of  the  pupils. 

Convulsions  are  rare  and  of  very  grave  import.  They  may  occur  at 
the  period  just  preceding  crisis,  when  the  nervous  irritation  is  most 
intense,  and  are  then  somewhat  less  indicative  of  a  fatal  result  than  if 
occurring  in  the  course  of  the  paroxysm,  when  they  are  apt  to  be  asso- 
ciated with  extreme  prostration  of  the  nervous  centres,  with  a  tendency 
to  subsequent  fatal  coma.  No  connection  has  been  observed  between 
their  occurrence  and  the  presence  of  albumen  in  the  urine. 

General  tremor  is  rare,  and  was  observed  only  in  those  of  our  cases 
where  there  had  been  habitual  intemperance,  witl/presuniably  a  tendency 
to  delirium  tremens.  Muscular  rigidity  was  noticed  occasionally,  but 
may  have  been  only  apparent,  being  induced  by  the  hypersesthesia  and 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  385 

soreness  which  were  marked  in  some  cases.  The  hypersesthesia  which 
was  observed  was  both  cutaneous  and  muscular,  and  was  attended  with 
tenderness  of  the  body  of  the  muscle,  and  also  of  the  nerve-trunk  sup- 
plying it.  Meschede  speaks  of  opisthotonos  as  a  rare  complication  in 
his  cases. 

Motor  paralysis  involving  single  muscles  or  groups  of  muscles  is  occa- 
sionally noticed,  as  of  the  deltoid  or  of  one  arm  (Meschede).  Parry 
observed  transient  loss  of  power  of  the  extremities  in  several  cases, 
chiefly  during  the  intermission  or  the  period  of  convalescence.  In 
one  of  our  cases  temporary  hemiplegia  occurred,  with  partial  loss  of 
sensation  on  the  aifected  side. 

The  bladder  and  rectum  are  rarely  aifected,  except  in  cases  where  the 
typhoid  state  with  tendency  to  coma  is  present.  Disorders  of  sensation 
are,  however,  much  more  common.  When  motor  palsy  occurs  the  aifected 
part  may  also  be  the  seat  of  impaired  sensibility,  while  in  a  large  pro- 
portion of  all  cases  numbness  of  the  extremities,  with  or  without  a  sense 
of  tingling,  is  complained  of;  out  of  182  cases  we  noted  this  symptom 
in  94,  affecting  the  fingers  alone  in  62,  the  feet  alone  in  6,  and  all  the 
extremities  in  25  cases.  Cutaneous  hypersesthesia  or  partial  anaesthesia 
are  also  occasionally  observed.  But  the  most  noteworthy  and  constant 
symptom  of  this  class  are  the  pains  in  the  muscles  and  joints  which  are 
bitterly  complained  of  by  nearly  all  patients  with  relapsing  fever.  They 
constitute,  indeed,  one  of  the  highly  characteristic  features  of  the  disease, 
and  possess  a  diagnostic  value.  They  may  occur  among  the  rarely  present 
prodromes,  but  usually  they  appear  with  the  chill  and  increase  in  intensity 
during  the  paroxysm  ;  they  may  persist  with  even  greater  severity  during 
the  intermission,  or,  if  they  have  then  subsided,  recur  with  the  relapse, 
and  may  constitute  one  of  the  most  troublesome  hindrances  to  convales- 
cence. It  will  thus  be  seen  that  in  frequency,  severity,  and  persistency 
they  differ  widely  from  the  aching  pains  in  the  extremities  complained 
of  in  typhus  and  other  specific  fevers.  They  are  one  of  the  most  potent 
causes  of  the  extreme  insomnia,  and  are  apt  to  dwell  in  the  mind  of  the 
patient  so  vividly  that  he  dreads  each  relapse  on  this  account,  and  con- 
sequently looks  back  upon  his  attack  of  relapsing  fever  as  a  terribly 
painful  experience.  These  pains  are  usually  described  as  rheumatic  in 
character,  and  several  times  patients  presenting  themselves  at  the  hospital 
on  the  second  or  third  day  of  the  initial  paroxysm  stated  that  they  had 
inflammatory  rheumatism.  As  a  fact,  we  observed  the  utmost  intensity 
of  these  pains  in  a  few  cases  where  the  patients  were  of  marked  rheu- 
matic diathesis.  The  nape  of  the  neck,  the  muscles  of  the  trunk  or 
extremities,  or  the  large  or  small  joints,  or  lower  parts  of  the  spinal 
region,  may  be  the  seat.  At  times  they  extend  along  the  course  of  nerve- 
trunks.  In  character  they  are  described  as  a  deep  intense  aching,  with 
occasional  severe  or  excruciating,  sharp,  lancinating  pains.  Pressure  or 
movement  increases  them.  The  joints  are  not  red  or  swollen  (though 
swelling  may  appear  as  a  sequel),  and  the  pains  seemed  to  us  rather  to  be 
referred  to  the  joints  than  to  be  caused  by  any  local  irritation  therein. 
As  already  stated,  there  is  often  tenderness  of  the  body  of  the  muscles, 
and  this  was  especially  marked  in  many  of  our  cases  on  pressure  along 
the  course  of  the  nerve-trunk. 

Murchison  suggests  that  they  are  due  to  the  circulation  in  the  blood  of  an 

VOL.  I.— 25 


386  RELAPSING  FEVER. 

abnormal  substance,  such  as  uric,  lactic,  or  phosphoric  acid  ;  but  it  appears 
to  us  altogether  probable  that  they  are  rather  to  be  connected  with  states 
of  congestive  irritation  of  the  sheaths  of  the  nerve-trunks  (early  stage 
of  perineuritis),  or  possibly  in  some  cases  of  the  spinal  membranes  also. 
It  is  true  that  they  are  sometimes  shifting  in  their  seat  and  fluctuating  in 
their  severity,  but  this  is  not  inconsistent  with  the  above  suggestion,  while 
the  widespread  irritative  processes  found  in  this  remarkable  disease,  the 
resemblance  of  these  pains  and  the  frequently  attendant  numbness  and 
tingling  to  the  sensations  caused  by  other  forms  of  perineuritis,  and  the 
occasional  development  of  local  palsies  of  a  single  muscle  or  group  of 
muscles,  all  are  in  its  support. 

The  special  senses  are  acute,  sometimes  painfully  so.  The  eyes  are  watery 
and  occasionally  injected,  but  this  latter  condition  is  rare  and  slight  in 
relapsing  as  compared  with  typhus  fever.  At  the  crisis  and  for  a  few  days 
subsequently  wide  dilatation  of  the  pupils  is  not  infrequently  observed. 
Duluess  of  hearing  was  present  during  the  paroxysm  in  14  of  our  cases, 
and  a  few  patients  complained  of  tinnitus ;  but  these  symptoms  are  not 
at  all  common  in  the  disease,  although  it  will  be  seen  hereafter  that 
affections  of  the  middle  ear  are  among  its  sequelse. 

Debility  is  not  such  a  prominent  symptom  as  in  typhus  and  typhoid 
fevers.  Patients  manage  to  drag  themselves  about  for  several  days  dur- 
ing the  initial  paroxysm  with  all  the  symptoms  fully  developed,  and  after 
admission  to  the  hospital  mil  often  be  able  to  help  themselves,  or  even  to 
rise  from  bed,  unless  prevented  by  the  severe  pains  or  the  vertigo.  Still, 
there  are  many  cases,  not  necessarily  of  very  grave  type,  in  which  there  is 
a  marked  sense  of  weariness  and  exhaustion,  and  of  course  in  all  cases  of 
typhoid  character  the  prostration  is  great.  It  must  constantly  be  borne 
in  mind  that  even  when  the  patient  feels  or  seems  able  to  sit  up  he  must 
on  no  account  be  permitted  to  do  so,  since  the  occurrence  of  sudden  and 
fatal  syncope  is  one  of  the  accidents  constantly  to  be  apprehended.  It  is 
not  only  during  the  pyrexia  that  this  precaution  must  be  enforced ;  we 
meet  with  extreme  debility  during  the  intermission  in  some  cases,  and 
syncope  has  followed  exertions  made  at  that  period  as  well  as  at 
others. 

During  the  paroxysms  the  respirations  are  much  accelerated,  at  times 
to  a  greater  degree  than  would  correspond  with  the  pulse-rate,  while  at 
others  extreme  rapidity  of  pulse  may  be  associated  with  moderate  eleva- 
tion of  the  rate  of  respirations. 

^  As  examples  of  the  relation  between  temperature,  pulse,  and  respira- 
tions we  quote  the  following  from  our  records  of  adult  cases  : 

(a)  Temperature,  108°  ;  pulse,  124  j  respiration,  40.  In  the  relapse  ; 
no  chest  trouble. 

(6)  Temperature,  107.5°;  pulse,  120;  respiration,  28;  falling  to  tem- 
perature, 96 ;  pulse,  68;  respiration,  18,  within  twelve  hours,  during 
which  crisis  occurred. 

(c)  Temperature,  107°;  pulse,  144;  respiration,  31.     In  the  relapse. 

(d)  Temperature,  107° ;  pulse,  108 ;  respiration,  44.     Initial  paroxysm  ; 
no  pulmonary  congestion. 

Temperature,  106°;  pulse,  116;  respiration,  28.  Kelapse;  no  pul- 
monary congestion. 

Temperature,  97°  ;  pulse,  76 ;  respiration,  24.     Critical  fall ;  cough, 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  387 

congestion  of  lungs  posteriorly,  and  left  one  relatively  dull  on  per- 
cussion, but  pneumonia  did  not  develop. 

In  many  epidemics  bronchitis,  hypostatic  congestion,  and  pneumonia 
are  of  rare  occurrence,  while  in  others,  as  in  Philadelphia  in  1870,  they 
are  comparatively  frequent  and  lead  to  serious  respiratory  symptoms. 
While  the  pyrexia  was  high  there  was  very  frequently  an  irritative  dry 
cough,  with  the  fine  crepitant  and  subcrepitant  rales  attending  congestion 
and  imperfect  expansion  of  the  lungs  heard  at  the  middle  and  lower  por- 
tions of  the  chest  posteriorly.  In  numerous  instances  the  rales  would 
disappear  entirely  after  a  few  full  inspirations  in  the  sitting  posture,  just 
as  in  the  corresponding  condition  in  typhoid  fever.  But  in  a  consider- 
able proportion  of  all  the  cases  (fully  35  per  cent.)  there  was  more  trouble- 
some bronchial  cough,  associated  with  sonorous,  sibilant  and  subcrepitant 
rales,  with  mucous  or  muco-purulent  expectoration. 

Bronchitis  of  this  character  was  a  source  of  serious  annoyance  to  many 
patients.  In  several  cases  there  was  impaired  resonance  at  the  lower 
margins  of  the  lungs  posteriorly,  with  imperfect  bronchial  respiration, 
but  without  the  symptoms  of  fully-developed  pneumonia.  Such  condi- 
tions were  regarded  as  due  to  hypostatic  congestion,  and  proved  amenable 
to  treatment.  Pneumonia  occurred  in  eleven  cases  out  of  200  recorded 
with  reference  to  this  complication.  It  will  be  more  fully  discussed 
under  the  head  of  Complications.  It  was  attended  with  the  usual 
physical  signs,  and  gave  rise  to  extremely  rapid  and  labored  breathing, 
especially  when  associated  with  painful  enlargement  of  the  liver  and 
spleen.  In  a  case  of  double  pneumonia,  with  enlarged  and  ruptured 
spleen,  the  respirations  were  from  80  to  90  for  two  days,  the  pulse  being 
130  to  136.  It  was  a  very  fatal  complication,  death  resulting  in  all  but 
two  instances. 

Leyden l  has  shown  that  though  the  percentage  of  carbonic  acid  in  the 
air  expired  during  the  pyrexia  is  diminished,  the  total  quantity  exhaled 
is  increased,  the  proportion  being  as  1>5  to  1  in  the  non-febrile  state. 

Elaborate  investigations  have  been  made  of  the  condition  of  the  urine 
in  relapsing  fever  by  numerous  observers,  and  in  the  Philadelphia  epi- 
demic of  1870  we  had  the  great  advantage  of  being  assisted  by  the  dis- 
tinguished chemist,  the  late  Horace  B.  Hare,  who  conducted  an  extensive 
series  of  analyses  in  our  cases.  In  a  number  of  cases  quantitative  anal- 
yses were  continued  daily  throughout  the  entire  course  of  the  disease. 

As  a  rule,  the  quantity  of  the  urine  is  comparatively  free  during  the 
febrile  periods,  very  scanty  at  the  time  of  crisis,  except  in  the  cases  where 
critical  discharges  of  urine  occur,  and  excessive  for  some  days  after  the 
crisis. 

Still,  there  were  not  rare  exceptions,  especially  to  the  first  of  these 
statements.  Thus  on  four  successive  days  of  the  relapse  of  a  severe 
case  with  delirium,  but  without  albumen,  and  which  ultimately  recovered, 
the  analysis  gave — 

Temperature.  Amount  in  com.  .          8p.  gr.  Urea  In  Grm.  Na.  CL 

103                        400  1024                       23.8  2.64 

105  300  1025                        15.27  1.95 

106  500  1024                       24.7  4.3 
106  to  97                    850  1021                       24.735  5.525 

1  "IT.  d.  Resp.  in  Fieber,"  Deutsch.  Arch.  f.  klin.  Med.,  1870,  536,  quoted  by  Murchison. 


388  RELAPSING  FEVEE. 

And  in  another  severe  case,  also  resulting  in  recovery,  the  analysis  was, 
for  two  days  preceding  the  crisis  of  the  initial  paroxysm — 

Amount.  Sp.  gr.  Urea.  Na.  Cl. 

500  1014  12.9  Traces  of  albumen. 

650  1014  15.85  1.365 

After  the  crisis : 

2250  1004  18.9  15.75          No  albumen. 

And  again,  in  another  case  at  the  height  of  the  initial  paroxysm,  within 
twenty-four  hours  of  the  crisis,  no  vomiting,  purging,  or  epistaxis  being 
present ;  temperature  105° ;  only  500  ccm.  was  passed  of  dark  reddish 
colored  urine,  non-albuminous,  and  with  sp.  gr.  1011. 

In  a  fatal  case  there  was  total  suppression  of  urine  for  three  days,  the 
catheter  drawing  off  only  a  few  drops  of  almost  pure  liquid  blood. 

When  crisis  occurs  by  copious  urination  the  discharges  are  frequent, 
large,  and  of  light  color  and  low  specific  gravity. 

The  urine  of  the  intermissions  is  of  similar  character,  and  for  several 
days  after  crisis  it  is  not  rare  to  have  2000  to  2500  ccm.  passed.  The 
largest  amounts  we  noted  were  in  a  man  who  recovered,  and  who  passed 
at  the  crisis  of  the  relapse  and  during  the  following  days  the  amounts 
here  given . 

Amount.  Sp.  Gr.  Urea.  Na.  Cl. 

1000  ccm.  1010  14.9  2.6 


2000 
3550 
2600 
2800 
2500 
2700 


1003  20.2         42.8 

1002  26.625  130.995 

1002  19.24  27.30 

1005  24.96        22.66 

1013  47.25        11.25 

1014  59.13         7.29 


Carter  reports  a  case  where  the  patient  continued  for  two  weeks  after 
the  relapse  to  pass  130  oz.  of  sp.  gr.  1002.6. 

The  amount  of  urea  varies  considerably,  and  is  evidently  under 
the  influence  of  complicated  conditions.  The  rule  appears  to  be  that 
it  increases  during  the  paroxysms,  diminishes  during  the  crisis,  in- 
creases during  the  few  days  following  crisis,  and  then  falls  off  again. 
These  results  are  stated  upon  the  authority  of  Murchison,  quoting  from 
Pribram  and  Robitschek,  Wyss  and  Bock,  and  others.  Our  own  obser- 
vations, however,  while  agreeing  in  the  main  with  these,  show  that  there 
are  numerous  and  important  exceptions,  especially  to  the  occurrence  of 
the  post-febrile  increase  in  the  elimination  of  urea. 

The  largest  amount  of  urea  excreted  in  twenty-four  hours  by  any 
of  our  patients  was  59.13  grammes,  or  912  grains,  on  the  sixth  day 
after  the  end  of  the  relapse,  but  as  much  as  74  grammes  (1142  grains) 
have  been  found. 

Deposits  of  urates  were  very  common  in  the  urine  of  the  paroxysms 
and  of  the  crisis.  The  uric  acid  has  been  found  increased,  and  so  also 
have  the  phosphates,  crystals  of  which  are  frequently  found  mixed  with 
the  urates. 

_The  chlorides  diminish  during  the  paroxysms,  until  just  before  the 
crisis  their  amount  is  very  small,  or  they  may  even  have  disappeared. 
Immediately  after  the  crisis  they  reappear  slowly  or  quickly,  and  even 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  389 

very  large  amounts  may  be  discharged,  as  seen  in  the  figures  given  by 
Hare's  analyses :  2.6  grm.  on  day  of  crisis,  42.8  grm.  the  following 
day,  and  the  enormous  amount  of  130.995  grm.  on  the  next  day.  A 
copious  flow  of  urine  corresponds  with  great  augmentation  in  the  amount 
of  the  chlorides. 

Bile-pigment  was  constantly  present  in  jaundiced  cases,  the  amount 
being  proportioned  to  the  depth  of  the  jaundice  and  the  quantity  of  the 
urine.  Bile-acids  have  been  detected  (Carter  and  Schmidt),  and  also 
leucin  and  tyrosin  (Pribram  and  Robitschek). 

Albumen,  with  or  without  tube-casts,  is  not  uncommonly  found,  and 
traces  of  sugar  have  been  detected  in  a  few  cases.  More  careful  consid- 
eration will  be  given  to  these  under  the  head  of  Complications. 

The  following  appearance  of  the  tongue  has  been  repeatedly  described, 
and  when  present  may  be  regarded  as  possessing  some  diagnostic  value  : 
The  body  of  the  tongue  slightly  swollen,  so  as  to  show  the  impressions 
of  the  teeth,  and  by  the  second  day  the  central  part  of  the  dorsum 
covered  with  a  peculiarly  white  fur,  while  the  edges  and  a  small  trian- 
gular space  at  the  tip  are  clean  and  red.  Such  a  tongue  was  seen  in 
many  cases  at  the  beginning  of  the  Philadelphia  epidemic,  but  later  it 
was  present  in  but  a  small  proportion.  We  find  it  specially  mentioned 
in  97  of  our  recorded  cases,  or  about  50  per  cent.,  the  general  descrip- 
tion being  given  that  it  was  moist,  rather  large,  with  pink,  clear  edges, 
and  a  triangular  clear  space  at  the  tip,  and  with  heavy  white  fur  in  the 
centre. 

Some  accurate  observers,  as  Wyss  and  Bock,  did  not  notice  anything 
peculiar  about  the  tongue,  but  merely  described  it  as  moist  and  coated 
with  a  thick  white  fur.  The  tongue  often  remains  moist  throughout  the 
case,  the  coat  becoming  yellowish,  and  later  brownish.  Of  course  if 
there  is  nasal  obstruction  from  epistaxis  or  catarrh,  and  the  patient 
breathes  through  the  mouth,  the  tongue  will  soon  become  dry  and 
brown ;  but  in  addition,  this  state  of  the  tongue  with  sordes  on  the 
teeth  and  lips,  appears  in  a  small  proportion  of  cases  (3  per  cent.,  Zuel- 
zer;  12  per  cent,  of  our  own  patients)  in  conjunction  with  grave  typhoid 
symptoms. 

During  the  intermissions  the  tongue  clears  off  quite  rapidly,  unless 
marked  gastric  disturbance  persists,  but  regains  its  former  state  as  soon  as 
the  relapse  occurs. 

In  rare  cases  the  tongue  is  red  and  glazed,  and  Parry  and  ourselves 
observed  peculiar  painful  cracks  continuing  obstinately  after  the  relapse. 
It  is  apparent,  therefore,  that  the  tongue  presents  evidences  of  vitiated 
secretions,  of  local  catarrh  of  the  buccal  mucous  membranes,  and  of  the 
high  grade  of  gastric  irritation  so  constantly  attendant  on  this  disease. 

As  a  rule,  there  is  complete  anorexia  during  all  of  the  febrile  par- 
oxysm, while  in  the  intermission  the  appetite  soon  returns,  and  is  some- 
times truly  ravenous.  We  did  not,  however,  observe  in  any  case  a 
voracious  appetite  during  the  febrile  paroxysms,  such  as  was  very  often 
present  during  the  London  epidemic  of  1843  and  the  Irish  epidemic  of 
1847,  and  is  particularly  mentioned  by  Murchison.1 

Thirst  is  constant  and  intense,  and  is  excited  not  only  by  the  high  tem- 
perature, but  by  the  irritation  of  the  stomach ;  it  may  continue  through 

1  Op.  dt,,  p.  360. 


390  '   RELAPSING  FEVER. 

the  intermission,  when  natural  appetite  and  the  power  of  digesting  solid 
food  have  returned. 

Nausea  and  vomiting  are  always  prominent  symptoms,  and  most  espe- 
cially so  in  children.  In  some  cases  nausea  occurs  among  the  prodromes ; 
and  occasionally  the  attack  is  ushered  in  by  profuse  and  uncontrollable 
vomiting  instead  of  by  a  chill,  and  the  stomach  continues  entirely  non- 
retentive  throughout  the  paroxysm.  Vomiting  is  not  usually  so  obstinate 
and  severe,  however,  and  with  extreme  care  in  feeding  and  medication  it 
will  often  be  allayed  after  two  or  three  days.  It  occasionally  recurs  pro- 
fusely immediately  before  the  crisis,  as  in  the  case  given  in  full  at  page 
394,  where  after  a  violent  attack  of  vomiting  the  patient  fell  asleep,  and 
awakened  in  a  profuse  sweat. 

This  symptom  was  present  in  146  out  of  182  of  our  cases,  was  usually 
confined  to  the  febrile  stages,  and  was,  as  a  rule,  worse  in  the  initial 
paroxysm. 

The  matters  vomited  consist  of  the  ingesta  colored  with  bile,  of  glairy 
mucus  tinged  with  bile,  or  of  green  bile,  sometimes  in  considerable  quan- 
tity. Small  particles  of  blood  may  occasionally  be  noticed  in  the  matters 
vomited,  and  in  rare  instances  true  hematemesis  occurs.  Judging 
from  the  frequency  with  which  in  fatal  cases  we  find  ecchymoses  of 
the  gastric  mucous  membranes  with  blood-stained  mucus  in  the  cavity 
of  the  stomach,  we  should  expect  black  vomit  to  be  more  often  observed 
than  is  the  case.  Murchison  (p.  361)  states  that  it  was  not  noted  in  any 
British  epidemic  except  that  of  1843,  and  then  it  occurred  in  only  a  few 
cases,  although  it  seems  to  have  varied  in  frequency  at  different  places. 
Arrott  at  that  time  described  the  symptoms  as  "quite  common"  in 
the  fever  at  Dundee ;  and  "W.  Reid  of  Glasgow  recorded  the  case  of  a 
girl  in  the  same  epidemic  who  vomited  large  quantities  of  clotted  blood, 
and  who  also  had  hemorrhages  from  the  bowels  and  from  the  ears.  It 
has  occasionally  been  observed  in  the  continental  epidemics.  It  was 
observed  in  four  of  our  cases.  By  all  who  have  observed  blood-vomiting 
in  relapsing  fever  it  is  recognized  as  a  symptom  of  almost  invariably 
fatal  import.  Three  of  the  four  cases  in  which  we  observed  it  proved 
fatal,  but  one  patient,  who  had  copious  hematemesis,  both  at  the  close  of 
the  first  relapse  and  during  the  second  relapse,  recovered  after  a  desperate 
and  protracted  struggle. 

The  bowels  are  not  so  often  constipated  as  in  typhus,  and  it  is  not  rare 
for  diarrhoea  and  constipation  to  alternate,  or  for  the  bowels  to  be  loose 
throughout  the  paroxysms.  They  are  noted  in  181  of  our  cases  as  regu- 
lar in  32,  loose  iu  61,  and  constipated  in  88  instances.  Meschede  states 
that  diarrhoea  was  present  in  nearly  one-half  the  cases  of  the  Konigsberg 
epidemic  of  1879,  though  usually  as  a  late  symptom,  the  early  stage 
being  marked  by  constipation,  which  in  a  few  cases  persisted  throughout. 
The  stools  may  be  consistent  and  dark  or  thin  and  bilious,  or  occasionally, 
when  gastric  or  intestinal  hemorrhage  has  occurred,  they  contain  black 
coffee-ground  matter.  Occasionally,  the  diarrhoea  has  a  critical  character, 
and  occurs  at  the  close  either  of  the  initial  paroxysm  or  of  the  relapse, 
though  it  may  not  entirely  substitute  sweating.  This  mode  of  crisis 
occurred  in  two  of  our  cases,  but  Douglas  observed  it  in  6  out  of  33 
cases. 

The  abdomen  may  appear  enlarged,  but  this  is  as  much  the  result  of  the 


DETAILED  STUDY  OF  SPECIAL  CONDITIONS.  391 

enlargement  of  the  liver  and  spleen  as  of  gaseous  distension,  which  is  rarely 
present  in  a  high  degree.  Abdominal  pain  is  almost  constant,  and  may  be 
very  severe.  It  is  especially  mentioned  as  having  been  present  in  148  out 
of  182  of  our  cases.  It  commonly  extends  throughout  the  epigastrium  and 
both  hypochondria,  but  may  be  present  on  one  or  the  other  side,  while, 
on  the  other  hand,  there  may  be  general  abdominal  soreness.  It  is  asso- 
ciated with  tenderness  on  pressure,  which  may  be  so  great  as  to  hinder 
the  movements  of  the  trunk  and  to  render  the  descent  of  the  diaphragm 
in  breathing  painful.  This  may  be  the  first  symptom  to  usher  in  the 
attack,  and  it  occurs  at  an  early  stage  in  most  cases.  Many  of  our 
patients  when  admitted  to  the  hospital  had  already  been  cupped  or  blis- 
tered over  the  region  of  the  liver  or  spleen.  This  distress  was  greatest 
in  cases  attended  with  jaundice  and  marked  gastric  irritation ;  and  Parry 
reports  that  in  his  cases  (occurring  in  the  early  part  of  the  epidemic 
which  we  studied)  jaundice  was  rare  (4  out  of  37),  and  abdominal  ten- 
derness was  not  present.  It  is  not  difficult  to  explain  its  almost 
universal  presence  in  view  of  the  severe  lesions  of  the  substance  of 
the  liver  and  spleen,  the  distension  of  their  capsules  from  the  acute 
swelling  of  the  organs,  and  the  implication  of  the  coats  of  the  stomach. 

Enlargement  of  the  liver  and  spleen  probably  exists  to  a  greater  or 
less  degree  in  every  case  of  relapsing  fever  without  exception.  This 
statement  is  based  on  the  concurrent  testimony  of  accurate  observers  in 
all  epidemics  and  upon  the  evidence  of  post-mortem  examinations. 

The  enlargement  of  the  liver  can  be  demonstrated  in  nearly  all 
instances  by  careful  percussion.  It  varies  greatly  in  its  degree,  however ; 
in  mild  cases,  it  may  be  slight,  while  in  severe  ones  the  liver  may  be 
found  extending  at  least  three  inches  below  the  margin  of  the  ribs 
within  three  or  four  days  from  the  initial  symptom.  In  our  own  fatal 
cases  the  weight  of  the  liver  averaged  between  four  and  four  and  a  half 
pounds. 

The  spleen  enlarges  even  more  rapidly  and  to  a  greater  degree  than  the 
liver.  In  fact,  its  enlargement  in  relapsing  fever  is  greater  than  in  any 
other  acute  disease.  It  may  be  detected  by  percussion  by  the  first  or 
second  day,  and  may  then  continue  to  rapidly  increase  until  by  the  fifth 
or  sixth  day  a  large  painful  mass  is  readily  recognized  by  palpation  and 
percussion,  or  even  by  inspection.  The  organ  often  weighs  twelve  or 
sixteen  ounces,  not  rarely  twenty  to  twenty-five,  and,  as  an  instance  of 
the  extreme  limit  that  may  be  reached,  Kiittner  reports  sixty-eight  ounces 
in  one  case.  This  enlargement  is  greatest  toward  the  close  of  the  first 
or  second  paroxysm,  and  subsides  quite  rapidly  in  most  cases  during  the 
intermissions  and  as  convalescence  progresses ;  we  have,  however,  known 
a  moderate  degree  of  enlargement  of  the  spleen  to  persist  for  some  weeks 
after  the  crisis  of  the  last  paroxysm. 

The  occurrence  of  jaundice  in  a  considerable  proportion  of  cases  of 
relapsing  fever  is  a  clinical  fact  of  much  interest.  Its  frequency  varies 
greatly  in  different  epidemics,  and  even  at  different  stages  of  the  same 
epidemic.  At  times  it  is  rarely  met  with  (1  out  of  14,  20,  or  35  cases), 
while  in  other  epidemics  it  is  present  in  1  out  of  every  6,  5,  or  even  4 
cases.  Of  182  of  our  own  cases  jaundice  is  recorded  in  45,  or  exactly 
in  1  out  of  4.  According  to  our  observation,  it  occurred  in  a  larger 
proportion  of  cases  among  negroes  (14  out  of  32)  than  in  whites,  and 


392  RELAPSING  FEVER. 

StillS  states  that  it  occurred  in  nearly  every  such  case  that  came  under 
his  observation.  When  present  it  usually  occurs  during  the  first  par- 
oxysm, and  may  be  limited  to  that  stage ;  or,  again,  it  may  be  present  in 
each  of  ^three  or  four  successive  paroxysms  in  the  same  case ;  or,  finally, 
it  may  first  appear  in  the  relapse.  As  a  rule,  it  subsides  speedily  after 
the  crisis,  though  Carter  states  that  in  two  or  three  cases  the  symptom 
made  its  first  appearance  just  after  the  crisis.  It  varied  from  the  slight- 
est yellow  tinge  of  the  conjunctiva  to  the  deepest  staining  of  the  whole 
surface.  The  urine  is  discolored  in  proportion  to  the  intensity  of  the 
jaundice,  and  the  serum  of  a  blister  will  be  deeply  tinged.  It  must  be 
carefully  noted,  however,  that  the  feces  are  not  decolorized,  but,  as 
already  described,  contain  fully  a  normal  amount  of  biliary  coloring 
matter.  This  fact  has  been  relied  on  by  Murchison  and  others  to  prove 
that  the  jaundice  in  relapsing  fever  is  purely  dependent  on  the  morbid 
state  of  the  blood,  and  is  not  due  to  obstruction  of  the  biliary  passages ; 
and  we  are  prepared  to  admit  that  the  element  of  blood-dyscrasia  may 
play  a  part  in  the  production  of  the  jaundice.  The  anatomical  evidence, 
however,  given  on  page  414,  renders  it  probable  that  in  many  cases  ai 
least  the  essential  cause  is  to  be  sought  in  an  obstructed  state  of  the 
minute  gall-ducts  of  certain  areas  of  the  liver.  If  the  main  hepatic 
duct  or  the  common  duct  were  obstructed,  there  would  of  course  be 
paleness  of  the  feces,  as  the  bile  would  be  prevented  from  entering  the 
duodenum.  But  when  a  large  amount  of  highly-colored  bile  is  being 
secreted,  as  in  relapsing  fever,  it  seems  clear  that  the  obstruction  of  a 
certain  number  of  minute  ducts  would  cause  sufficient  resorption  of  the 
bile  to  induce  jaundice  of  varying  degrees  of  intensity,  while  at  the  same 
time  allowing  a  flow  of  bile  through  the  patulous  ducts. 

Jaundice  must  be  regarded  as  an  unfavorable  or  even  a  grave  symp- 
tom in  relapsing  fever,  but  not  to  the  extent  that  would  be  the  case 
^ere  it  directly  connected  with  the  intensity  of  the  blood-dyscrasia. 
Many  of  the  most  violent  cases  in  all  epidemics  have  been  unattended 
with  jaundice,  while,  on  the  other  hand,  many  cases  in  which  jaun- 
dice has  been  marked  "  have  had  not  a  single  symptom  that  made  them 
differ  from  ordinary  cases  excepting  the  yellowness"  (Henderson).  It 
follows,  therefore,  that  the  gravity  of  a  certain  proportion  of  the  jaun- 
diced Ceases  does  not  follow  directly  from  the  presence  of  bile  in  the  blood 
and  tissues,  but  from  the  lesions  of  the  liver  of  which  the  jaundice  is  a 
symptom,  or  from  the  existence  of  widespread  irritation  of  many  parts 
of  the  body.  Thus  jaundice  is  present  in  an  unusually  large  proportion 
»t  the  cases  attended  with  marked  enlargement  and  tenderness  of  the 
li  ver  and  spleen,  whether  vomiting  is  also  present  in  extreme  degree  or 
not.  It  was  noteworthy  that  it  was  disproportionately  frequent  in 
negroes,  and  that  in  these  patients  the  lesions  of  the  liver  and  spleen 
were  also  unusually  pronounced.  Again,  jaundice  is  present  in  an 
unusually  large  proportion  of  the  cases  attended  with  low  delirium, 
extreme  prostration,  defective  secretion  of  urine,  and  the  other  features 
of  the  typhoid  state — so  much  so  that  such  cases  have  been  described  by 
various  writers  under  the  name  of  bilious  typhoid  fever. 

But,  as  already  stated,  it  is  not  legitimate  to  consider  the  gravity  of 
these  cases  as  the  result  of  the  jaundice,  but  rather  that  the  jaundice  is 
merely  a  symptom  of  the  widespread  irritative  lesions,  which  in  such 


SYMPTOMS  ATTENDING  THE  CRISIS.— CONVALESCENCE.      393 

cases  not  only  involve  the  liver  and  spleen,  but  the  kidneys,  the  lungs, 
the  marrow  of  the  bones,  the  muscle  of  the  heart,  and  occasionally  the 
membranes  or  substance  of  the  brain  and  cord. 

The  true  prognostic  value  of  jaundice  in  relapsing  fever  would  then 
seem  to  be,  that  of  itself  it  indicates  merely  an  obstructed  state  of  a 
certain  number  of  minute  bile-ducts,  but  that  its  presence  justifies  the 
apprehension  that  the  local  lesions  of  the  liver  may  become  excessively 
developed,  or  that  there  is  a  tendency  to  widespread  tissue-changes  which 
at  a  later  stage  of  the  disease  may  lead  to  the  appearance  of  grave  con- 
stitutional disturbance  of  a  typhoid  type. 

Hemorrhage  in  relapsing  fever  is  not  uncommon,  and  may  occur  from 
various  surfaces.  Epistaxis  is,  however,  the  only  form  which  is  frequent 
enough  to  justify  being  regarded  as  a  symptom.  It  usually  occurs  in 
from  5  to  15  per  cent,  of  cases  of  relapsing  fever,  but  in  the  Philadel- 
phia epidemic  it  was  much  more  frequent  than  this,  occurring  in  not  less 
than  83  out  of  182  of  our  cases.  It  was  not  more  frequent  or  profuse 
in  grave  cases  than  in  those  of  ordinary  severity,  and  consequently  could 
not  be  regarded  as  a  reliable  indication  of  the  intensity  of  the  blood- 
dyscrasia.  Although  ordinarily  moderate  in  amount,  it  was  occasionally 
so  copious  and  persistent  as  to  require  prolonged  plugging  of  the  nostrils,  and 
in  at  least  one  case  contributed  chiefly  to  cause  (an  intense  anaemia,  which 
long  delayed  convalescence.  It  occurs  at  all  periods  of  the  paroxysms, 
but  more  commonly  toward  the  close.  In  fifteen  of  our  cases  extraordi- 
narily profuse  epistaxis  attended  the  crisis,  and  evidently  replaced  in  part 
the  copious  sweating  by  which  the  paroxysm  more  commonly  terminates. 

SYMPTOMS  ATTENDING  THE  CRISIS. — We  have  already  described  the 
aggravation  of  all  the  symptoms  which  immediately  precedes  the  crisis  in 
typical  cases  of  relapsing  fever,  and  the  abrupt  fall  of  temperature,  and 
usually  of  the  pulse,  that  follows.  But  this  extraordinary  change  is 
nearly  always  attended  with  some  profuse  critical  discharge,  of  which 
sweating  is  by  far  the  most  common,  though  copious  epistaxis, 
metrorrhagia,  diarrhrea,  or  vomiting  may  also  occur,  and  to  a  greater  or 
less  degree,  but  seldom  entirely,  replace  the  sweating.  In  182  cases  in 
which  we  carefully  noted  the  mode  of  termination  of  the  paroxysm  there 
was  no  definite  crisis  (termination  by  lysis  or  gradual  and  irregular  defer- 
vescence) in  76 ;  profuse  sweating,  89 ;  profuse  epistaxis,  15 ;  profuse 
diarrhoea,  2. 

In  most  epidemics  the  proportion  of  true  crises  is  greater  than  in  the 
above  table — a  fact  dependent  upon  the  unusually  severe  and  complicated 
form  of  the  disease  which  we  were  studying.  The  beginning  of  the 
sweat  may  be  preceded  by  chilliness  or  rigors,  by  extreme  and  dangerous 
prostration,  or  by  violent  nervous  disturbances ;  or  there  may  be  an 
attack  of  profuse  vomiting,  followed  by  sleep,  during  which  sweating 
begins.  The  sweat  may  be  moderate  in  amount,  but  is  often  extraordi- 
narily copious  ;  the  patient  is  literally  bathed  in  it,  the  bed-  and  body- 
clothing  is  saturated,  and  we  have  seen  the  mattress  saturated.  It  has  an 
acid  reaction,  but  we  do  not  know  of  any  accurate  analyses  of  it.  Some 
writers  have  attributed  to  it  a  characteristic  disagreeable  odor,  but  we  did 
not  notice  any  in  our  cases  that  could  be  considered  peculiar  to  this  dis- 
ease. 

CONVALESCENCE. — We  have  already  stated  the  average  duration  of 


394  RELAPSING  FEVER. 

relapsing  fever  to  be  eighteen  or  twenty  days,  while  the  extreme  limits 
are  from  eighteen  to  ninety  days.  Despite  the  fact,  however,  that  the 
mortality  is  in  most  epidemics  only  about  5  or  7  per  cent. — greatly 
less,  therefore,  than  in  typhus  fever — the  convalescence  from  relapsing 
fever  is  frequently  slow  and  protracted.  The  obvious  cause  is,  just  as  in 
the  case  of  typhoid  fever,  the  existence  of  numerous  and  serious  lesions 
of  the  solids  and  the  tendency  to  many  troublesome  complications  and 
sequelae.  We  have,  however,  seen  many  instances  of  rapid  recovery  of 
strength  and  health,  even  after  prolonged  attacks  with  several  successive 
relapses. 

The   following  case  is   quoted   partly  on   account  of  the   numerous 
relapses,  and  the  long  duration  of  the  sickness : 

B.  B.  Y.,  medical  student,  was  much  exposed  to  the  contagion  of 
relapsing  fever  in  the  wards  of  the  Philadelphia  Hospital  during  the 
spring  of  1870,  and  in  May  had  an  attack  apparently  of  this  disease, 
which,  however,  subsided  in  four  or  five  days  and  was  followed  by  no 
immediate  relapse.  He  continued  his  attendance  at  the  hospital  during 
the  remainder  of  May  and  the  whole  of  June ;  in  July  took  a  trip  to 
the  South,  where  there  was  no  relapsing  fever  prevailing,  and  after  exert- 
ing himself  for  several  days  during  intensely  hot  weather,  he  became 
sleepless  and  much  prostrated.  He  returned  home,  and  after  recovering 
from  the  fatigue  felt  quite  well  for  about  a  week,  until  3  A.  M.,  August 
1st,  when  he  was  attacked  with  a  severe  chill,  followed  by  great  insomnia, 
obstinate  vomiting,  intense  headache,  especially  in  the  back  of  the  neck, 
occasional  sweating,  violent  fever,  recurrence  of  very  severe  chill  the  fol- 
lowing day  at  11  A.  M.,  epigastric  and  hypochondriac  tenderness,  decided 
jaundice,  costive  bowels,  and  scanty,  high-colored  urine.  This  paroxysm 
lasted  till  the  morning  of  August  9th,  when  severe  vomiting  took  place, 
followed  by  sleep,  during  which  crisis  occurred  by  drenching  sweat  last- 
ing several  hours.  Appetite  and  strength  soon  began  to  return,  though 
some  jaundice  persisted,  and  by  August  17th  he  felt  able  to  drive  out  a 
short  distance,  and  retired  feeling  somewhat  fatigued.  He  awoke  with 
pain  in  the  back  of  the  neck,  which  continued  increasing  till  11  A.  M., 
August  18th  (second  paroxysm),  when  a  severe  chill  occurred,  lasting 
three  hours  and  followed  by  the  same  train  of  symptoms,  including  jaun- 
dice, which  persisted  five  days,  till  Aug.  23d,  when  crisis  again  occurred 
by  sweating.  On  the  24th  he  felt  well  enough  to  use  slight  exercise,  which 
was  followed  by  prostration  and  by  a  return  of  chill  (third  paroxysm) 
the  next  day  at  11  A.  M.,  with  subsequent  headache,  fever,  irregular 
sweats,  etc.,  lasting  but  one  day.  Again  felt  well  until  Aug.  30th,  when 
he  was  attacked  (fourth  paroxysm)  at  11  A.  M.  with  severe  chill,  lasting 
three  hours,  followed  by  severe  paroxysm,  lasting  six  days,  till  Sept.  5th, 
when  crisis  again  occurred  by  sweating.  Again  felt  well  for  eight  days, 
until  Sept.  13th,  when  the  fifth  paroxysm  occurred,  lasting  five  days, 
ending  Sept.  18th  by  critical  sweating.  This  was  followed  by  an  inter- 
mission of  nine  days,  until  Sept.  27th,  at  11  A.  M.,  when  the  sixth  parox- 
ysm occurred,  lasting  four  days,  and  less  severe  than  the  preceding  ones. 
This  was  followed  by  an  intermission  of  ten  days,  till  Oct.  llth,  when 
the  seventh  paroxysm  occurred  at  the  same  hour  of  the  day,  and  lasted 
three  days.  He  then  went  sixty  miles  from  home  to  a  fine,  pine-bearing 
district,  and  enjoyed  an  intermission  of  eleven  days,  when  the  eighth  and 


VARIETIES.  395 

last  paroxysm  occurred  at  the  same  hour,  and  lasted  three  dajs,  until 
Oct.  25th.  His  convalescence  was  very  satisfactory,  and  he  was  enabled 
to  resume  his  studies  by  the  middle  of  November.  No  sequelae  occurred. 
In  1878  Dr.  Y.,  who  had  been  working  very  steadily  with  a  rapidly- 
growing  practice,  was  attacked  with  severe  typhoid  fever,  with  grave  ner- 
vous symptoms  and  with  albumen  and  tube-casts  in  the  urine,  and  died  on 
the  twelfth  day. 

It  will  thus  be  seen  that  in  this  unusually  protracted  case  there  were 
seven  distinct  relapses,  one  of  which  was  brief  and  interrupted  one  of 
the  regular  intermissions,  while  the  rest  were  all  severe. 
Duration  of  1st  paroxysm,  violent,          8  days.         1st  intermission,  9  days. 


2d 

3d 

4th 

5th 

6th 

7th 

8th 


violent,  5     <f  2d 

less  violent,  1  day.  3d 

severe,  6  days.  4th 

severe,  5     "  5th 

less  severe,  4     "  6th 

less  severe,  3     "  7th 


1 


6  days. 


10 

11  days,  followed  by 


mild,  3     "  convalescence. 

The  total  duration  of  the  case,  which  was  entirely  free  from  complications, 
was  therefore  ninety  days. 

VAEIETIES. — The  foregoing  clinical  description  prepares  us  to  appre- 
ciate the  varieties  of  relapsing  fever  that  may  be  said  to  exist.  They  con- 
sist of — 

The  abortive  form,  in  which  a  single  paroxysm  of  variable  length  and 
severity  occurs,  terminating  in  a  critical  fall  of  temperature  and  usually 
with  some  critical  discharge,  but  not  followed  by  any  relapse.  There  can 
be  no  doubt  of  the  existence  of  such  cases,  although  they  are  not  common  ; 
and  at  times  the  paroxysm  is  so  slight  that  were  it  not  for  the  known 
exposure  of  the  individual  to  the  prevalent  epidemic  influence,  in  the 
absence  of  any  other  adequate  cause,  the  case  might  readily  be  regarded 
as  one  of  non-specific  febricula.  The  caution  must,  however,  be  borne 
in  mind  as  to  the  occurrence  of  relapses  of  such  extreme  shortness  of 
duration  (less  even  than  twenty-four  hours)  as  to  readily  escape  notice 
unless  a  careful  watch  be  kept  for  their  detection. 

The  ordinary  or  typical  form,  including  the  cases  with  one  or  two 
relapses,  presenting  the  usual  variations  in  the  severity  of  the  symptoms 
and  in  the  duration  of  the  paroxysms  and  of  the  intermissions. 

The  multiple  or  protracted  form,  if  it  be  thought  desirable  to  thus  par- 
ticularize cases  presenting  an  excessive  and  unusual  number  of  relapses,  as 
three,  four,  five,  six,  or  even  seven. 

The  grave  or  subintrant  form,  which  is  designed  to  include  the  highly 
congestive  form  of  Cormack  and  the  bilious  typhoid  of  Griesinger  and 
Lebert. 

Under  another  heading  (see  relations  to  other  diseases,  p.  420)  we  shall 
give  reasons  for  regarding  the  bilious  typhoid  fever  of  Griesinger  and 
Lebert  as  merely  a  form  of  relapsing  fever,  with  which  a  certain  propor- 
tion of  cases  of  true  typhoid  fever  complicated  with  hepatic  catarrh  may 
have  been  included. 

The  characteristics  of  this  grave  subintrant  form  are  as  follows :  Jaun- 
dice, occasionally  absent,  but  usually  present  in  an  intense  degree ;  marked 
enlargement  of  the  liver  and  spleen ;  a  tendency  to  hemorrhage  from 
various  mucous  surfaces ;  extreme  prostration ;  defective  or  suppressed 


396  RELAPSING  FEVER. 

secretion  of  urine ;  hypostatic  congestion  or  inflammation  of  the  lungs  in 
a  large  proportion  of  cases ;  dry  brownish  tongue ;  low  muttering  delir- 
[om,  often  passing  into  stupor  or  coma ;  hiccough  ;  imperfect  crisis  ;  and 
a  continuance  of  some  morbid  phenomena,  so  that  merely  a  remission 
occurs  to  separate  the  paroxysms ;  and  a  high  percentage  of  mortality. 
The  great  modification  of  the  intermission  which  is  so  highly  character- 
istic of  typhoid  relapsing  fever  is  doubtless  due  in  chief  part  to  the  serious 
local  lesions  developed,  and  seems  to  justify  the  name  of  subintrant  as 
above  suggested.  The  course  of  such  fever  is  well  illustrated  by  the 
following  case,  in  which  the  characters  of  typhoid  relapsing  fever  were 
present  in  the  highest  degree,  death  occurring  on  the  fifteenth  day : 

Charles  Hood,  colored,  set.  28,  of  temperate  habits,  was  taken  ill  on 
April  5,  1870,  after  malaise  lasting  thirty-six  hours,  with  fever,  nausea 
and  vomiting,  headache,  and  general  aching  throughout  body ;  and  was 
admitted  to  the  hospital  April  6th.  There  was  already  marked  jaundice, 
and  epistaxis  had  occurred ;  there  were  also  insomnia ;  wandering  delir- 
ium ;  extreme  tenderness  over  the  liver  and  spleen,  both  of  which  were 
enlarged ;  dryness  of  tongue,  vomiting,  and  distension  of  the  abdomen. 
These  symptoms  continued,  his  condition  becoming  daily  more  aggravated. 
Restless  delirium  alternated  with  heavy  sopor.  The  jaundice  grew  deeper. 
Marked  digital  formication  existed,  but  the  arthritic  pains  were  not  so 
severe  as  in  ordinary  cases.  The  tongue  was  dry  and  of  a  red  orange 
color.  Profuse  epistaxis  occurred  on  the  seventh  day  of  the  disease, 
requiring  plugging  of  both  anterior  and  posterior  nares,  and  followed  by 
great  prostration.  A  gradual  fall  in  the  temperature  occurred  during  the 
sixth,  seventh,  and  eighth  days,  reaching  99°  on  the  latter  day.  During 
this  decline  the  delirium  ceased  and  the  mind  remained  merely  dull ;  the 
jaundice  decreased,  as  did  also  the  tenderness  of  the  hypochondriac  zone. 
The  pulse  and  respirations  improved,  and  diarrhoea  ceased.  The  improve- 
ment was  but  brief;  for  about  eighteen  hours  he  lay  apyretic,  with  cool 
hands  and  feet,  and  with  eyes  closed  and  mind  dull  but  free  from  dilir- 
ium.  Fever  then  reappeared  and  with  the  ascent  of  the  temperature  the 
unfavorable  symptoms  recurred.  The  relapse  lasted  but  two  days,  and  was 
followed  by  irregular  decline  of  fever  till  death  occurred  on  the  fifteenth 
day  of  the  disease.  Obstinate  hiccough  appeared  on  the  eleventh  day,  and 
continued,  accompanied  with  occasional  vomiting  on  the  fourteenth  day. 
Delirium  alternating  with  sopor  reappeared.  Jaundice  again  became 
marked,  and  again  there  was  extreme  tenderness  over  the  liver  and 
spleen.  The  pulse  grew  small  and  feeble,  the  respirations  shallow  and 
labored,  with  an  expiratory  moan.  Cough  began  on  the  twelfth  day,  and 
was  soon  followed  by  the  physical  signs  of  pneumonia  of  the  lower  lobe 
of  both  lungs.  The  urine  continued  free  from  albumen.  The  patient 
sank  into  deeper  coma,  and  died  on  the  fifteenth  day.  Post-mortem 
examination  showed  highly-developed  characteristic  lesions  of  the  spleen 
and  liver,  with  red  hepatization  of  lower  lobe  of  both  lungs.  There  was 
no  affection  of  the  glands  of  Peyer.  The  course  of  the  fever  is  shown 
in  the  following  tracing  (see  Fig.  22). 

COMPLICATIONS  AND  SEQUELJE. — As  would  be  anticipated  from  what 
has  been  said  of  the  wide  range  of  the  symptoms  and  of  the  remarkable 
course  of  the  temperature  in  relapsing  fever,  there  are  many  complica- 
tions and  sequelae  liable  to  occur,  and  which  require  special  consideration. 


COMPLICATIONS  AND  SEQUELAE. 


397 


They  may  be  classified  according  as  they  affect  the  febrile  movement,  the 
state  of  the  blood,  or  one  or  other  of  the  groups  of  organs. 

We  have  already  described  the  various  irregularities  presented  by  the 
febrile  paroxysms  and  the  intermissions,  and  no  further  allusion  need  be 
made  to  mere  variations  in  length,  severity,  or  number  of  the  former. 
In  rare  cases,  however,  a  peculiarity  is  presented,  usually  in  the  first 
intermission,  which  is  difficult  of  explanation.  About  twenty-four  hours 

FIG.  22. 


From  a  case  of  the  bilious  typhoid  or  grave  subintrant  form  of  Relapsing  Fever.    See  p.  396. 


after  an  apparently  complete  crisis,  with  a  fall  of  temperature  to  a  sub- 
normal point,  there  may  be  a  sudden  and  rapid  rise  or  rebound  of  tem- 
perature to  104°  or  105°,  attended  with  distressing  symptoms  of  high 
fever,  but  lasting  only  twenty-four  or  forty-eight  hours.  A  good  exam- 
ple of  this  is  given  in  the  case  described  on  page  394 ;  and  Carter l 
cites  several  examples  of  it  terminating  either  in  recovery  or  in  rapid 
death.  He  asserts  that  examinations  of  the  blood  during  such  post- 
critical  febrile  rebounds  invariably  showed  an  absence  of  spirilla,  so 
that  in  his  opinion  such  fever  must  be  considered  non-specific.  Their 
explanation  seems  difficult,  since  the  pyrexia  is  too  brief  to  be  associated 
with  any  local  inflammatory  complication. 

More  frequent  and  serious  is  the  protracted  post-critical  pyrexia  which 
we  have  already  described  as  modifying  the  interval,  so  as  to  produce  a 
subintrant  type  by  maintaining  continuous  though  irregular  fever  until 
the  accession  of  the  relapse,  unless  cut  short  by  death.  This  post-critical 
fever  is  non-specific,  is  unattended  with  spirilla  in  the  blood,  and  is  to  be 
associated  with  the  extensive  irritative  processes  in  the  liver,  spleen,  kid- 
neys, lungs,  and  other  parts  that  are  present  in  these  grave  and  compli- 

1  Op.  tit.,  p.  172. 


398  RELAPSING  FEVER. 

cated  cases.  It  is  to  be  noted  that  the  course  of  those  paroxysms  which 
terminate  in  lysis  indicates  that  they  may  represent  a  milder  type  of  the 
above  process. 

The  peculiarities  of  the  delirium,  amounting  sometimes  to  maniacal 
excitement,  which  attends  some  cases  of  relapsing  fever,  has  been  fully 
described. 

Less  common  are  the  following :  mental  hebetude,  lasting  some  days  or 
even  weeks  after  the  close  of  the  last  paroxysm,  or,  as  in  a  case  of  Carter's, 
gradually  increasing  mental  feebleness,  terminating  in  imbecility.  In 
such  cases  suspicion  must  arise  of  the  occurrence  of  some  local  lesion  of 
the  membranes  or  substance  of  the  brain. 

Partial  palsy  is  mentioned  by  numerous  authors  as  occurring  during  or 
shortly  after  attacks  of  relapsing  fever.  Paralysis  of  one  or  both  deltoids 
has  been  noted,  the  latter  by  Cormack,  who  saw  it  continue  ten  days  after 
the  patient  was  well  in  all  other  respects.  Temporary  paralysis  of  the 
forearm  (Douglas)  or  of  the  whole  arm  (Parry,  Meschede)  has  been 
observed ;  and  Parry  also  describes  loss  of  power  in  the  legs  lasting 
for  one  week.  In  one  of  our  cases  temporary  loss  of  power  of  the  left 
arm  and  leg  occurred,  attended  with  such  impairment  of  sensibility  that 
the  woman  had  to  feel  for  the  fingers  of  the  left  hand  to  assure  herself 
of  their  existence.  This  loss  of  power  occurred  during  the  initial  par- 
oxysm, and  gradually  passed  away,  but  she  was  unable  to  stand  alone  on 
the  thirty-first  day  of  the  disease.  In  a  case  reported  by  Tennent1  facial 
palsy  was  developed  six  days  after  the  second  crisis. 

Various  explanations  have  been  offered  for  these  local  palsies,  but,  as 
already  stated  (see  page  386),  it  seems  probable  that  they  are  referable  to 
morbid  conditions  of  the  nerve-trunks,  or,  less  commonly,  of  the  spinal 
cord.  It  must  be  noted,  however,  that  in  a  certain  number  of  autopsies 
serious  intracrauial  lesions  are  found,  which  are  evidently  the  results  of 
the  attack  of  relapsing  fever.  These  consist  of  abscess  of  the  brain,  men- 
ingitis, and  specially  cerebral  hemorrhage.  This  was  present  in  one  of  oui 
cases,  but  Carter  found  copious  hemorrhage  in  no  less  than  8  out  of  54 
autopsies,  and  in  5  others  there  were  minute  capillary  cerebral  hemor- 
rhages. Still,  in  nearly  all  the  cases  of  large  hemorrhage  we  have  found 
recorded  the  effusion  was  upon  the  surface  of  the  brain,  and  this,  com- 
bined with  the  absence  of  true  hemiplegia  from  the  forms  of  paralysis 
noted  in  relapsing  fever,  and  the  transient  character  of  these  palsies, 
makes  it  clear  that  they  are  not  to  be  explained  by  any  considerable 
cerebral  hemorrhage.  On  the  other  hand,  however,  it  must  be  admitted 
that  an  additional  possible  cause  of  them  is  to  be  found  in  minute 
hemorrhage  into  small  areas  known  to  govern  the  movements  of  certain 
groups  of  muscles.  Again,  we  have  had  occasion  to  note  the  occurrence 
of  both  thrombosis  and  embolism  among  the  lesions  of  relapsing  fever, 
and  it  s  evident  that  either  of  these  accidents,  if  involving^  compara- 
tively small  branch  of  a  cerebral  vessel  in  certain  motor  areas,  might  cause 
transient  paralysis,  such  as  has  been  described.  Nor  can  we  fail  to  see 
that,  while  such  symptoms  as  the  delirium,  mania,  coma,  or  subsequent 
mental  impairment  may  receive  other  explanations,  it  is  possible  that 
they  may  arise  from  similar  processes  of  minute  hemorrhage,  thrombosis, 
or  embolism  involving  other  parts  of  the  brain. 

1  Glasgow  Med.  Jour.,  May,  1871,  p.  379. 


COMPLICATIONS  AND  SEQUELAE.  399 

The  frequent  occurrence  of  severe  rheumatic  pains  in  the  muscles  and 
joints  during  the  course  of  the  disease  has  been  dwelt  upon  (p.  385) ;  but 
in  some  cases  they  persisted  during  the  intermissions  and  for  a  considerable 
time  after  all  other  symptoms  of  disease  had  passed  away.  Occasionally 
they  greatly  retarded  convalescence  by  interfering  with  exercise  and  sleep. 
These  pains  were  mostly  in  the  legs,  and  were  increased  by  exercise,  and 
also  seemed  to  be  influenced  by  changes  of  weather.  Patients  who  suf- 
fered thus  were  also  liable,  after  exposure  or  in  consequence  of  severe 
atmospheric  changes,  to  sharp  attacks  of  similar  pains  elsewhere,  and 
especially  in  the  course  of  the  intercostal  nerves.  Occasionally  violent 
and  persistent  headache  follows  the  disease,  not  improbably  associated 
with  changes  in  the  membranes  of  the  brain,  although  in  other  cases 
severe  neuralgia  occurs  in  consequence  of  the  anaemia  which  may  remain 
in  an  intense  degree  after  the  fever.  Troublesome  numbness  and  soreness 
of  the  soles  of  the  feet  and  of  the  palms  of  the  hands,  increased  by  pres- 
sure, has  been  noted  as  a  sequel  persisting  for  several  days  or  weeks. 

Affections  of  the  special  senses  are  not  rare.  The  most  remark- 
able among  these  is  the  affection  of  the  eyes,  which  is  apt  to  occur  far 
more  frequently  in  connection  with  relapsing  fever  than  with  typhus 
or  typhoid.  The  proportion  of  cases  in  which  this  sequel  appears 
varies  greatly  in  different  epidemics.  In  the  British  epidemics  of 
1826  and  1843,  when  this  form  of  post-febrile  ophthalmia  was  first 
accurately  described  by  Mackenzie  of  Glasgow,  it  was  very  frequent; 
and  it  was  equally  so  in  Finland  in  1867-68,  when  Estlander1  again 
carefully  studied  it. 

On  the  other  hand,  so  far  as  can  be  stated  in  regard  to  a  sequel  which 
may  appear  after  convalescence  is  far  advanced  and  the  patient  discharged 
from  medical  care,  it  was  very  uncommon  in  the  Philadelphia  epidemic 
of  1869-70.  This  ophthalmia  may  occur  during  the  course  of  the  fever, 
but  more  frequently  it  begins  during  convalescence,  and  even  some 
months  after  convalescence  has  been  established.  It  occurs  in  patients 
of  both  sexes  and  at  all  ages.  Usually  it  affects  but  one  eye,  but  both 
may  be  attacked  simultaneously  or  consecutively.  Patients  who  were 
very  ill-nourished  and  debilitated  were  most  apt  to  present  this  sequel, 
and  Murchison  regards  previous  starvation  as  one  of  its  main  causes. 
The  exciting  cause  and  true  pathology  appear  obscure  as  yet,  however, 
and  the  existence  of  a  neural  origin  is  not  improbable.  In  some  cases 
the  ophthalmia  has  seemed  to  result  directly  from  exposure  to  cold. 
Among  our  own  patients,  as  already  stated,  eye  symptoms  were  less 
common  and  severe.  A  careful  record  of  184  cases  was  kept  in  reference 
to  this  question.  Several  patients  complained  of  diplopia  during  the 
febrile  stage,  and  one  asserted  that  every  object  appeared  fourfold  to 
him.  Conjunctivitis  of  moderate  severity,  usually  associated  with  otor- 
rhoea,  occurred  in  about  5  per  cent,  of  our  cases ;  it  generally  affected 
only  one  eye,  and  occurred  in  a  few  instances  as  late  as  the  third  week 
after  the  relapse.  In  a  few  cases  (four)  also  there  was  dulness  of  vision 
in  one  eye,  noted  during  the  course  of  the  disease  and  persisting  for  some 
time  after  convalescence  began.  In  only  one  instance,  however,  did  per- 
manent impairment  of  vision  ensue,  and  this  man  had  passed  through 
a  violent  attack  of  the  fever  with  unusually  grave  nervous  symptoms. 

1('U.  Choroiditis  nach  Febris  Kecurrens,"  Arch.f.  Ophth.,  1869,  Bd.  xv.,  Abth.  ii.,  108. 


400  RELAPSING  FEVER. 

It  left  him  with  optic  neuritis  on  the  right  side,  which  induced  partial 
atrophy  of  the  nerve  and  great  limitation  of  the  field  of  vision.  Mes- 
chede  reports  intraocular  affections  in  6  cases  out  of  180  specially  exam- 
ined, though  it  is  not  certain  that  such  affections  were  directly  connected 
with  the  febrile  process.  Occular  ecchymosis  occurs  in  a  small  propor- 
tion of  cases,  especially  of  the  graver  types. 

Dulness  of  hearing  is  not  so  common  in  relapsing  fever  as  it  is  in 
typhoid.  It  was  present  in  14  out  of  184  of  our  cases  during  the 
course  of  the  disease,  and  in  a  few  instances  partial  or  almost  complete 
deafness  in  one  ear  persisted  after  convalescence,  owing  doubtless  to  a 
slight  affection  of  the  middle  ear.  In  one  case  marked  deafness 
appeared  suddenly  on  the  day  after  the  termination  of  the  relapse  by 
crisis.  Meschede1  found  disease  of  the  middle  ear  in  no  less  than  8 
per  cent,  of  his  cases. 

Purulent  otorrhcea  from  one  or  both  ears  is  of  more  frequent  occur- 
rence, and  without  any  special  exciting  cause  may  present  itself  at  any 
time  during  the  course  of  the  disease  or  more  commonly  after  the  relapse. 
In  the  same  manner  purulent  coryza  may  occur. 

The  eruptions  occasionally  present  during  the  fever  have  been  described. 
Bed-sores  from  pressure  are  much  less  common  than  in  typhus,  but  are 
met  with  in  a  small  proportion  of  cases.  As  a  rule,  they  are  of  moderate 
size  and  heal  quickly.  Superficial  gangrene  of  the  lips,  nose,  and  ears  has 
also  been  noted  in  rare  cases  (Zuelzer)  in  connection  with  gangrene  of  the 
extremities,  probably  from  embolism.  The  occasional  occurrence  of  pain- 
ful boils,  of  abscesses  in  the  cellular  tissues  (Wyss  and  Bock),  and  the 
more  rare  occurrence  of  erysipelas  may  be  mentioned  among  the  sequelae. 

As  already  stated,  the  severe  pains  in  the  joints  and  members  which 
so  frequently  occur  during  relapsing  fever  are,  as  a  rule,  unattended  by  any 
redness  or  swelling  of  the  joints.  In  rare  cases,  however,  there  is  effu- 
sion into  the  joints  during  the  fever,  or  more  commonly  there  are  attacks 
during  convalescence  which  simulate  subacute  rheumatic  arthritis.  Such 
attacks  may  last  but  a  few  days,  but  in  several  of  our  cases  there  was 
painful  swelling  of  the  knees,  wrists,  and  fingers  which  persisted  for 
several  weeks  after  the  fever,  being  attended  with  slight  crepitation  on 
motion,  and  altogether  behaving  like  subacute  rheumatism. 

As  would  be  expected  from  the  severity  of  the  fever,  the  marked 
disorder  of  digestion,  and  the  lesions  of  the  spleen  and  liver  in  relapsing 
fever,  ansemia  is  a  common  sequel.  In  cases  where  there  has  also  been 
free  hemorrhage,  usually  in  the  form  of  epistaxis,  the  anemia  may  indeed 
reach  an  intense  degree. 

The  cardiac  murmurs  which  have  been  described  as  present  in  a  certain 
proportion  of  cases  are  dependent  upon  the  blood-changes,  and  when  the 
anaemia  is  extreme  these  murmurs  are  also  audible  over  the  large  veins 
and  the  pulmonary  artery,  and  persist  after  convalescence  is  fully 
established. 

GEdema  of  the  lower  extremities  occurs  in  a  considerable  number  of 
cases.  It  is  clearly  due  in  part  to  the  anaemia,  but  the  cardiac  debility 
which  follows  the  fever  is  also  largely  concerned  in  its  production.  It 
was,  indeed,  marked  in  some  of  our  cases  where  no  anaemic  murmurs 
existed,  but  where  there  was  great  nervous  and  muscular  debility. 

1  Loc.  cit. 


COMPLICATIONS  AND  SEQUELS.  401 

Usually  limited  to  the  feet  and  ankles,  it  occasionally  extended  above 
the  knees,  and  in  one  case,  where  great  anaemia  and  debility  from  fever 
and  over-exertion  coexisted,  there  was  oedema  of  the  hands  and  wrists, 
with  great  distension  of  the  legs  up  to  the"  hips.  It  is  not  associated  with 
albuminuria  as  a  rule,  and  yields  readily  to  treatment  and  rest,  in  the 
course  of  a  few  weeks. 

Hemorrhages  from  various  surfaces  have  already  been  mentioned,  and 
a  full  account  given  of  epistaxis,  which  is  by  far  the  most  common  form. 
Bloody  vomiting  has  been  noticed  in  a  small  proportion  of  cases  in  vari- 
ous epidemics.  It  varies  in  amount,  but  is  always  attended  with  great 
gravity  of  the  attack,  and  usually  is  followed  by  fatal  results.  It 
occurred  in  four  of  our  cases,  two  of  which  presented  also  black  stools 
containing  altered  blood,  and  suppression  of  urine;  while  in  another 
it  occurred  at  the  close  of  the  first  relapse,  and  during  the  second 
relapse  was  copious  and  repeated.  In  this  case  it  was  attended  with 
alarming  symptoms  of  collapse,  from  which  the  patient  rallied,  and  after 
a  desperate  struggle  recovered. 

Blood  may  also  be  discharged  from  the  bowels  in  such  large  amount 
as  to  constitute  actual  hemorrhage — a  symptom  of  great  gravity ;  or  in 
small  quantity  and  completely  altered,  so  as  to  impart  an  inky  black 
color  to  the  stools — a  condition  not  necessarily  attended  with  urgent  dan- 
ger ;  or,  finally,  there  may  be  frequent  bloody  dysenteric  stools. 

Hemorrhage  has  also  been  observed  from  the  uterus,  from  the  kidneys, 
from  the  ears,  and  from  the  old  cicatrix  of  a  syphilitic  chancre.  Hemor- 
rhage occurred  in  87  out  of  183  of  our  cases,  or  in  nearly  50  per  cent. 
It  was  from  the  nostrils  in  82  cases,  from  the  uterus  in  1  case,  from  the 
stomach  in  4  cases,  and  from  the  cicatrix  of  a  chancre  in  1  case. 

Sudden  collapse  occurs  with  such  comparative  frequency  in  relapsing 
fever  as  to  require  special  attention  as  one  of  its  complications.  It  may 
occur  at  any  period  of  the  disease,  but  it  is  most  common  at  the  crisis  of 
the  first  paroxysm  or  of  the  relapse.  The  symptoms  are  usually  those 
of  cardiac  failure,  with  rapid,  small,  and  feeble  pulse ;  shallow  and  hur- 
ried, or  slow,  labored,  and  imperfect  respiration ;  coldness  of  the  extrem- 
ities, while  the  central  temperature  may  remain  elevated ;  muttering 
delirium,  rapidly  passing  into  unconsciousness.  Occasionally  almost 
instantaneous  death  occurs  from  syncope  induced  by  some  muscular 
exertion,  as  standing  up  or  even  rising  in  bed.  In  other  cases  the  symp- 
toms indicate  the  development  of  cardiac  thrombosis,  and  subsequent 
examination  has  verified  this  opinion.  In  still  other  cases  the  symptoms 
resemble  those  which  occur  in  extreme  hyperpyrexia  dependent  upon 
overwhelming  and  paralysis  of  the  nervous  centres.  Copious  hemor- 
rhage from  the  stomach  and  nose  may  also  induce  syncope  of  alarming 
and  even  fatal  severity.  When  from  the  latter  cause,  reaction  may  be 
induced  and  the  patient  may  ultimately  recover,  as  we  saw  in  a  case 
where  after  repeated  hematemesis  the  patient  sank  into  profound  col- 
lapse. In  all  of  its  forms,  however,  this  complication  is  of  extreme  and 
imminent  danger,  and  death  follows,  as  a  rule,  in  a  few  hours.  The 
cases  in  which  it  occurs  are  usually  of  severe  type,  occurring  in  persons 
who  have  previously  been  in  poor  health  or  intemperate,  or  who  have 
been  subjected  to  privation  and  improper  exposure  previous  to  and  during 
the  early  stages  of  their  attack.  Still,  collapse  may  occur  in  mild  cases 

VOL.  I.— 26 


402  RELAPSING  FEVER. 

also,  and  whatever  the  type  of  the  disease  there  may  be  no  special  indi- 
cation of  approaching  trouble,  when  the  patient  rapidly  passes  into  col- 
lapse, to  be  followed  by  death  in  a  few  hours.  It  occurred  in  nine  of 
about  two  hundred  cases  under  t»ur  observation.  In  one  it  was  the  result 
of  hemorrhage  from  the  stomach,  and  ended  in  recovery ;  in  one,  at  the 
close  of  the  initial  paroxysm  the  patient,  who  was  stupid,  with  mutter- 
ing delirium,  sank  into  collapse  as  the  temperature  rapidly  fell  from  105° 
to  97°,  and  died  in  a  few  hours ;  in  one,  on  the  fourth  day  of  the  relapse 
the  temperature  suddenly  fell  from  102°  to  96°,  with  free  sweating,  but 
suddenly  rebounded  to  102°,  with  very  rapid,  feeble  pulse,  distinct  basic 
cardiac  murmur,  constriction  of  chest,  restlessness  and  delirium,  slight 
convulsions,  and  death  in  eight  hours ;  in  one,  a  man  at  the  end  of  the 
initial  paroxysm,  immediately  after  his  admission  to  the  hospital  in 
apparently  fair  condition,  became  violently  delirious,  with  bounding 
pulse,  soon  grew  comatose,  and  died  in  one  hour ;  in  one,  a  man  who 
was  in  feeble  condition,  on  the  nineteenth  day,  with  irregular  persistent 
fever  (he  had  splenic  abscess),  sat  up  on  the  edge  of  the  bed,  sank  back 
in  syncope,  and  died  in  less  than  an  hour ;  in  one,  a  man  who  did  well 
until  the  second  day  of  the  relapse,  when  pleuro-pneumonia  and  peri- 
carditis were  developed,  died  suddenly  four  days  later :  there  was  con- 
siderable pericardial  effusion ;  in  one,  sudden  death  from  syncope  or 
cardiac  thrombosis  occurred  on  the  twelfth  day  in  a  man  who  had  sup- 
purative  parotitis  and  metastatic  abscesses  of  the  lungs ;  in  one,  sudden 
collapse  and  death  occurred  in  one  and  a  half  hours  at  the  end  of  the 
initial  paroxysm ;  in  one,  a  drunkard  with  large  fatty  liver  had  pyrexia 
continuing  after  the  initial  paroxysm,  and  on  the  ninth  day,  while  in  a 
state  of  hebetude,  with  mild  delirium  and  a  pulse  of  112,  coma  suddenly 
occurred,  and  death  followed  in  two  hours. 

Pericarditis  is  a  rare  complication,  and  is  apt  to  coexist  with  pleuro- 
pneumonia.  This  combination  occurred  in  one  of  our  cases  where 
pleuro-pneumonia  and  pericarditis  were  developed  on  the  second  day  of 
relapse,  and  proved  fatal  by  sudden  collapse  on  the  fifth  day,  with  the 
pericardial  sac  distended  with  serum  and  its  layers  coated  with  plastic 
lymph. 

Thrombosis  of  veins,  as  in  phlegmasia  alba  dolens,  occurs  much  more 
rarely  than  after  typhoid  fever.  Arterial  embolism,  on  the  other  hand, 
is  not  uncommon.  Murchison1  reports  a  case  in  which  gangrene  of  the 
left  foot  from  obstruction  of  the  left  femoral  artery,  together  with  cere- 
bral softening  from  obstruction  of  the  left  middle  cerebral  artery,  occurred 
in  connection  with  cardiac  thrombosis.  Zuelzer  alludes  to  similar  cases 
in  the  St.  Petersburg  epidemic  of  1865-66,  where,  in  addition  to  the 
extremities,  the  nose,  ears,  and  lips  became  gangrenous.  Other  examples 
of  embolism  are  found  in  lesions  of  the  spleen  and  kidneys,  where 
infarctions  are  of  frequent  occurrence. 

Heart-clot,  or  cardiac  thrombosis,  appears  to  occur  more  frequently 
than  in  any  other  acute  zymotic  disease,  with  the  exception  of  diph- 
theria. Even  when  the  occurrence  of  passive  hemorrhages  and  of 
ecchymoses  of  various  tissues  indicates  marked  dyscrasia  of  the  blood, 
there  will  not  rarely  be  found  firm  white  clots  in  one  or  other  of  the 
cavities  of  the  heart.  These  frequently  present  unmistakable  evidences 

1  Op.  til.,  p  384. 


COMPLICATIONS  AND  SEQUEL JB.  403 

of  ante- mortem  formation,  and,  as  already  stated,  there  is  a  certain  pro- 
portion of  the  cases  of  rapid  and  unexpected  death  where  the  fatal 
result  is  directly  due  to  cardiac  thrombosis,  attended  with  the  usual 
symptoms. 

The  constant  affection  of  the  spleen  has  been  fully  described ;  it 
is  not  therefore  surprising  that  both  complications  and  sequelae  arise 
in  connection  with  it.  At  times,  in  cases  which  ultimately  recover, 
the  pain  in  the  splenic  region  is  so  violent  and  continuous,  and  is 
attended  with  so  much  tenderness  over  the  enlarged  organ,  that 
localized  peritonitis  is  undoubtedly  present.  Occasionally  this  peri- 
splenitis  persists,  and  in  conjunction  with  the  inflammatory  changes  in 
the  substance  of  the  spleen  maintains  an  irregular  fever  after  the  specific 
pyrexia  has  run  its  course.  This  was  noticed  in  several  of  our  cases, 
but  especially  so  in  a  case  where,  after  the  initial  paroxysm,  an  irregular 
fever  was  kept  up,  obscuring  the  relapse,  until  the  nineteenth  day,  when 
death  occurred  suddenly  from  syncope  on  rising  on  the  edge  of  the  bed, 
and  where  examination  showed  splenic  peritonitis,  with  a  splenic  abscess 
as  large  as  a  pigeon's  egg. 

The  enlargement  of  the  spleen  usually  subsides  during  the  intermis- 
sion, and  disappears  speedily  or  in  the  course  of  a  few  weeks  after  con- 
valescence is  established.  Occasionally,  however,  it  persists,  and  is 
attended  with  marked  auremia.  In  one  case,  where  death  occurred  from 
pneumonia,  the  sequel  of  relapsing  fever,  at  about  the  thirtieth  day,  the 
spleen  weighed  twenty-nine  ounces ;  and  in  another  case,  where  death 
occurred  from  gangrenous  pleuro-pneumonia,  at  the  fortieth  day,  the 
spleen  was  still  enlarged  and  presented  characteristic  changes  in  its  pulp. 
On  the  other  hand,  in  a  case  where  death  occurred  on  the  twelfth  day  of 
typhus,  occurring  forty-four  days  after  recovery  from  a  very  bad  case 
of  relapsing  fever,  making  it  altogether  the  one  hundredth  day,  none 
of  the  lesions  of  the  first  disease  were  discoverable. 

Rupture  of  the  spleen  occurs  occasionally,  and  is  usually  attended  with 
sudden  pain,  collapse,  and  speedy  death.  Mnrchison  refers  to  two  exam- 
ples recorded  by  Zuelzer  and  one  by  Hudson ;  Petersen  reports  fifteen 
cases,  in  seven  of  which  sudden  rupture  occiirred  with  speedy  death, 
while  in  the  other  eight  the  rupture  followed  local  softening  from 
infarction,  and  resulted  in  death  in  a  few  days  from  purulent  peri- 
tonitis. 

In  one  of  our  cases,  where  death  occurred  on  the  sixteenth  day,  appar- 
ently from  double  pneumonia  and  heart-clot,  it  was  found  that  there  was 
a  rupture  in  the  enlarged  spleen  near  its  upper  end,  recent  plastic  peri- 
tonitis in  the  region  of  the  spleen,  and  a  moderate  amount  of  bloody 
pulpy  fluid  throughout  the  peritoneal  cavity. 

As  we  have  seen,  disturbances  within  the  respiratory  tract  occur  with 
very  different  frequency  in  different  epidemics.  In  many  they  are  rare, 
while  in  1870  we  noticed  cough  and  other  evidences  of  respiratory 
trouble  in  no  less  than  90  out  of  200  cases. 

Severe  catarrhal  laryngitis  is  a  rare  and  dangerous  complication.  It 
did  not  occur  in  our  cases,  but  both  Bcgbie  and  Paterson  report  cases  of 
it  which  required  tracheotomy,  and  Wyss  and  Bock  met  with  ulcerative 
laryngitis  with  perichondritis. 

Bronchitis  of  moderate  severity,  although  rare  in  many  epidemics, 


404  RELAPSING  FEVER. 

occurs  so  frequently  in  others,  as  in  Philadelphia  in  1870,  as  to  rank  as 
a  symptom  of  the  disease. 

Pneumonia  is  one  of  the  most  fatal  complications.  The  results  of  our 
own  observations  agree  with  the  statements  of  Jenuer  and  of  Carter,  that 
it  is  the  next  most  common  lesion  after  enlargement  of  the  liver  and 
spleen.  On  the  other  hand,  Murchison  noted  it  only  in  4  or  5  out  of 
600  cases.  It  occurred  in  at  least  11  of  our  cases,  8  of  which  were  fatal ; 
and  unquestionably  less  extensive  inflammation  was  present  in  other  cases 
which  recovered,  in  view  of  the  marked  respiratory  disturbances  fre- 
quently present.  Both  lungs  were  involved  in  4  cases ;  of  the  remainder, 
the  rif'ht  and  left  were  about  equally  divided.  Out  of  23  autopsies,  the 
lesions  of  pneumonia  were  found  8  times.  The  lower  lobes  were  affected 
in  every  case.  The  form  of  this  disease  was  croupous  in  9  cases ;  in  1  it 
was  that  of  metastatic  suppuration,  and  in  1  it  was  more  proj>erly 
described  as  splenification.  The  amount  of  plastic  pleurisy  associated 
with  it  was  usually  great,  and  in  one  case  there  was  also  severe  pericar- 
ditis. In  another  case  the  disease  advanced  to  the  stage  of  gangrene  of 
a  circumscribed  area  of  the  pleura  and  of  the  superficial  layer  of  the  lung. 
In  only  one  instance  was  albuminuria  present.  In  two  cases  the  pneu- 
monia occurred  so  late  in  the  course  of  the  disease  that  it  might  be 
regarded  as  a  sequel.  Death  occurred  in  one  of  these  on  the  thirtieth 
day,  and  in  the  other  (that  in  which  gangrene  ensued)  it  ran  a  subacute 
course,  and  death  did  not  take  place  until  the  fortieth  day.  In  the  other 
cases  the  disease  began  at  the  close  of  the  initial  paroxysm,  during  the 
intermission,  or  early  in  the  relapse.  As  would  be  expected,  the  sympa- 
thetic fever  due  to  this  complication  modified  and  obscured  the  charac- 
teristic course  of  the  specific  pyrexia. 

This  rare  termination  in  gangrene  has  been  noted  by  other  observers  ; 
in  all  five  or  six  times.  Parry  met  with  a  truly  remarkable  case  of 
double  pneumonia,  followed  by  gangrene,  and  yet  resulting  in  recovery. 
Jaundice  is  apt  to  attend  cases  of  relapsing  fever  which  are  complicated 
with  pneumonia. 

Pleurisy  is  an  almost  constant  accompaniment  of  pneumonia,  and  fre- 
quently occurs  in  marked  degree.  It  may  also  be  present  in  cases  of 
severe  splenic  inflammation.  In  all  probability,  localized  plastic  pleurisy 
is  not  infrequent,  and  may  cause  some  of  the  severe  thoracic  pains  so 
frequently  present. 

Metastatic  abscesses  of  the  lung  occur  occasionally  as  a  result  of  the 
profound  toxaemia,  and  are  apparently  preceded  by  patches  of  infarction, 
which  soften  in  the  centre,  as  in  the  usual  development  of  pyaemic 
abscesses.  This  condition  was  found  in  one  of  our  cases  in  conjunction 
with  suppurative  parotitis.  It  has  been  included  among  the  instances 
of  pneumonia. 

Acute  miliary  tuberculosis,  involving  chiefly  the  lungs  and  intestinal 
canal,  occurred  as  a  sequel  in  one  case  under  our  observation,  and 
phthisis  has  been  found  to  follow  by  other  observers  (Carter).  It  is 
to  be  expected  that  if  the  patient  did  not  so  quickly  pass  from  under 
observation  it  would  be  found  that  an  affection  so  gravely  complicating 
nutrition  as  does  relapsing  fever  is  frequently  followed  by  serious  organic 
disease. 

Parotitis   is   mentioned   by  so  few  authors   as  to  show  that  it  is  a 


COMPLICATIONS  AND  SEQUELS.  405 

rare  complication  in  most  epidemics,  varying  from  1  in  600  to  1  in 
50  cases.  One  gland  only  is  affected  at  a  time  as  a  rule,  though 
both  may  be  involved  successively.  The  inflammation  begins  either 
during  the  intermission  or  the  relapse,  and  may  terminate  by  reso- 
lution or  by  suppuration.  Although  a  painful  and  severe  complication, 
it  is  followed  by  recovery  in  a  considerable  proportion  of  cases.  Carter * 
states  "  that  in  some  degree  it  was  noted  in  2  or  3  per  cent,  of  all  cases, 
and  nearly  as  often  amongst  survivors  as  in  the  casualties."  It  occurred 
in  three  of  our  cases  (185) ;  once  it  underwent  resolution;  once  suppura- 
tion occurred  in  the  parotid  and  in  the  masseter  muscle,  with  metastatic 
abscesses  in  the  lungs,  and  death ;  and  once  the  patient,  who  had  pre- 
viously existing  amyloid  degeneration  of  liver  and  spleen  without  albumin- 
uria,  had  severe  relapsing  fever  with  two  relapses,  in  the  first  of  which 
parotitis  occurred  in  both  glands,  successively  terminating  in  suppuration, 
after  which  he  did  well  through  an  apyretic  period  of  six  weeks,  when 
sudden  high  fever  appeared,  followed  by  speedy  death. 

Pharyngitis  and  tonsillitis  of  mild  grade  occur  in  from  3  to  25  per  cent, 
of  the  cases  in  different  epidemics. 

Hiccough  deserves  to  be  ranked  among  the  complications,  because  it 
is  of  frequent  occurrence,  obstinate  and  annoying.  It  occurred  in  a  con- 
siderable proportion  of  our  cases,  and  much  more  frequently  in  those  who 
had  jaundice.  It  was  often  present  both  in  the  initial  paroxysm  and  in 
the  relapse,  but  disappeared  soon  after  the  end  of  the  pyrexia.  It  bore 
no  constant  relation  to  the  severity  of  the  vomiting.  Not  rarely  it  lasted 
several  days  and  nights,  causing  exhaustion  and  interference  with  sleep 
and  proving  rebellious  to  treatment.  Hypodermic  injections  of  morphia 
and  atropia,  chloroform  internally,  and  extremely  careful  alimentation 
proved  most  serviceable. 

Hemorrhage  from  the  stomach  has  already  been  spoken  of  (see  p.  390). 

Diarrhoea,  as  already  stated  (see  p.  390),  occurs  much  more  frequently 
than  in  typhus  fever,  varying  from  1  per  cent.  (Murchison)  to  15  per 
cent.  (Scotch  epidemics)  or  33  per  cent.  (Philadelphia),  or  even  50  per 
cent.  (Konigsberg).  It  is  usually  of  moderate  severity,  but  occasionally 
is  so  profuse  and  intractable  as  to  constitute  the  main  cause  of  death.  In 
some  epidemics  the  attacks  of  looseness  occur  almost  exclusively  after  the 
relapse,  but  in  others  the  bowels  are  frequently  loose  during  the  febrile 
stages.  In  our  cases  there  were  not  infrequently  from  three  to  eight 
thin,  dark,  bilious  or  light  yellowish  stools  daily  after  the  second  or  third 
day  of  the  initial  paroxysm,  and  then  the  looseness  would  stop  during 
the  intermission,  probably  to  recur  in  the  relapse.  Occasionally  diarrhoea 
with  very  frequent  liquid  stools  occurs  at  the  close  of  one  or  both  of  the 
febrile  stages,  assuming  a  critical  character,  and  substituting  more  or  less 
of  the  sweating  which  is  the  common  mode  of  crisis,  although  in  several 
cuch  cases  quoted  by  Murchison  from  Douglas  the  sweating,  despite  the 
critical  diarrhoea,  was  usually  profuse.  It  can  scarcely  be  said  that  there 
is  any  relationship  between  diarrhoea  and  vomiting ;  both  are  frequently 
present,  and  may  even  be  severe  and  persistent  in  the  same  case,  though 
either  may  be  marked  while  the  other  is  moderate  or  slight.  Abdominal 
pain  and  tenderness  in  the  epigastrium  and  hypochondria  are  constant 
symptoms,  but  when  diarrhoea  is  marked  there  are  apt  also  to  be  griping 

1  Op.  cit.,'p.  210. 


406  RELAPSING  FEVER. 

pains  and  tenderness  in  the  lower  segment  of  the  abdomen.  When  diar- 
rhoea occurs  as  a  sequel,  either  beginning  after  the  close  of  the  relapse 
or  continuing  in  cases  where  the  bowels  have  been  loose  during  pyrexia,  it 
is  apt  to  prove  obstinate  and  intractable,  or  even  to  lead  to  a  fetal  result. 

The  character  of  the  stools  varies  much ;  usually  thin  and  dark,  they 
may  be  light  yellowish  or  even  whitish.  Thus,  in  a  severe  case  with 
deep  jaundice  we  observed  seven  liquid  and  decidedly  whitish  stools  in 
twenty-four  hours.  In  such  instances  there  is  undoubtedly  more  or  less 
complete  closure  of  the  biliary  ducts  by  plugs  of  mucus  or  by  swelling 
of  the  mucous  membrane.  On  the  other  hand,  the  stools  may  be  inky 
black  from  admixture  with  altered  blood,  or,  lastly,  they  may  consist  of 
mucus  and  blood,  in  which  event  the  complication  assumes  the  form  of 
actual  dysentery  and  is  attended  with  increased  abdominal  pain  and  with 
tenesmus.  Dysentery  was,  as  would  be  expected,  quite  frequent  in  the 
Indian  epidemics  studied  by  Carter.1  It  is  usually  of  moderate  severity, 
but  occasionally  it  runs  into  gangrenous  inflammation,  is  attended  with 
perforation  of  the  bowel,  or  is  followed  by  hepatic  abscess.  In  one 
instance  we  noticed  a  peculiarly  fetid  puriforni  discharge  from  the  anus, 
which  occurred  during  the  relapse  and  persisted  for  several  weeks, 
gradually  subsiding,  as  though  from  some  unhealthy  ulceration  which 
slowly  healed. 

Jaundice  is  of  frequent  occurrence,  but  has  been  sufficiently  discussed 
at  page  391. 

Peritonitis  is  not  rare  in  its  circumscribed  form.  This  statement  is 
based  on  the  comparative  frequency  with  which  localized  splenic  perito- 
nitis, of  varying  degrees  of  severity,  is  found  after  death  in  relapsing 
fever  from  various  causes,  and  from  the  great  frequency  of  severe  pain 
and  tenderness  in  the  region  of  the  enlarged  spleen  in  favorable  cases. 
In  its  lesser  degrees  it  may  not  add  materially  to  the  danger  of  the 
patient,  but  in  more  severe  forms,  associated  with  serious  splenic  lesions, 
it  may  run  a  protracted  subacute  course  and  maintain  irregular  fever. 

General  peritonitis  is,  on  the  other  hand,  a  rare  complication,  occurring 
not  more  than  once  in  several  hundred  cases.  It  results  from  dysenteric 
perforation  of  the  bowel,  from  rupture  of  a  splenic  abscess,  or  from 
rupture  of  the  spleen  itself.  An  example  of  this  latter  accident  which 
occurred  under  our  observation  has  already  been  given.  Speedy  death 
invariably  follows,  though  in  the  case  just  referred  to  the  symptoms  of 
peritonitis  were  totally  masked  by  those  of  the  coexisting  double  pneu- 
monia, which  seemed  to  be  the  immediate  cause  of  death. 

Suppuration  of  the  mesenteric  glands  is  a  rare  complication,  mentioned 
especially  by  Wyss  and  Bock.  As  these  glands  are  not  usually  found 
enlarged,  there  being  no  irritative  lesion  of  the  intestines  of  common 
occurrence  in  relapsing  fever,  it  is  probable  that  the  collections  of  pus 
which  have  been  found  were  metastatic  in  origin. 

Dyspepsia  is  not  an  infrequent  sequel,  as  would  necessarily  be  the  case 
after  a  disease  characterized  by  so  much  gastric  irritation  and  by  such 
serious  lesions  of  the  liver  and  spleen.  As  a  consequence,  care  in  diet  is 
often  required  for  a  considerable  period  after  the  course  of  the  disease  has 
ended ;  dyspeptic  symptoms  are  frequently  complained  of,  and  marked 
emaciation  and  anaemia  often  protract  convalescence. 

1  Op.  eii.,  p.  218. 


COMPLICATIONS  AND  SEQUELS.  407 

It  may  be  observed  that  a  striking  appearance  of  emaciation  is  often 
developed  shortly  after  the  crisis  of  the  first  paroxysm,  or,  more  particu- 
larly, of  the  relapse.  It  is  partly  due  to  the  actual  loss  of  weight  during 
the  high  pyrexia,  but  even  more  to  the  abrupt  transition  from  a  state  of 
extreme  febrile  turgescence  to  one  of  equally  extreme  relaxation  and 
maceration  of  the  surface. 

The  amount  of  urine  has  been  seen  (p.  387)  to  vary  greatly  in  cases  distin- 
guished by  no  special  disorder  of  the  kidneys ;  the  extremes  in  ordinary 
cases  being  from  twelve  or  fifteen  ounces  just  before  the  crisis  to  from 
eighty  to  one  hundred  and  twenty  within  forty-eight  hours  after  the  crisis. 
Suppression  is,  however,  sometimes  noted,  and  is  always  a  grave  symptom, 
though  Parry l  reports  more  than  one  case  in  which  on  several  successive 
days  there  was  not  more  in  twenty-four  hours  than  one  fluidounce  of 
non-albuminous  urine,  and  in  which  no  symptoms  of  uraemia  occurred, 
and  the  sweat  had  no  urinous  odor.  In  one  of  our  fatal  cases,  with 
intense  jaundice,  hematemesis,  inky  black  stools,  and  oedema  of  the  feet 
and  of  the  lungs,  there  was  not  a  drop  of  urine  secreted  during  the  last  four 
days  of  the  initial  paroxysm ;  death  occurred  on  the  eighth  day,  and  the 
kidneys  were  found  intensely  engorged,  of  a  deep  blackish-blue  color, 
with  numerous  ecchymoses  in  the  cortex,  due  to  impaction  of  the  con- 
voluted tubules  with  blood,  while  the  renal  epithelium  was  granular  and 
swollen,  and  many  tubules  were  filled  with  epithelial  cells  and  granular 
matter.  At  the  autopsy  the  urinary  bladder  was  firmly  contracted  and 
contained  a  very  small  amount  of  bloody  liquid. 

More  frequently,  incontinence  of  urine,  with  or  without  retention, 
occurs  during  the  febrile  stages — according  to  our  observation,  most  com- 
monly in  cases  attended  with  mental  disturbance  and  tending  to  a  typhoid 
condition.  The  symptom  was  not  of  very  grave  significance,  however, 
and  after  the  use  of  the  catheter  for  a  few  days  the  bladder  regained  its 
tone. 

Albumen  is  quite  frequently  present  in  small  amounts  during  the 
pyrexia  of  relapsing  fever.  Thus,  in  18  cases  of  ordinary  severity,  which 
all  recovered,  and  in  which  the  urine  was  carefully  examined  daily,  a 
trace  of  albumen  was  found  in  5 ;  in  2  cases  it  appeared  both  in  the 
initial  paroxysm  and  in  the  relapse,  but  in  all  instances  its  presence  was 
of  brief  duration.  In  one  of  these  five  cases  the  albumen  appeared  at 
both  critical  periods,  when  the  amounts  of  urine  in  twenty-four  hours 
were  respectively  150  ccm.  and  250  ccm. ;  but  in  the  other  cases  the 
transient  albuminuria  coincided  with  free  secretion  of  urine  (1250  ccm., 
1850  ccm.).  It  is  probable  that  were  the  same  careful  search  to  be  made 
in  all  cases  the  presence  of  albumen  would  be  detected  in  fully  20  to  25 
per  cent.  On  the  other  hand,  in  fatal  cases  the  occurrence  of  albuminuria 
is  by  no  means  constant,  although  undoubtedly  it  is  present  in  a  larger 
proportion  of  such  cases  than  of  those  of  ordinary  severity. 

Our  experience  does  not  confirm  that  of  Murchison,  who  states 
that  he  never  met  with  typhoid  symptoms  in  relapsing  fever  without 
albumin uria  or  some  other  evidence  of  retarded  elimination  by  the  kid- 
neys. In  several  of  our  cases  where  the  typhoid  state  was  developed  in 
the  highest  degree  repeated  examination  of  the  urine  failed  to  discover 
albumen. 

1  Op.  dt. 


408  RELAPSING  FEVER. 

Most  observers  have  been  struck  with  the  comparative  immunity  of 
the  kidneys  from  serious  disturbance  in  a  disease  presenting  such  com- 
plicated morbid  processes  and  widespread  lesions  as  relapsing  fever.  To 
show,  however,  that  these  organs  suffer  specially  in  certain  epidemics,  it 
may  be  mentioned  that  Obermeier l  reports  having  found  albumen  with 
tube-casts  of  various  kinds  in  32  out  of  40  cases  of  relapsing  fever,  thus 
showing  that,  in  the  particular  epidemic  he  was  studying,  catarrhal 
nephritis  was  of  almost  uniform  occurrence.  It  is  true  that  serious 
interference  with  the  elimination  of  urea  and  other  nitrogenous  matters 
may  occur  without  the  coexistence  of  alburninuria,  so  that  it  is  impossi- 
ble to  deny  that  severe  nervous  symptoms  may  result  from  impaired  renal 
activity  even  when  the  urine  contains  no  albumen. 

Attention  has  already  been  called  to  the  variations  presented  in 
the  amounts  of  urea,  but  more  extended  observations  are  required 
to  show  the  precise  relations  of  these  variations  to  the  graver  nervous 
phenomena.  It  will  be  found,  we  venture  to  opine,  that,  while  in  one 
group  of  relapsing-fever  cases  of  grave  type,  cerebral  symptoms  are 
dependent  upon  the  retention  and  accumulation  in  the  system  of  urea 
and  other  effete  nitrogenous  products,  owing  to  interference  with  renal 
activity  from  pre-existing  organic  disease  of  the  kidneys  or  from  an 
exceptional  degree  of  congestion  of  those  organs,  there  are  other  groups 
where  similar  typhoid  cerebral  symptoms  are  more  directly  dependent 
upon  the  specific  toxaemia,  upon  the  hyperpyrexia,  upon  exhaustion  of 
the  nerve-centres  by  intense  peripheral  irritation,  or  upon  congestion  or 
other  morbid  conditions  of  the  nerve-centres  themselves. 

In  all  cases  where  cerebral  symptoms  manifest  themselves  in  relapsing 
fever  the  daily  examination  of  the  urine — which  here,  as  in  other  zymotic 
diseases,  is  a  duty  in  all  cases— -becomes  of  extreme  importance.  Three 
conditions  should  be  borne  in  mind  in  such  examinations.  In  the  first 
place,  the  attack  of  fever  may  have  occurred  in  one  already  the  subject 
of  organic  kidney  disease,  and,  considering  the  classes  from  which  the 
majority  of  the  cases  of  relapsing  fever  are  drawn,  this  possibility  cannot 
be  of  rare  occurrence.  Out  of  eighteen  post-mortem  examinations  in 
which  the  kidneys  were  studied  with  especial  care  we  found  positive  evi- 
dence of  pre-existing  organic  disease  four  times.  In  these  cases  the 
albuminuria  was  marked  and  persistent,  though  tube-casts  were  rarely 
found,  and  severe  cerebral  symptoms  of  typhoid  type  were  prominently 
present.  In  another  highly  interesting  case  the  patient,  who  had  amyloid 
disease  of  the  liver,  spleen,  and  kidneys,  contracted  severe  relapsing  fever ; 
he  had  increased  albuminuria  during  both  febrile  stages,  suppurative  paro- 
titis, but  no  grave  cerebral  symptoms,  and  apparently  recovered.  After 
an  apyretic  period  of  six  weeks,  during  which  the  symptoms  of  the 
amyloid  visceral  disease  persisted,  a  sudden  and  rapidly  fatal  pyrexia 
occurred.  Unfortunately,  the  existence  of  spirillar  infection  of  the  blood 
was  not  known  at  the  time. 

In  the  second  place,  the  attack  of  fever  may  become  complicated  with 
acute  nephritis  from  special  localization  of  the  poison,  as  in  Obermeier's 
cases,  or  from  vulnerability  of  the  kidneys.  In  such  cases  careful  study 
of  the  urine  should  indicate  the  event,  and  the  prognosis,  though  grave, 
is  not  so  hopeless  as  in  the  first  instance.  An  interesting  example  of 
1  "  U.  d.  wiederkehrende  Fieber,"  Arch.  f.  path.  Anat.  u.  klin.  Med.,  Bd.  xlvii.  p.  170. 


COMPLICATIONS  AND  SEQUEL -JE.  409 

this  occurred  under  our  observation,  where  the  patient,  who  had  appar- 
ently an  ordinary  attack,  was  seized  with  acute  catarrhal  nephritis,  with 
temporary  uraemia,  during  the  relapse,  but  after  a  dangerous  illness  recov- 
ered without  any  organic  renal  disease  as  a  sequel. 

In  the  third  place,  may  be  found  the  more  usual  and  more  readily- 
determined  condition  of  slight  and  transient  albuminuria  (with  variations 
in  urea  excretion)  which  has  already  been  discussed,  and  which  has  no 
serious  prognostic  significance. 

The  following  very  interesting  case  deserves  special  mention :  The 
patient,  a  man  aged  thirty-six,  was  admitted  on  the  fifteenth  day  of  an 
attack  of  acute  catarrhal  nephritis,  with  slight  ascites,  marked  oedema  of 
the  feet  and  legs,  and  highly  albuminous  urine.  In  the  course  of  ten 
days  the  oedema  and  albumiuuria  were  much  diminished,  when  on  the 
thirteenth  day  after  admission  he  was  attacked  with  relapsing  fever,  the 
ward  in  which  he  lay  containing  a  number  of  persons  ill  with  that 
disease.  The  initial  paroxysm  was  severe,  but  without  any  grave  cere- 
bral symptoms ;  the  urine  grew  scanty,  dark,  and  bloody,  and  the  oedema 
increased  and  invaded  the  pelvis.  Crisis  occurred  on  the  fifth  day,  tem- 
perature falling  9°,  sweating  copious,  urine  473  com.  in  twenty-four 
hours,  color  of  porter,  highly  albuminous,  and  depositing  blood,  renal 
epithelium,  hyaline,  granular  and  epithelial  casts,  all  stained  reddish. 
Two  days  later,  urine  1600  ccni.,  light  colored,  with  only  a  small  amount 
of  albumen. 

A  slight  and  brief  relapse  (101°  for  two  days)  occurred  after  an  inter- 
val of  four  days ;  a  second  imperfect  relapse  (100.5°  for  three  days)  after 
a  further  interval  of  six  days ;  and  finally,  after  a  further  interval  of 
only  two  days,  a  violent  relapse  (temperature  rising  rapidly  to  106°)  with 
crisis  (fall  of  8°  in  twelve  hours)  at  close  of  fifth  day.  The  oedema 
gradually  diminished  from  the  time  of  the  first  crisis,  did  not  increase  in 
the  relapses,  and  disappeared  completely  and  finally  about  ten  days  after 
the  last  relapse.  The  urine  was  very  free  after  the  first  paroxysm,  aver- 
aging from  2000  to  2300  ccm.  During  the  subsequent  febrile  periods 
it  did  not  decrease,  and  indeed  on  the  second  day  of  the  last  relapse, 
with  the  temperature  at  105°,  the  amount  in  twenty-four  hours  was 
3200  ccm.  Four  days  subsequently,  during  crisis,  the  amount  was 
only  350  ccm. 

The  albumen  disappeared  entirely  from  the  urine  in  two  weeks  from 
the  close  of  the  last  relapse ;  there  had  then  been  no  tube-casts  for  some 
days,  and  the  patient  was  discharged  entirely  well  a  short  time  afterward. 
The  treatment  consisted  of  hot  vapor-baths,  repeated  dry  cupping  over 
the  kidneys,  infusion  of  digitalis  with  acetate  of  potash  during  pyrexia, 
and  Basham's  iron  mixture  in  the  intermissions.  It  seemed  that  the 
occurrence  of  the  relapsing  fever  interfered  wonderfully  little  with  the 
recovery  from  nephritis. 

Hematuria  is  a  comparatively  rare  and  very  grave  complication.  It 
may  occur  as  an  additional  evidence  of  the  dyscrasia  of  the  blood  in 
connection  with  hemorrhages  from  other  surfaces,  or  as  in  the  case  we 
have  before  referred  to  or  in  that  reported  by  Murchison,1  it  results 
from  intense  engorgement  of  the  kidneys.  In  Murchison's  case  hema- 
turia,  with  much  albumen  and  tube-casts,  occurred  in  both  paroxysms 

1  Op.  cit.,  p.  370. 


410  RELAPSING  FEVER. 

without  aiiy  uraemia  or  typhoid  symptoms,  aud  was  followed  by  satis- 
factory recovery. 

Sugar  is  sometimes  present  in  small  quantity  as  a  transient  symptom ; 
and  diabetes  has  beau  observed  as  a  sequel.1 

Metastatic  inflammation  of  the  kidneys,  with  centres  of  suppuration, 
was  observed  by  "VVyss  and  Bock. 

When  menstruation  occurs  during  relapsing  fever,  as  it  may  do  at 
any  time,  it  is  apt  to  be  excessive,  and  may  amount  to  severe  hemorrhage. 
Crisis  has  been  known  to  occur  in  this  manner. 

The  numerous  cases  reported  by  various  observers  of  relapsing  fever 
occurring  in  pregnant  women  establish  the  rule  that  abortion  almost  inva- 
riably occurs,  whatever  may  be  the  stage  of  the  pregnancy.  In  a  large 
majority  of  cases  the  mother  recovers,  but  the  child,  if  viable,  is  still- 
born or  dies  in  a  few  hours.  Only  two  of  our  patients  were  pregnant 
women,  and  the  result  in  each  was  unusual.  In  one,  the  patient,  already 
the  mother  of  several  children,  was  in  the  fifth  mouth  of  gestation ;  the 
initial  paroxysm  was  severe,  with  delirium,  but  no  symptoms  of  abortion 
occurred ;  the  intermission  lasted  six  days,  during  which  she  felt  very 
well ;  the  relapse  was  also  severe,  and  crisis  occurred  on  the  fifth  day, 
the  temperature  falling  below  normal,  and  the  case  promising  to  do  well ; 
but  on  the  following  day  there  was  a  sudden  rebound  of  temperature, 
pulse  140,  severe  prsecordial  pain,  and  death  occurred  in  twenty-four 
hours,  the  contents  of  the  uterus  being  partially  expelled  during  the  act 
of  dying.  In  the  other  case,  a  girl  of  eighteen  years,  who  had  aborted  at 
the  third  month  of  gestation  eight  months  previously,  and  who  was  again 
three  months  advanced  in  pregnancy  when  attacked  with  relapsing  fever, 
went  safely  through  a  bad  attack  and  carried  her  baby  successfully  to  full 
term. 

MORBID  ANATOMY. — The  surface  of  the  body  often  presents  patches 
of  livid  discoloration,  and  jaundice  persists  in  cases  where  it  has  been 
present  during  life.  There  is  but  little  appearance  of  emaciation,  except 
in  cases  where  it  has  been  present  before  the  attack. 

When  death  occurs  while  the  temperature  is  high  the  body  remains 
warm  an  unusual  length  of  time.  Thus,  in  one  case  where  death  oc- 
curred at  11.30  P.  M.,  the  temperature  at  12  was  103°,  and  at  1  A.  M.  it 
was  101f°,  that  of  the  room  being  73°  ;  at  6  A.  M.  it  remained  at  93°,  the 
room  being  at  73° ;  between  9  A.  M.  and  2  p.  M.  the  room  was  kept  at 
55°,  but  the  body  was  still  at  82°  at  the  latter  hour. 

The  voluntary  muscles  are  often  jaundiced,  and  in  prolonged  cases 
they  may  be  found  flabby  and  having  undergone  marked  granular 
degeneration.  In  many  cases,  however,  they  remain  quite  dark  and  firm. 
Ecchymoses  of  the  muscular  substance  are  met  with  occasionally. 

In  one  case,  where  during  life  there  had  been  painful  swelling  of  the 
left  parotid  region,  with  fistulous  openings  on  the  cheek,  and  where 
death  occurred  on  the  twelfth  day  of  the  disease,  the  masseter  muscle  was 
swollen,  with  patches  of  dark,  almost  black,  discoloration  from  ecchy- 
mosis,  and  was  studded  throughout  with  small  collections  in  its  sub- 
stance. The  fluid  from  these  contained  very  numerous  cells  indistin- 
guishable from  leucocytes.  The  muscular  fibrils  were  friable  and  granu- 
lar, and  there  was  multiplication  of  the  nuclei  of  the  sarcolemma. 
1  Tyson,  Phila.  Med.  Times,  1871,  i.  418. 


MORBID  ANATOMY.  411 

These  unusual  lesions  seerned  to  have  originated  in  interstitial  disinte- 
grating thrombi,  with  consequent  inflammation  of  the  muscle. 

The  muscle  of  the  heart  is  more  frequently  affected,  and  in  the  fatal  cases 
our  attention  was  particularly  drawn  to  those  lesions.  Ponfick1  has  also 
described  them  minutely.  The  degree  of  change  varies  from  a  partial  loss 
of  transverse  striation,  with  slight  granular  appearance,  up  to  a  very  high 
degree  of  granulo-fatty  degeneration.  The  organ  is  then  flabby,  its  sub- 
stance pale  gray  or  brownish,  either  wholly  or  in  streaks,  and  microscopic 
examination  shows  an  extreme  degree  of  fatty  granular  change.  It  must 
not  be  forgotten,  however,  that  many  of  the  subjects  of  relapsing  fever 
have  been  leading  irregular  and  dissipated  lives,  and  that  in  some  instances 
the  lesions  of  fatty  degeneration  detected  in  their  organs  may  have  been 
the  result  of  their  previous  habits. 

Lesions  of  the  cardiac  muscle  were  most  marked  in  those  of  our 
patients  who  had  been  intemperate,  and  in  whom  fatty  degeneration  of 
the  viscera  (chiefly  liver  and  kidneys)  was  also  found.  They  were  most 
fully  developed  in  cases  where  death  occurred  at  a  comparatively  late 
period,  while  in  some  very  severe  cases,  in  which  death  occurred  as  early 
as  the  fifth  day,  the  cardiac  fibre  presented  merely  faintness  of  striation 
without  actual  granular  degeneration. 

Ponfick  in  particular  notes  that  the  great  majority  of  the  bodies  he 
examined  were  of  persons  who  had  been  habitual  drunkards. 

Pericarditis  is  occasionally  present,  and  is  marked  by  the  usual  lesions. 
In  a  very  severe  case  in  which  it  contributed  largely  to  the  production  of 
the  fatal  result  it  was  associated  with  pneumonia.  In  addition  to  this, 
effusions  of  blood  beneath  the  endocardium  and  pericardium  are  not 
rare ;  and  we  have  seen  them  quite  large  and  numerous  in  cases  where 
the  muscular  fibre  was  firmly  contracted  and  the  cavities  contained 
quite  firm  decolorized  clots. 

Thus  in  our  case  No.  62,  Series  C.,  "  the  heart  was  normal  in  size, 
with  no  appearances  of  previous  disease.  There  were  numerous  ecchy- 
moses  of  both  layers  of  the  pericardium.  The  right  cavities  contained 
large,  firm,  yellowish,  fibrous  clots,  forming  a  cast  of  the  upper  part  of 
the  ventricle  and  of  the  auricle,  and  extending  both  into  the  pulmonary 
artery  and  back  into  the  veins,  and  so  firm  that  by  gentle  traction  a  com- 
plete cast  of  these  vessels  was  drawn  out.  The  clot  in  the  pulmonary 
artery  was  throughout  firm,  fibrous,  and  yellowish.  There  were  numer- 
ous ecchymoses  of  the  pleura  and  of  the  mucous  membranes  of  the 
stomach  and  urinary  bladder,  hemorrhagic  infarctions  in  the  kidneys  and 
lungs,  and  granulo-fatty  degeneration  of  the  cardiac  muscle."  Death  had 
occurred  in  this  case  about  the  close  of  the  third  week,  and  was  preceded 
by  hematemcsis  and  suppression  of  urine.  We  must  note  in  this  con- 
nection the  tendency  to  embolism  that  exists  in  this  disease. 

Especial  interest  attaches  to  the  condition  of  the  blood  in  relapsing 
fever.  Usually  it  presents  no  abnormal  appearance  if  drawn  during 
life,  though  in  grave  cases  it  may  coagulate  imperfectly.  We  have 
no  knowledge  of  its  minute  chemical  characters,  save  that  in  several 
cases  where  there  was  great  diminution  in  the  amount  of  urine,  with 
ursemic  symptoms,  urea  has  been  found  in  considerable  amount  in  the 
blood  (Murchison,  p.  368).  The  red  globules  present  no  definite  or 
1  Virchow's  Archiv.f.  path.  Anal.,  Bd.  Ix.  Hft.  2,  p.  162. 


412  RELAPSING  FEVER. 

characteristic  changes.  In  some  of  our  examinations  they  appeared 
of  light  color  and  became  crenated  very  quickly  on  exposure.  On 
the  other  hand,  the  white  corpuscles  have  repeatedly  been  observed  to 
be  increased  in  number,  at  times  considerably  so  (Cormack,  Thompson, 
Zuelzer,  Carter,  Boeckmann,  and  ourselves),  though  this  change  is  not 
regarded  as  constant  or  essential.  It  has,  however,  a  very  great  interest 
in  connection  with  the  characteristic  lesions  of  the  spleen  which  will  be 
described  hereafter.  In  several  cases  we  observed  that  many  white  cor- 
puscles were  small  and  apparently  imperfectly  developed.  Boeckmann 1 
concludes  that  they  increase  in  number  during  the  febrile  paroxysm, 
reaching  their  highest  number  at  the  crisis,  and  then  diminishing  grad- 
ually to  the  normal.  The  red  globules  are  much  decreased  during  the 
fever,  and  return  to  the  normal  slowly  during  convalescence. 

In  addition  to  these  changes,  various  abnormal  elements  have  been 
observed  more  or  less  constantly.  By  far  the  most  important  of  these  is 
the  spirillum  or  spirochete  of  Obermeier,  which  has  been  already  care- 
fully described.  In  proportion  as  this  organism  has  been  carefully  looked 
for  it  has  been  found  constantly,  so  that  the  evidence  has  become  very 
strong  in  favor  of  its  uniform  presence  in  the  blood  of  relapsiug-fever 
patients  during  the  febrile  stage  of  the  disease. 

Ponfick  in  1874 2  called  attention  to  the  occurrence  of  large  granule- 
cells  in  the  blood  in  this  disease.  They  are  found  during  life  as  well  as 
after  death,  when  they  exist  in  largest  proportion  in  the  blood  of  the 
splenic,  hepatic,  and  portal  veins.  Their  shape  is  spherical,  ovoid,  or 
elongated ;  the  basis  of  the  cells  is  a  delicate,  translucent,  albuminous 
substance;  and  the  granules  are  of  a  fatty  nature,  as  shown  by  the 
action  of  reagents.  These  cells  have  been  found  by  other  observers, 
and  the  view  is  generally  received  that  they  are  derived  from  the 
lyniphoid  elements  of  the  spleen,  and  perhaps  of  other  portions  of  the 
lymphatic  system;  and  Carter,  who  has  studied  them  carefully,  is 
inclined  to  think  there  is  some  connection  between  them  and  the 
development  of  the  spirillum. 

Ponfick  also  first  described3  certain  other  large,  irregularly-shaped,  pale, 
granular,  nucleated  cells,  which  occur  in  smaller  number  in  the  blood  in 
relapsing  fever,  and  which  he  regarded  as  altered  endothelium,  derived 
from  the  lining  of  the  blood-vessels,  of  the  lymphatics,  or  of  the  lacunar 
spaces  of  the  spleen.  Occasionally  these  cells  are  found  with  such  highly 
granular  contents  as  to  make  them  closely  simulate  the  large  granule- 
cells  described  above.  These  results  of  Ponfick  have  been  confirmed  by 
other  observers. 

In  several  of  our  reports  of  examinations  of  blood  there  is  mention 
made  of  quite  abundant,  free  granular  matter — an  appearance  also 
observed  by  Carter.  Finally,  the  latter  describes  the  occurrence  of 
thread-like  filaments  and  of  short,  rod-like  bodies. 

There  are  no  characteristic  lesions  connected  with  the  gastro-intestinal 
canal.  The  mucous  membrane  of  the  stomach  may  be  normal  or  merely 
injected,  though  where  there  has  been  much  vomiting,  and  especially 
bloody  vomiting,  there  is  marked  injection,  and  not  rarely  ecchymosis 
and  submucous  extravasations  of  blood,  with  softening  of  the  membrane. 

1  Deutsr.h.  Arch.f.  Urn.  med.,  Sept.  1881,  p  513. 

•  Centrcdbl.f.  d.  med.  Wissensch.,  1874,  p.  25.  !  Loc.  cit. 


MORBID  ANATOMY.  413 

These  extravasations  are  usually  small,  but  Cormack  reports  a  case  where 
one-third  of  the  mucous  membrane  of  the  stomach  was  the  seat  of  ecchy- 
mosis  and  extravasation.  In  one  of  our  own  cases  the  extravasations 
occupied  an  area  of  four  inches  square. 

The  small  intestines  exhibit  patches  of  congestion  or  ecchymosis  less  fre- 
quently than  the  stomach,  though  it  is  usual  to  find  injection  of  the  mucous 
membrane,  especially  of  the  lower  portion,  in  cases  where  there  has  been 
diarrhoea.  Carter,  observing  the  disease  in  India,  found  in  one-half  of 
all  autopsies  some  amount  of  congestion,  hemorrhage,  or  inflammation  of 
the  ileum.  In  two  instances  he  found  a  layer  of  diphtheritic  deposit  over 
the  mucous  membrane  of  the  lower  part  of  the  ileum. 

There  are  no  special  alterations  of  the  solitary  or  agminated  glands, 
and  ulceration  never  occurs.  Even  in  cases  where  the  constitutional 
infection  is  severe,  whether  diarrhoea  has  been  present  or  not,  it  is  note- 
worthy that  there  is  rarely  any  swelling  of  the  solitary  glands  or  Peyer's 
patches,  such  as  is  met  with  in  many  other  acute  specific  diseases.  It  was 
not  present  in  any  of  our  autopsies. 

The  large  intestine  in  like  manner  exhibits  no  characteristic  lesions. 
Patches  of  congestion  and  occasionally  submucous  ecchymoses  may  be 
observed,  and  croupous  exudation  occurs  here  somewhat  more  frequently 
than  in  the  small  intestine. 

Wyss  and  Bock l  speak  of  enlargement  of  the  mesenteric  and  retro- 
peritoneal  glands  as  of  frequent  occurrence,  but  we  did  not  observe  it, 
and  Murchisoii  states  that  these  glands  present  no  abnormal  appearance. 

Alterations  of  vascularity  of  the  brain  or  its  membranes  are  met  with, 
but  they  are  variable  and  bear  no  definite  relation  to  the  precedent  symp- 
toms. Ecchymoses  of  the  membranes  are  occasionally  observed,  and  in 
one  of  our  cases  extensive  meningeal  hemorrhage  was  found.  Murchison 
reported  a  case  in  which  embolism  of  the  left  femoral  artery  occurred,  and 
subsequently  of  the  left  middle  cerebral  artery,  inducing  death.  The  sug- 
gestion may  be  hazarded  that  in  some  of  the  cases  where  there  is  severe 
delirium  ending  in  stupor  and  death  there  has  been  multiple  capillary 
embolism  of  the  cerebral  vessels. 

There  is  occasionally  the  evidence  of  catarrhal  inflammation  of  the 
upper  air-passages,  and  in  some  epidemics  diphtheritic  exudation  in  the 
pharynx  and  larynx  has  been  noted  (Wyss  and  Bock) ;  and  Ponfick 
found  acute  oedema  of  the  glottis  in  a  considerable  proportion  of  the 
fatal  cases  at  Berlin.  The  lesions  of  pleurisy  are  met  with  in  a  small 
proportion  of  cases ;  in  our  own  autopsies  this  complication  was  more 
frequent  than  in  most  epidemics. 

The  lungs  may  be  normal,  and  Murchison  concludes  that  they  are 
more  frequently  so  than  in  typhus.  Still,  they  often  present  congestion  or 
oedema,  and  subpleural  ecchymoses,  hemorrhagic  infarctions,  and  pneu- 
monic consolidation  are  not  rare.  Lobar  pneumonia  was  present  in  33 
per  cent,  of  our  own  autopsies,  in  28  per  cent,  of  Carter's,  and  in  20  per 
cent,  of  those  conducted  by  Ponfick.  The  inflammation  usually  presents 
the  regular  stages,  and  is  associated  with  a  moderate  degree  of  plastic 
pleurisy ;  but  occasionally,  as  in  one  of  our  cases,  it  terminates  in  gan- 
grene. In  the  instance  referred  to  there  was  an  area  of  gangrene  about 
three  inches  square  and  one  inch  in  depth,  involving  the  pleura  and  a 

1  Op.  dt.,  p.  223. 


414  RELAPSING  FEVER. 

superficial  layer  of  lung  on  the  antero-lateral  aspect  of  the  left  lower  lobe. 
In  another  remarkable  instance,  already  referred  to  on  account  of  the 
suppurative  inflammation  of  one  masseter  muscle,  the  lungs,  which  were 
stained  yellow  throughout,  presented  numerous  deep  purplish  patches, 
which  on  section  altogether  resembled  the  secondary  metastatic  deposits 
of  pyfemia,  with  yellowish  softening  or  even  puriform  centres  surrounded 
by  a  rim  of  purplish  livid  discoloration.  Very  numerous  similar  patches, 
varying  from  the  size  of  a  pea  to  that  of  a  hazel-nut,  and  presenting 
every  stage  of  development,  were  found  throughout  both  lungs.  In  a 
few  instances  we  found  the  lesions  of  chronic  phthisis,  which  had,  of 
course,  existed  before  the  attack  of  relapsing  fever.  The  bronchial  glands 
were  found  swollen  and  infiltrated  in  cases  where  inflammatory  processes 
in  the  lungs  have  existed. 

Much  interest  attaches  to  the  state  of  the  genito-urmary  organs  in 
relapsing  fever,  but  caution  is  required  to  distinguish  lesions  that  have 
existed  prior  to  the  attack  from  those  properly  referable  to  it. 

Owing  to  the  intemperate  and  exposed  lives  of  many  of  the  patients, 
renal  lesions  might  reasonably  be  expected  in  no  small  proportion.  The 
comparative  rarity  of  albuminuria  (see  p.  407),  even  in  severe  cases,  is 
suggestive  of  the  view  that  when  it  is  present  it  may  at  least  sometimes 
be  due  to  pre-existing  lesions  aggravated  by  the  acute  infectious  process, 
and  further  that  the  extreme  gravity  generally  presented  by  such  cases 
may  be  in  part  due  to  the  impaired  condition  of  the  kidneys. 

The  morbid  changes  most  frequently  referable  to  the  fever  are  mode- 
rate enlargement  and  congestion,  occasionally  very  intense  so  that  we  find 
it  described  in  our  notes  as  deep  blackish-purple  or  blue ;  ecchymoses  of 
the  capsule  or  of  the  mucous  membrane  of  the  pelvis ;  small  hemorrhagic 
infarctions,  usually  in  the  cortex ;  and  cloudy  swelling  of  the  glandular 
cells.  Less  commonly  are  found  hemorrhagic  infarctions,  or  small  embolic 
patches  advanced  to  various  stages  of  disintegration,  even  to  the  formation 
of  small  puriform  collections.  In  quite  rare  cases  the  lesions  of  acute 
nephritis  are  present,  while  caution  must  be  used  in  interpreting  other 
changes  occasionally  met  with,  such  as  pallor  with  grai.ulo-fatty  degenera- 
tion or  other  advanced  alterations  of  the  glandular  cells,  or  hyperplasia  of 
the  intertubular  connective  tissue,  with  or  without  contraction  of  the  kidneys. 

The  mucous  membrane  of  the  bladder,  as  already  mentioned,  may  present 
ecchymoses,  or,  more  rarely,  croupous  exudation  (Wyss  and  Bock).  The 
urine  contained  may  be  bloody,  or,  as  in  one  of  our  cases  where  there  had 
been  total  suppression  of  urine  for  over  seventy-two  hours  before  death, 
there  may  be  but  a  small  amount  of  almost  pure  blood,  containing  a 
few  phosphate  crystals,  but  no  tube-casts.  In  this  case  there  were  also 
ecchymoses  of  the  bladder  and  of  the  pelvis  of  the  kidneys,  with 
intense  congestion  and  numerous  small  hemorrhagic  infarctions  of  the 
kidneys. 

The  liver  is  constantly  though  variously  affected.  It  is  found  enlarged 
in  the  great  majority  of  cases,  especially  if  death  has  occurred  during  the 
febrile  stage.  The  ordinary  degree  of  enlargement  in  our  cases  was 
from  four  to  four  and  a  half  pounds,  but  in  a  few  instances  the  liver 
weighed  one  hundred  or  one  hundred  and  two  ounces,  though  in  most  of 
these  extreme  cases  the  patients  had  been  drunkards,  and  there  was  such 
advanced  fatty  alteration  of  the  liver  as  to  make  it  probable  that  the 


MORBID  ANATOMY.  415 

organ  had  beeu  diseased  previously.  These  figures  correspond  with  the 
results  of  other  observers. 

In  many  cases,  especially  when  death  occurs  early  and  during  the 
febrile  stage,  the  capsule  and  substance  of  the  liver  are  congested,  at 
times  intensely  so ;  and  when  ecchymoses  are  found  elsewhere  they  are 
apt  to  be  present  here  also,  appearing  as  purplish  patches  dotted  over  the 
capsule  and  extending  into  the  superficial  layer  of  hepatic  tissue.  Not 
rarely,  however,  the  liver  substance  is  paler  than  normal,  and  presents  a 
yellowish  tinge,  apart  from  the  decided  yellowish  staining  present  incases 
attended  with  jaundice.  Carter  describes  a  partial  mottled  paleness  of 
the  liver  as  having  been  frequently  observed  in  his  cases,  the  circum- 
scribed pale  areas  presenting  a  corresponding  localized  degeneration  of 
the  cells,  as  though  from  some  local  interruption  of  circulation. 

Cloudy  swelling  and  fatty  degeneration  of  the  liver-cells  are  indeed 
very  often  present,  and  in  some  epidemics  with  preponderance  of  bilious 
symptoms  are  constantly  found  (Ponfick).  The  degree  of  the  cell-altera- 
tion varies  from  a  slight  granulo-fatty  change  to  an  advanced  fatty  degen- 
eration, even  with  a  marked  tendency,  in  rare  cases,  to  disintegration  of 
the  cells,  so  as  to  produce  lesions  analagous  to  those  of  acute  yellow 
atrophy  (St.  Petersburg  epidemic). 

The  whitish  deposits  described  by  Kiittner  as  due  to  albuminous  or 
fibrinous  infiltration  are  probably  referable  to  transformed  hemorrhagic 
infarctions,  and  the  minute  puriform  collections  that  have  been  observed 
at  the  centre  of  the  acini  (Wyss  and  Bock)  may  have  been  metastatic  in 
origin,  or  attributable  to  the  disintegration  of  minute  thrombi  associated 
with  irritative  hyperplasia  of  the  adjacent  lymphoid  elements.  The  con- 
sistence of  the  liver  varies :  when  death  occurs  early  and  bilious  symp- 
toms have  not  been  marked,  it  may  be  even  firmer  than  normal,  but  more 
frequently  it  is  softer,  and  it  may  be  relaxed,  flabby,  and  friable. 

The  condition  of  the  bile-ducts  is  of  great  interest  in  view  of  the  fre- 
quency of  jaundice  as  a  symptom  in  relapsing  fever,  and  most  authorities 
unite  in  saying  that  they  present  no  lesions  capable  of  explaining  it. 

The  gall-bladder  is  usually  found  full  of  dark  bile,  but  there  is  no 
such  degree  of  inspissation,  except  in  rare  instances,  as  could  interfere 
with  its  passage  through  the  ducts.  Murchison  quotes  the  statement  of 
Peacock  that  in  some  instances  the  bile  was  thick  and  viscid,  so  as 
appaiently  to  cause  obstruction,  but  all  observations  agree  in  showing 
that  this  is  exceptional.  The  mucous  membranes  of  the  larger  ducts 
may  present  evidences  of  slight  catarrhal  inflammation,  but  in  nearly  all 
cases  where  they  have  been  carefully  examined,  even  when  jaundice  had 
been  marked,  they  have  been  found  patulous  and  free,  so  that  the  jaundice 
cannot  be  regarded  as  due  to  obstruction  of  the  larger  ducts  save  in  rare 
instances  (Pastau).  In  further  confirmation  of  this  may  be  stated  the  fact 
that  there  is  no  want  of  bile  in  the  duodenum  and  feccs. 

On  the  other  hand,  a  careful  consideration  of  the  lesions  of  the  sub- 
stance of  the  liver  will  show  that  it  would  be  most  improbable  that  the 
minute  biliary  ducts  in  the  areas  most  affected  should  escape  implication. 
Munch,  who  investigated  this  subject  carefully,  found  that  there  was  a 
catarrhal  state  of  the  fine  bile-ducts  in  every  case  of  relapsing  fever  with 
jaundice ;  and  Litten  found  the  smallest  ducts  plugged  with  bile-stained 
pellets  of  mucus.  It  would  appear,  therefore,  that  in  many  cases  at  least 


416  RELAPSING  FEVER. 

the  jaundice  is  really  obstructive  in  its  origin,  the  seat  of  the  obstruction 
being  in  the  too-rarely  examined  minute  bile-ducts,  though  further  inves- 
tigation of  this  interesting  question  is  required. 

The  clinical  bearing  of  these  conditions  has  been  fully  discussed  in  the 
appropriate  section. 

The  changes  in  the  spleen  are  constant,  and  even  more  remarkable 
than  those  in  the  liver.  It  is  enlarged  with  rare  exceptions,  and  espe- 
cially so  if  death  has  occurred  during  the  febrile  stage.  Upon  the 
subsidence  of  the  fever  the  spleen  probably  returns  to  its  normal  size 
more  rapidly  than  the  liver.  The  more  common  extent  of  the  enlarge- 
ment in  our  own  cases  was  from  ten  to  eighteen  ounces,  though  we 
found  the  spleen  in  one  case  weighing  twenty-nine  and  a  half  ounces  and 
in  another  forty-four  and  a  half  ounces.  In  neither  of  the  latter 
instances  was  there  any  reason  to  suspect  malarial  complication.  The 
most  extensive  enlargement  we  have  found  recorded  is  sixty-eight  ounces 
in  a  case  reported  by  Kiittner l 

There  is  usually  a  correspondence  between  the  stage  and  extent  of  the 
splenic  and  hepatic  lesions,  but  this  is  not  invariable,  and  one  or  the 
other  organ  may  present  a  far  higher  degree  of  enlargement  or  much 
more  intense  interstitial  changes.  It  may  be  mentioned,  moreover,  that 
in  some  unusual  cases  the  lesions  of  the  lungs,  such  as  ecchymoses  and 
hemorrhagic  infarctions,  may  be  disproportionately  marked  as  compared 
with  those  of  either  the  liver  or  spleen. 

The  capsule  of  the  spleen  often  presents  a  mottled  look,  with  at  times 
large  purplish  ecchymoses ;  it  is  apt  to  be  more  or  less  opaque,  and  local 
peritonitis,  with  thin  layers  of  plastic  exudation  often  forming  friable 
adhesions  with  the  abdominal  wall,  may  exist. 

In  one  of  our  cases  the  capsule  presented  a  small  perforation  or  rup- 
ture, with  an  exudation  of  plastic  lymph  over  an  area  of  four  by  six 
inches,  and  diffuse  peritonitis,  with  effusion  of  bloody  liquid  with  shreds 
of  lymph  throughout  the  abdominal  cavity.  This  fatal  termination  is 
fortunately  rare,  but  there  are  several  other  instances  on  record.  The 
splenic  pulp  may  retain  its  consistency  and  firmness,  even  in  cases  that 
have  run  a  long  course ;  but  more  frequently  it  is  softened,  and  may  be 
almost  diffluent.  The  pulp  is  often  swollen,  so  that  when  cut  it  projects 
above  the  section.  The  color  is  darker  than  normal,  and  often  is  of  a 
deep  maroon  color.  This  swelling  is  due  to  enlargement  of  the  blood- 
vessels, associated  with  great  increase  of  the  cellular  elements  of  the  pulp 
and  with  enlargement  of  the  Malpighian  corpuscles. 

When  death  occurred  early  in  the  disease  wre  found  these  bodies  gray- 
ish or  grayish-yellow  in  color  and  of  the  size  of  hempseed,  so  that  the 
section  very  thickly  studded  with  them  closely  resembled  shad-roe,  and 
this  stage  of  the  lesion  is  frequently  described  in  our  notes  as  the  shad- 
roe  spleen.  Subsequently,  the  Malpighian  bodies  enlarge  still  more,  and 
stand  out  above  the  section  a  line  or  more  in  diameter,  and  of  a  lighter 
color ;  not  rarely,  several  of  them  come  in  contact,  and  thus  form  a  con- 
siderable mass  of  irregular  shape,  resembling  the  infarctions  described 
below.2  It  is  probable  that  central  softening  may  occur  later  in  the 

1  Schmidts  Jahrb.,  1865,  vol.  cxxvi. 

2 Thus,  Wyss  and  Bock  describe  "multitudes  of  minute  abscesses  as  large  as  poppy  or 
hempseed,  and  containing  a  single  drop  of  pus." 


MORBID  ANATOMY.  417 

Malpighian  bodies,  though  we  are  inclined  to  regard  the  puriform  col- 
lections frequently  found  as  chiefly  due  to  the  disintegration  of  hemor- 
rhagic  infarctions  or  of  erabolic  patches.  Of  these,  hemorrhagic  infarc- 
tions are  by  far  the  most  common  and  present  the  familiar  appearances. 
They  may  be  quite  numerous,  superficial,  or  deep-seated,  and  of  variable 
shape  and  size.  At  first  dark  reddish,  firm,  and  sharply  separated  from  the 
surrounding  pulp,  they  grew  reddish-yellow  or  yellowish  later,  softened 
in  the  centre,  and  eventually  were  transformed  into  puriform  collections. 
Doubtless,  in  a  large  proportion  of  cases  that  recover  such  infarctions 
exist  and  are  slowly  absorbed.  Ponfick  has  shown  that  these  are  venous 
infarctions,  the  arterioles  leading  to  them  being  patulous.  True  arterial 
embolism  does,  however,  occur,  though  much  more  rarely  (Ponfick,  Mur- 
cliison),  giving  rise  to  firm,  wedge-shaped  infarctions  at  the  periphery  of 
the  spleen,  which  may  undergo  degenerative  changes  similar  to  those 
above  described.  The  resulting  abscesses  may  burst  into  the  peritoneum, 
pleura,  lung,  or  bowel.  The  microscopic  appearances  have  been  most 
fully  described  by  Ponfick,  our  own  comparatively  meagre  observations 
having  accorded  entirely  with  his  subsequent  accurate  description.  The 
cells  of  the  swollen  pulp  contain  red  blood-discs  and  pigment,  and  some 
present  collections  of  bright  granules.  The  lymphoid  cells  of  the  Mal- 
pighian corpuscles  are  at  first  in  a  state  of  cloudy  swelling  with  multi- 
plication of  their  nuclei,  and  later  show  marked  granular  fatty  degener- 
ation. 

The  lymphatic  glands  present  no  lesions,  and  the  pancreas  is  normal. 

The  peritoneum  is  not  affected  as  frequently  as  other  serous  membranes 
in  this  disease.  Superficial  ecchymoses  are,  however,  quite  common,  espe- 
cially so  over  the  solid  viscera ;  and  more  rarely  effusions  of  blood  have 
been  found  in  the  subperitoueal  connective  tissue,  involving  the  muscular 
or  glandular  tissues  beneath.  We  have  already  mentioned  (p.  406)  the  oc- 
casional occurrence  of  local  peritonitis,  most  frequently  of  the  splenic 
capsule,  and  also  the  rare  accident  of  diffuse  inflammation  from  rupture 
of  the  spleen. 

The  marrow  of  the  bones  was  carefully  examined  by  Ponfick,  who  first 
called  attention  to  the  presence  of  important  changes  in  relapsing  fever, 
which  have  since  been  confirmed  by  other  observers.  These  changes 
consist  in  proliferation  and  subsequent  degeneration  of  the  lymphoid 
cells  of  the  marrow,  with  multiplication  of  the  nuclei  in  the  walls  of  the 
minute  vessels  and  fatty  degeneration  of  their  coats.  As  a  result  of 
these  changes,  spots  of  puriform  softening  may  form,  chiefly  in  the  can- 
cellous  tissue  of  the  extremities  of  the  long  bones,  with  the  production 
of  localized  necrosis,  and  possibly  with  extension  of  inflammation  to  the 
neighboring  articular  cavity. 

Considerable  space  has  been  devoted  to  the  detailed  consideration  of 
the  pathological  changes  in  relapsing  fever,  partly  because  we  believe  the 
fact  has  not  been  sufficiently  recognized  that  the  disease  is  constantly 
attended  with  important  and  characteristic  lesions.  These  consist,  in 
brief,  of  remarkable  changes  in  the  blood;  of  widespread  ecchymoses 
and  infarctions,  which  not  rarely  undergo  puriform  disintegration  ;  of 
hyperplasia  and  subsequent  degeneration  of  the  Malpighian  corpuscles 
of  the  spleen,  with  changes  in  the  cellular  elements  of  the  splenic  pulp; 
of  cloudy  swelling  of  the  gland-cells  of  the  liver  and  kidneys,  with  a 
VOL.  I.— 27 


418  RELAPSING  FEVER. 

marked  tendency  to  fatty  degeneration  ;  of  changes  in  the  marrow  of  the 
lono-  bones ;  aud,  finally,  of  grauulo-fatty  degeneration  of  the  muscles, 
and  especially  of  the  heart. 

DIAGNOSIS  AXD  KELATION  TO  OTHER  DISEASES. — The  entire  ques- 
tion of  the  diagnosis  of  relapsing  fever  is  dominated  by  that  of  spirillar 
infection.  Before  Obermeier's  discovery  the  differential  diagnosis  of  the 
initial  paroxysm,  and  to  a  less  extent  that  of  the  subsequent  events 
of  a  case  of  relapsing  fever,  was  attended  with  considerable  difficulty. 
But  if,  as  now  seems  established,  immediately  before  and  throughout  the 
initial  paroxysm  and  subsequent  relapses  a  characteristic  spirillum  is  to 
be  detected  in  the  blood  upon  proper  examination,  while  it  rapidly  dis- 
appears after  the  crisis,  it  is  evident  that  as  soon  as  a  suspicion  is  aroused 
as  to  the  possible  presence  of  relapsing  fever  the  question  may  be  settled 
conclusively  by  the  microscope. 

None  the  less  is  it  important  to  consider  carefully,  but  briefly,  the 
symptoms  by  which  relapsing  fever  is  to  be  distinguished  from  various 
affections  which  may  simulate  it,  because  even  the  most  experienced 
observers  admit  that  the  spirillum  cannot  be  invariably  detected ;  because 
it  is  not  yet  known  that  a  similar  organism  may  not  be  found  in  some 
other  affections ;  and,  finally,  because  on  the  outbreak  of  an  epidemic  of 
relapsing  fever,  especially  in  America,  where  its  occurrence  has  hitherto 
been  so  rare,  there  is  strong  probability  that  the  nature  of  the  early  cases 
will  not  be  even  suspected  until  the  relapse  occurs. 

Typhus  fever  often  prevails  in  an  epidemic  form  simultaneously  with 
relapsing  fever,  so  that  it  was  inevitable  they  should  have  been  for  a  time 
confused.  Their  essential  non-identity  is,  however,  now  too  well  recog- 
nized to  require  any  lengthy  demonstration.  The  following  statement  of 
the  heads  of  the  argument  may  therefore  suffice. 

In  typhus  there  is  no  characteristic  spirillum,  and  the  lesions  which  are 
truly  characteristic  of  relapsing  fever  are  totally  wanting.  There  are 
convincing  differences  in  the  symptoms,  course,  and  results  of  the  two 
diseases.  There  is  no  evidence  to  show  that  when  fever  has  been  im- 
ported into  a  locality  by  a  single  case,  typhus  fever  has  ever  produced 
other  than  typhus,  or  relapsing  other  than  relapsing  fever.  The  two 
diseases  often  prevail  together,  and  may  coexist  in  the  same  house,  each 
preserving  its  own  distinct  characteristics ;  and  persons  exposed  to  the 
double  contagion  may  contract  one  or  the  other,  or  first  one  and  then  the 
other  at  a  shorter  or  longer  interval,  so  that  an  attack  of  either  exerts  no 
protective  power  against  the  other.  It  must  be  noted,  however,  that  in 
a  large  majority  of  such  cases  of  successive  contagion  it  is  relapsing 
fever  which  has  been  followed  by  typhus,  while  the  reverse  has  been 
observed  much  more  rarely. 

In  1869-70  the  two  diseases  were  prevalent  in  Philadelphia,  and  the 
wards  of  the  municipal  hospitals  constantly  contained  a  considerable  num- 
ber of  cases  of  both.  Three  instances  came  under  our  care  in  which  after 
recovery  from  relapsing  fever  the  patient  contracted  typhus.  All  of  these 
patients  were  employed  as  assistant  nurses,  and  were  continuously  under 
observation  from  the  early  part  of  their  attack  of  relapsing  fever  to  the 
end  of  the  attack  of  typhus.  In  one  case  the  interval  of  health  between 
the  close  of  the  relapse  and  the  onset  of  typhus  was  forty-four  days ;  in 
the  second  it  was  thirteen  clays.  In  both  cases  the  original  disease  was 


DIAGNOSIS  AND  RELATION  TO   OTHER  DISEASES.  419 

thoroughly  characteristic  and  the  subsequent  attack  of  typhus  was  typ- 
ical. In  both  death  followed,  and  the  post-mortem  examination  verified 
the  above  statement.  The  third  patient  had  severe  relapsing-  fever,  from 
which  he  recovered  and  returned  to  work,  though  with  pains  in  the  legs, 
shoulders,  and  forehead.  After  an  interval  of  apparent  health  of  eleven 
days  he  developed  a  well-marked  attack  of  typhus,  which  terminated  on 
the  twelfth  day  in  recovery.  It  may  be  added  that  although  typhus  is 
not  of  frequent  occurrence  in  any  portion  of  North  America,  there  have 
been  a  number  of  epidemics  unattended  with  a  single  case  presenting  the 
features  of  relapsing  fever. 

Between  well-marked  cases  of  the  two  diseases  there  should  be  no  dif- 
ficulty in  making  a  prompt  diagnosis.  Relapsing  fever  is  distinguished 
from  typhus  clinically  by  the  severity  of  the  initial  chill ;  the  rapid  ele- 
vation of  the  pulse  and  temperature ;  the  comparative  infrequency  and 
mildness  of  cerebral  symptoms,  despite  the  intense  fever ;  the  severity  of 
the  gastric  symptoms,  nausea  and  vomiting ;  the  enlargement  of  the  liver 
and  spleen,  with  marked  abdominal  pain  and  soreness ;  the  frequency  of 
jaundice,  of  epistaxis,  and  of  other  hemorrhages,  and  of  ansemic  murmurs 
over  the  heart  and  large  vessels ;  obstinate  insomnia ;  vertigo ;  peculiar 
rheumatoid  pains  and  perversions  of  sensation  ;  the  frequency  of  sweating 
during  the  high  pyrexia ;  by  the  occurrence  of  crisis,  subnormal  tempera- 
ture, apyretic  interval,  and  relapse ;  the  rarity  of  measly  eruption  and  of 
bed-sores;  the  frequency  of  pneumonia,  diarrhoea,  ophthalmia,  oedema, 
and  desquamation  as  complications  and  sequelre ;  the  usual  occurrence  of 
abortion  in  pregnant  females ;  the  protracted  course  of  the  disease,  and 
its  remarkably  low  mortality  despite  the  severity  of  the  symptoms,  except 
in  cases  of  complicated  or  typhoid  type ;  and,  finally,  by  the  modes  in 
which  death  occurs.  Of  course  to  this  must  be  added  the  specific  result 
of  examination  of  the  blood  in  relapsing  fever. 

Doubt  will  arise  only  in  very  rare  cases  where  a  measly  eruption 
appears  on  or  before  the  fifth  day  of  relapsing  fever,  with  headache  and 
mild  delirium,  but  without  severe  gastric  symptoms,  epistaxis,  or  jaun- 
dice. If  no  relapsing  fever  were  prevalent  at  the  time,  such  a  case 
might  well  be  regarded  as  one  of  mild  typhus  until  the  crisis  and  the 
relapse  disclosed  its  real  nature.  But  if  the  two  diseases  were  known  to 
be  prevalent  in  the  community,  examination  of  the  blood  would  properly 
be  made  at  once  and  the  diagnosis  be  established. 

The  diagnosis  between  ordinary  cases  of  relapsing  fever  and  typhoid 
is  readily  made  by  the  gradual  onset  and  peculiar  course  of  the 
pyrexia  in  the  latter  disease,  as  well  as  by  the  frequency  of  delirium, 
of  abdominal  distension,  and  of  diarrhoea,  and  by  the  characteristic 
eruption.  The  occurrence  of  epistaxis,  bronchial  irritation,  and  splenic 
enlargement  is  common  to  both,  and  an  eruption  of  small  rose-pink 
spots  has  been  noted  by  some  observers  (Carter,  pp.  194,  317).  But 
jaundice,  enlargement  of  the  liver,  hypochondriac  pain  and  soreness, 
excessive  nausea  and  vomiting,  severe  rheumatoid  pains,  and  numbness 
and  tingling  of  the  extremities,  are  very  significant  symptoms  of  relaps- 
ing fever.  Attention  has  already  been  called  to  the  grave  type  of  relaps- 
ing fever  in  which  the  typhoid  state  is  fully  developed,  and  to  the  fact 
that  in  such  cases  the  pyrexia  is  often  modified,  the  onset  less  abrupt,  the 
crisis  imperfect,  and  the  interval  occupied  by  an  irregular  post-critical 


420  RELAPSING  FEVER. 

•symptomatic  fever.  It  is  altogether  probable  that  such  cases  have  not 
rarely  been  regarded  as  of  true  typhoid  character ;  and  indeed  the  attempt 
has  been  made  by  Griesinger  to  establish  as  a  separate  and  independent 
affection,  under  the  name  of  bilious  typhoid  fever,  a  group  of  cases  which 
close  examination  seems  to  show  to  be  chiefly  composed  of  grave  compli- 
cated relapsing  fever  with  a  certain  proportion  of  true  typhoid  fever, 
complicated  with  jaundice. 

The  recognition  of  the  bilious  typhoid  type  of  relapsing  fever  is  based 
upon  the  history  of  the  case ;  the  mode  of  onset ;  the  greater  severity  of 
the  pains,  arthritic  and  abdominal ;  the  early  appearance  and  intensity  of 
the  jaundice;  the  more  marked  enlargement  of  the  liver  and  spleen;  the 
marked  tendency  to  hemorrhages  from  various  surfaces ;  the  peculiarities 
which  careful  study  of  the  temperature  curve  will  show,  especially  about 
the  time  of  crisis;  the  rarity  of  eruption;  the  characteristic  spirillum;1 
and  the  totally  different  anatomical  lesions,  which  are,  unfortunately, 
often  demonstrable,  as  this  form  of  relapsing  fever  is  fatal  in  from  33  to 
50  per  cent,  of  cases. 

Since  the  discovery  of  the  spirillar  test  for  relapsing  fever  it  may  be 
said  that  Griesinger's  bilious  typhoid  must  be  stricken  from  medical  nosol- 
ogy as  an  independent  affection. 

The  case  of  Charles  Hood,  on  page  396,  is  a  good  example  of  the  bilious 
typhoid  form  which  occurred  not  rarely  in  the  Philadelphia  epidemic : 

Murchison  points  out  that,  owing  to  the  frequent  occurrence  of  jaun- 
dice in  relapsing  fever,  this  disease  has  been  mistaken  for  yellow  fever 
by  such  good  observers  as  Graves,  Stokes,  and  Cormack.  Difficulty  in 
diagnosis  would  be  likely  to  arise  only  in  regard  to  the  bilious  typhoid 
type  of  relapsing  fever,  and  since  its  clinical  history  has  become  so  well 
known,  a  mistake  is  not  likely  to  occur.  The  geographical  distribution 
of  the  diseases  is  widely  different.  Yellow  fever  is  influenced  powerfully 
by  season  and  temperature,  while  relapsing  fever  is  independent  of  both. 
Negroes  are  but  slightly  liable  to  yellow  fever,  while  relapsing  fever 
attacks  them  with  special  violence.  Yellow  fever  is  not  contagious,  but 
infectious,  and  second  attacks  are  extremely  rare ;  relapsing  fever  is  one 
of  the  most  contagious  of  the  zymotic  diseases,  but  one  attack  does  not 
protect  against  a  subsequent  one.  The  mortality,  the  anatomical  lesions, 
the  course  of  the  pyrexia,  the  leading  clinical  symptoms,  are  all  widely 
distinct  in  the  two  affections;  and,  finally,  no  spirillum  has  been  found 
in  the  blood  in  yellow  fever.  Yellow  fever  is  an  extremely  fatal  disease ; 
the  ordinary  form  of  relapsing  fever  has  a  mortality  of  2  to  10  per  cent.; 
the  bilious  typhoid  form,  one  of  33  to  50  per  cent.  In  yellow  fever  the 
spleen  is  but  slightly  enlarged,  and  the  liver  is  pale  and  softened ;  in 
relapsing  fever  the  liver  and  spleen  are  greatly  enlarged,  and  there  is 
great  tenderness  over  the  hypochondriac  region.  In  yellow  fever  albu- 
minuria  is  much  more  common,  and  the  urine  more  frequently  suppressed, 
than  in  relapsing  fever. 

The  sudden  onset,  the  severe  headache  and  pains  in  the  limbs,  the  vomit- 
ing, jaundice,  epigastric  tenderness,  enlargement  of  the  liver  and  spleen,  occa- 
sional epistaxis,  hematemesis,  or  hematuria,  absence  of  characteristic  erup- 
tion, liability  to  herpes  facialis,  pneumonia,  and  diarrhoea;  the  occasional 
occurrence  of  remissions  in  the  pyrexia,  and  even  of  more  or  less  fully- 
developed  chills  for  several  successive  days  during  the  initial  paroxysm  or 
1  As  first  demonstrated  by  Motschutkoffiky. 


DIAGNOSIS  AND  RELATION  TO   OTHER  DISEASES.  421 

the  relapse,  suffice  to  explain  the  difficulty  which  may  arise  in  distinguishing 
the  bilious  form  of  relapsing  fever  from  bilious  remittent  fever.  But  the 
latter  disease  arises  exclusively  from  malaria,  and  is  therefore  powerfully 
influenced  by  season  and  locality  ;  is  not  contagious ;  does  not  present  any- 
thing approaching  to  the  crisis,  the  apyretic  interval,  or  the  abrupt  relapse 
of  relapsing  fever;  presents  pigmentary  changes  in  the  blood,  instead  of  the 
spirillum ;  and  lesions  of  the  spleen  and  liver  totally  unlike  those  charac- 
teristic of  relapsing  fever;  can  be  promptly  controlled  by  autiperiodic 
doses  of  quinine,  and  therefore  should  have  a  mortality  far  less  than  that 
of  the  grave  form  of  relapsing  fever.  It  is  not  necessary  to  pursue  this 
subject  further,  but  a  reference  to  the  temperature  charts  of  Carter1  or 
of  Litten2  will  show  that  in  some  epidemics  single  paroxysms  resembling 
those  of  quotidian  ague  might  occur  during  the  interval  between  the 
initial  paroxysm  and  the  relapse,  or  a  series  of  two,  three,  or  more  such 
paroxysms  of  quotidian  or  tertian  type  might  represent  an  entire  relapse. 
Such  phenomena  are  wholly  uncontrollable  by  quinia,  and  are  presum- 
ably dependent  upon  irregularities  in  the  specific  infection,  instead  of 
upon  a  blending  of  malaria  with  the  poison  of  relapsing  fever.  There 
is  some  ground  for  believing,  however,  that  those  who  have  recently 
passed  through  an  attack  of  the  latter  are  highly,  perhaps  unusually, 
susceptible  to  malarial  infection,  as  we  have  already  seen  they  are  liable 
to  contract  typhus. 

The  chill,  the  sudden  and  high  fever,  the  acid  sweat,  the  high-colored 
urine,  the  intense  pains  and  soreness,  and  the  occasional  murmur  over 
the  heart,  will  in  some  cases  of  relapsing  fever  suggest  the  idea  of  severe 
rheumatic  fever,  with  illy-developed  articular  inflammation  and  with  a  tend- 
ency to  hyperpyrexia.  The  urgent  danger  presented  by  the  latter  condi- 
tion and  the  necessity  for  immediate  recourse  to  cold  baths  and  large  doses  of 
quinine  or  of  the  salicylates,  render  it  highly  important  that  no  such  error 
of  diagnosis  should  be  made.  It  will  usually  be  avoided  readily  by 
observing  that  in  relapsing  fever  there  are  great  nausea,  repeated  vom- 
iting, insomnia,  peculiar  formication  of  the  extremities,  jaundice,  early 
enlargement  of  the  liver  and  spleen,  with  abdominal  pain  and  soreness,  and 
a  tendency  to  epistaxis  ;  and,  further,  that  despite  the  high  temperature, 
cerebral  symptoms  such  as  result  from  rheumatic  hyperpyrexia  are  not 
threatened,  except  in  grave  typhoid  cases  or  just  preceding  the  crisis. 

The  onset  of  relapsing  fever  may  suggest  forcibly  the  invasion  period 
of  small-pox,  with  its  marked  rigors,  high  fever,  lumbar  pain,  aching  in 
the  head  and  limbs,  nausea  and  vomiting,  and  if  the  patient  is  known  to 
have  been  exposed  to  the  contagion  of  both  diseases  a  diagnosis  would 
be  impossible  until  the  third  day.  But  such  a  dilemma  can  rarely  occur, 
and  under  ordinary  circumstances  the  patient's  antecedents  will  enable 
a  correct  opinion  to  be  formed. 

Severe  cases  of  simple  febricula  with  marked  gastric  disturbance  may, 
as  remarked  by  Jenner,  closely  simulate  relapsing  fever ;  and  the  same  is 
true  of  attacks  of  acute  gastro-hepatic  catarrh,  with  severe  headache,  sharp 
fever,  choltemic  eye,  epigastric  tenderness,  and  frequent  vomiting.  Of 
course  there  is  no  danger  under  ordinary  circumstances  of  these  simple 
conditions  being  regarded  as  relapsing  fever,  but  when  the  latter  is  prev- 
alent in  epidemic  form  it  is  probable  that  the  mistake  is  frequently  made. 

1  Op.  dt.  2  Deut.  Arch.f.  klin.  Med.,  xlii.  1874. 


422  RELAPSING  FEVER. 

Although  an  immediate  diagnosis  might  be  possible  only  by  microscopic 
examination  of  the  blood,  the  peculiar  clinical  symptoms  of  relaps- 
ing fever  would  soon  be  found  wanting,  and  suitable  treatment  would 
bring  the  simpler  affection  under  control. 

Acute  yellow  atrophy  of  the  liver  occurs  chiefly  in  pregnant 
women,  though  it  is  also  met  with  in  men  and  children ;  but  it  is  so 
rare  that  should  a  case  of  it  come  under  observation  during  the  prev- 
alence of  relapsing  fever  there  is  considerable  danger  that  its  nature 
would  be  overlooked.  It  resembles  relapsing  fever  in  the  occurrence  of 
jaundice  and  other  signs  of  hepatic  disorder,  of  delirium,  and  of  a  tend- 
ency to  hemorrhage  from  various  surfaces.  The  temperature,  however,  is 
more  moderate,  and  does  not  exhibit  the  sudden  remission  of  relapsing 
fever;  the  liver  is  usually  demonstrably  diminished  in  size;  severe  nervous 
disturbances,  such  as  convulsions  followed  by  stupor  and  then  by  coma, 
are  more  constant ;  while  the  occurrence  of  spirilla  in  the  blood  of  relaps- 
ing fever  and  of  leucin  and  ty rosin  in  the  urine  of  acute  yellow  atrophy 
serves  to  distinguish  completely  the  two  diseases.  Acute  yellow  atrophy 
is,  moreover,  invariably  fatal. 

With  ordinary  care  there  is  but  little  danger  that  any  of  the  local 
complications  of  relapsing  fever  will  so  absorb  attention  as  to  lead  to  a 
neglect  of  the  specific  general  disease,  so  that  the  cerebral  symptoms 
should  be  readily  distinguished  from  the  onset  of  any  acute  intracranial 
affection;  the  parotitis  which  occasionally  appears  early  in  the  disease 
should  not  be  confounded  with  idiopathic  mumps ;  and  so  for  other  com- 
plications. There  is  far  more  danger,  indeed,  lest  some  of  the  complica- 
tions may  be  overlooked ;  and  this  is  especially  true  of  pneumonia,  one 
of  the  most  frequent  and  most  important  of  them  all.  Its  occurrence  is 
the  cause  of  the  supervention  of  grave  typhoid  symptoms  or  of  the  modi- 
fication of  the  normal  course  of  the  pyrexia  in  so  many  cases  that  noth- 
ing but  a  systematic  daily  examination  of  the  lungs  will  avert  serious 
oversights. 

MORTALITY  AND  PROGNOSIS. — The  rate  of  mortality  has  varied  in 
different  epidemics  from  2  or  3  to  24  per  cent.  Murchison  shows  that 
out  of  2115  cases  admitted  to  the  London  Fever  Hospital  during  a  period 
of  twenty-two  years,  and  embracing  two  distinct  outbreaks,  only  39 
proved  fatal,  making  1.84  per  cent,  mortality.  Adding  to  these  the 
results  of  Scotch  and  Irish  epidemics,  a  total  of  18,859  cases,  with  761 
deaths,  is  reached,  giving  the  rate  of  mortality  for  Great  Britain  as  4.03 
per  cent.  The  great  Indian  epidemics  studied  by  Carter  gave  111  deaths 
out  of  616  cases,  equal  to  18.02  per  cent.  Kecent  German  epidemics 
have  given  from  5  to  10  per  cent.  The  above  rates  are  obtained  where 
all  the  cases  observed  during  an  epidemic  are  included.  If,  however,  the 
mortality  of  the  ordinary  form  of  relapsing  fever  is  computed  separately 
from  that  of  the  bilious  typhoid  form,  it  does  not  exceed  2  to  5  per  cent., 
whilst  the  mortality  of  the  latter  form  rises  to  from  33  to  50  per  cent.,  or 
even  higher. 

In  the  Philadelphia  epidemic,  out  of  a  total  of  1174  cases  there  were, 
as  nearly  as  can  be  ascertained,  169  deaths,  giving  a  rate  of  mortality  of 
14.4  per  cent.  Taking  all  the  cases  admitted  to  the  hospital  under  our 
observation,  many  of  which  entered  at  a  late  period  of  the  disease  and 
not  a  few  when  moribund,  the  mortality  was  not  less  than  13  per  cent. 


MORTALITY  AND  PROGNOSIS.  423 

The  mortality  among  the  negroes  who  were  attacked  with  the  disease 
was  considerably  greater  than  among  the  whites.  Finally,  if  the  mor- 
tality of  the  bilious  typhus  form  be  considered  separately — although  from 
the  frequency  of  jaundice  in  this  epidemic  and  the  numerous  gradations 
of  severity  presented  it  is  difficult  to  form  a  sharply  defined  group  of 
this  character — it  was  certainly  not  less  than  50  per  cent. 

The  date  of  death  varies  with  the  epidemic,  the  form  of  the  disease, 
and  the  previous  condition  of  vitality  of  those  attacked.  Ordinarily,  by 
far  the  larger  proportion  of  deaths  occur  during  the  first  relapse  or  the 
second  interval,  but  in  bilious  typhoid  cases,  presenting  grave  complica- 
tions, especially  pneumonia  or  severe  hemorrhages  at  an  early  date,  or  in 
cases  occurring  in  intemperate  subjects,  or  in  those  previously  in  impaired 
health,  the  mortality  is  much  heavier  in  the  initial  paroxysm  or  the  first 
interval  than  at  later  periods. 

Youth  exerts  the  same  favorable  influences  upon  the  result  of  relapsing 
fever  as  it  does  in  the  case  of  typhus  and  typhoid.  Murchisou  states 
that  of  717  male  patients  under  twenty-five  years  of  age  admitted  into 
the  London  Fever  Hospital,  not  one  died,  and  in  most  epidemics  similar, 
though  not  equally  marked,  results  have  been  noted.  In  some  epidemics 
the  mortality  among  young  children  has  been  considerable.  As  a  rule, 
the  percentage  of  deaths  increases  with  each  decade  after  thirty  years. 

Sex  does  not  exert  any  definite  or  constant  influence  upon  the  mor- 
tality. The  number  of  males  affected  is  far  greater ;  they  are  liable  to 
be  exposed  to  the  contagion  in  its  most  concentrated  form ;  a  larger  pro- 
portion of  them  are  probably  the  subjects  of  intemperance  than  in  the 
case  of  females ;  and  thus  most  statistics  agree  in  making  the  mortality 
somewhat  greater  in  the  male  sex ;  but,  all  things  being  equal,  there 
is  no  good  reason  for  holding  that  sex  itself  has  any  value  in  determin- 
ing the  result. 

As  in  other  zymotic  diseases,  the  mortality  from  relapsing  fever  is  highest 
during  the  early  period  of  an  epidemic,  and  the  type  of  the  disease  grows 
milder  as  the  epidemic  declines.  Cases  of  the  bilious  typhoid  form  have 
become  notably  less  frequent  during  the  later  stages  of  some  epidemics 
than  at  an  earlier  period. 

Marked  difference  has  been  observed  also  as  to  the  action  of  remedies 
at  different  stages  of  epidemics,  the  early  cases  exhibiting  an  extraordinary 
resistance  to  remedies,  and  especially  to  anodynes,  which  passes  away  later. 
"When  typhus  and  relapsing  fevers  have  prevailed  together,  and  a  clear 
discrimination  between  the  two  sets  of  cases  has  not  been  made,  it  has 
appeared  that  the  mortality  increased  as  the  epidemic  advanced,  but  this 
apparent  exception  has  been  due  to  the  fact  that  at  first  the  cases  of  relaps- 
ing fever  were  in  the  majority,  while  later  those  of  typhus,  the  much 
more  fatal  disease,  preponderated. 

Epidemics  of  relapsing  fever  prevail  at  all  seasons,  but  more  com- 
monly they  are  at  their  height  during  the  colder  mouths  of  the  year. 
The  total  mortality  will  of  course  correspond,  but  the  actual  percentage 
is  not  constantly  greater  during  any  one  season,  although  it  is  probable 
that  the  greater  liability  to  chest  complications  during  the  colder  months 
will  render  the  disease  more  fatal  then. 

The  gravity  of  relapsing  fever  has  varied  so  greatly  in  different  epidem- 
ics that  it  is  very  difficult  to  determine  what  influence  upon  the  mortality 


424  RELAPSING  FEVER. 

has  been  exerted  by  mere  difference  of  race.  A  further  source  of  difficulty 
is  found  in  estimating  the  differences  in  the  physical  conditions  of  the  poorer 
classes  in  the  various  communities  affected.  The  mortality  has  been  excep- 
tionally high  in  the  Russian  and  Indian  epidemics  and  in  some  of  the 
German  ones,  while  in  the  British  epidemics  it  has  uniformly  been  light. 
It  is  interesting  to  note  that  in  the  Philadelphia  epidemic,  where  the 
great  majority  of  patients  were  Irish  or  negroes,  the  mortality  was  high, 
over  14  per  cent.  The  previous  condition  of  the  Irish  patients  must  cer- 
tainly have  contrasted  favorably  with  that  of  the  individuals  attacked 
in  the  Dublin  and  Belfast  epidemics,  so  that  the  difference  in  result 
seems  attributable  only  to  a  greater  virulence  of  the  disease.  As  an  ample 
opportunity  was  here  afforded  to  judge  of  the  relative  severity  of  relaps- 
ing fever  in  the  negro  and  white  races  when  the  cases  occurred  at  the 
same  season,  at  the  same  stage  of  the  epidemic,  and  in  individuals  living 
under  nearly  similar  conditions,  it  may  be  stated  that  the  conclusion  of 
all  who  studied  the  question  closely  was  that  the  disease  was  much  more 
severe  among  negroes,  and  in  particular  that  they  displayed  a  greater 
tendency  to  serious  complications  and  to  the  bilious  typhoid  form. 

Although  the  degree  and  virulence  of  the  infection  undoubtedly  con- 
stitute the  most  important  elements  in  determining  the  mortality,  the 
previous  health  and  habits  of  those  attacked  with  relapsing  fever  exert 
an  influence  upon  the  result.  This  is  especially  true  of  habitual  intem- 
perance, which,  by  disposing  to  disease  of  the  liver  and  kidneys,  greatly 
increases  the  liability  to  a  fatal  result.  It  has  been  seen  (page  409),  however, 
that  even  when  acute  catarrhal  nephritis  existed  at  the  time  of  the  attack 
severe  relapsing  fever  might  terminate  favorably.  Another  observation 
which  we  made  frequently,  and  which  coincides  with  what  is  well  known 
in  regard  to  typhoid  and  typhus,  is  that  improper  exertion  and  exposure 
during  the  stage  of  incubation  and  immediately  after  the  invasion  pro- 
duced a  highly  unfavorable  effect  on  the  subsequent  course  of  the  disease, 
aud  seemed  in  particular  to  dispose  to  dangerous  or  fatal  collapse  at  the 
critical  periods. 

Apart  from  these  general  considerations,  there  are  many  special  points 
to  be  considered  in  regard  to  the  prognosis  of  relapsing  fever : 

If  after  the  crisis  of  the  invasion  there  is  not  rapid  and  decided 
improvement,  complications  should  be  suspected. 

A  sharp  rebound  of  temperature  quickly  following  crisis  may  be  fol- 
lowed by  speedy  death. 

Mere  elevation  of  temperature  during  the  invasion  and  the  relapse,  even 
though  to  an  extreme  height,  is  not  attended  with  the  danger  which  even 
a  somewhat  lower  degree  would  indicate  in  other  zymotic  diseases. 

Increased  elevation  toward  the  expected  time  of  crisis  should  arouse 
anxiety,  as  sudden  and  dangerous  cerebral  symptoms  may  occur. 

Prolonged  duration  of  the  pyrexia,  or  the  substitution  of  irregular 
gradual  defervescence  (lysis)  for  the  characteristic  crisis  often  associ- 
ated with  typhoid  symptoms  as  are  these  conditions,  is  significant  of 
complications  and  of  danger. 

Wild  delirium  during  the  pyrexia,  or  transient  active  delirium  about 
the  time  of  crisis,  is  not  necessarily  unfavorable,  but  continuous  low 
delirium,  with  disposition  to  stupor,  is  associated  with  a  typhoid  tend- 
ency and  is  frequently  followed  by  death.  Excessive  muscular 


MORTALITY  AND  PROGNOSIS.  425 

tremor  or  convulsions  are  highly  unfavorable,  but  not  necessarily 
fatal,  symptoms. 

Cardiac  murmurs  are  not  of  serious  import.  The  pulse  is  not  usually 
as  rapid  in  proportion  to  the  temperature  as  in  typhus  or  typhoid,  and 
an  excessively  rapid  pulse  toward  the  expected  time  of  crisis,  especially 
if  associated  with  feebleness  of  the  heart's  action,  points  to  the  danger 
of  sudden  collapse  at  or  soon  after  that  time.  Previous  cardiac  disease, 
especially  fatty  degeneration  in  habitually  intemperate  persons,  increases 
this  danger.  Continued  frequency  of  pulse  after  the  crisis  indicates  some 
complication  or  the  danger  of  some  accident. 

Cough  of  a  bronchial  origin  is  not  a  specially  unfavorable  symptom, 
but  if  associated  with  the  physical  signs  of  pneumonia  and  with  marked 
disturbance  of  respiration  it  indicates  extreme  danger. 

Epistaxis,  even  when  copious,  often  occurs  in  favorable  cases,  but  hem- 
orrhage from  the  stomach  or  the  kidneys  is  usually,  though  not  invari- 
ably, followed  by  death. 

An  eruption,  measly  or  of  pink  spots,  with  or  without  minute 
petechise,  is  rare,  and  usually  occurs  in  severe  cases,  but  is  not  of  spe- 
cially unfavorable  significance  unless  associated  with  the  typhoid  state  or 
with  patches  of  purpura. 

Hiccough  is  a  much  less  unfavorable  symptom  in  relapsing  fever  than 
in  typhoid  or  typhus,  and  vomiting,  even  frequent  and  persistent,  may 
occur  in  cases  of  ordinary  severity. 

Enlargement  of  the  liver  and  spleen  indicates  special  risk  only  when 
persistent  for  some  time  after  the  relapse,  in  connection  with  persistent 
irregular  fever.  Jaundice  has  no  necessarily  unfavorable  signification,  is 
frequent  in  ordinary  cases  in  some  epidemics,  but  when  it  is  associated 
with  the  other  features  of  the  bilious  typhoid  form  the  danger  is  extreme, 
at  least  33  per  cent,  of  such  cases  proving  fatal. 

Slight  transient  albuniinuria  may  exist  without  special  danger,  but  if 
associated  with  evidences  of  catarrhal  nephritis,  or  if  extreme  diminu- 
tion of  urine,  with  or  without  albuniinuria,  exists,  cerebral  symptoms  are 
apt  to  ensue,  with  a  high  degree  of  danger. 

All  serious  complications — parotitis,  erysipelas,  dysentery,  abortion, 
pneumonia,  and,  above  all,'  peritonitis — greatly  increase  the  risk. 

It  is  not  possible  to  determine  in  what  cases  the  relapse  will  fail  to 
occur.  Motschutkoffsky's  statement,  that  when  a  slight  post-critical  rise 
occurs  a  relapse  will  follow,  must  be  applicable  only  to  a  limited  number 
of  cases. 

In  all  cases  at  least  one  relapse  must  be  expected ;  the  patient  in  the 
interval  must  be  regarded  as  still  sick,  and  after  the  close  of  the  relapse 
he  must  still  be  treated  with  rigid  care  until  convalescence  is  permanently 
established.  It  must  be  remembered  in  hospital  practice  that  many 
patients  enter  toward  or  after  the  crisis  of  the  first  paroxysm,  so  that 
caution  is  needed  in  estimating  the  eifect  of  remedies  and  the  period  of 
the  disease. 

The  undue  prominence  of  certain  conditions  during  the  course  of  the 
disease  is  apt  to  be  followed  by  corresponding  sequelae,  and  emaciation, 
anaemia,  dyspepsia,  diarrhoea,  dysentery,  enlargement  of  the  spleen  and 
rheumatoid  pains  may  then  be  anticipated.  The  liability  to  ophthalmia 
a  ad  affections  of  the  middle  ear  is  not  to  be  forgotten. 


426  RELAPSING  FEVER. 

CAUSES  OF  DEATH. — In  fatal  cases  death  occurs  from  exhaustion 
dependent  on  the  protracted  and  severe  sufferings  of  the  patient ;  from 
cerebral  symptoms ;  from  hyperpyrexia ;  from  the  virulence  of  the  tox- 
semia;  from  ursemic  poisoning;  from  sudden  collapse;  or  from  some 
complication,  such  as  hemorrhagic  meningitis,  hemorrhages,  pneumonia, 
dysentery,  rupture  of  the  spleen,  peritonitis,  or  abortion. 

TREATMENT. — The  indications  for  treatment  presented  by  regular 
cases  of  relapsing  fever  seem  to  be — to  moderate  the  pyrexia  ;  to  relieve 
distressing  symptoms,  especially  pain,  insomnia,  and  gastric  irritability ; 
to  sustain  the  strength  of  the  system ;  to  prevent  or  modify  the  relapses ; 
and  to  avoid  complications  and  sequelae. 

It  is  needless  to  observe  that  until  the  nature  of  the  specific  cause  of 
relapsing  fever  is  fully  determined,  whether  the  spirillum  occupy  that 
relation  or  not,  it  is  impossible  to  direct  our  efforts  rationally  toward 
its  neutralization  or  elimination.  The  various  remedies  which  have  been 
employed  for  these  special  purposes  have  no  clinical  support  to  recom- 
mend them.  And  while  experiment  has  shown  that  the  activity  of  the 
spirillum  is  readily  destroyed  by  the  direct  action  of  various  weak  solu- 
tions, as  of  quinine,  carbolic  acid,  iodine,  and  mineral  acids,  no  special 
curative  effect  follows  the  internal  administration  of  these  remedies,  even 
in  the  largest  doses  consistent  with  safety.  In  fact,  there  can  scarcely  be 
any  disease  in  which  treatment  is  less  satisfactory  or  its  results  more 
difficult  to  estimate.  The  marked  difference  between  various  epidemics, 
and  the  wide  variation  presented  by  the  development  of  individual  symp- 
toms in  different  cases  of  the  same  epidemic,  fully  account  for  this. 

Quinine,  as  might  be  expected,  has  been  largely  used,  in  the  hope  that 
it  might  control  the  pyrexia  or  prevent  the  relapse.  Murchison  1  quotes 
a  considerable  amount  of  evidence  from  various  sources  to  show  that  it 
does  not  possess  either  of  these  powers.  It  was  administered  to  a  con- 
siderable number  of  our  cases,  either  in  small  and  frequently  repeated  doses 
during  the  pyrexia  or  the  intermission,  or  else  in  large  doses  repeated 
several  times  in  immediate  anticipation  of  the  expected  time  of  the  relapse. 
Thus  in  some  cases  three  grains  of  sulphate  of  quinia  were  given  every 
two  or  three  hours  until  tinnitus  was  produced,  and  then  this  was  main- 
tained during  the  remainder  of  the  pyrexia  and  of  the  intermission.  The 
amount  given  daily  was  from  thirty  to  forty-two  grains.  It  seemed  to 
rather  increase  the  discomfort  in  the  head,  and  in  some  cases  it  aggravated 
the  irritability  of  the  stomach.  The  pyrexia  was  certainly  not  controlled 
by  it.  Given  in  the  same  manner  during  the  intermission,  it  was  usually 
well  borne,  but  was  not  effectual  in  preventing  the  relapse.  It  is  true  that 
in  some  cases  the  subsequent  relapse  seemed  to  be  somewhat  modified. 

Thus  in  one  case  30  grains  were  given  on  the  6th  of  April ;  39  grains  on 
the  7th  ;  39  grains  on  the  8th ;  42  grains  on  the  9th  ;  and  60  grains  on  the 
10th ;  the  critical  fall  had  occurred  during  the  night  of  the  7th,  and  the 
relapse  began  on  the  evening  of  the  9th,  but  the  rise  in  temperature  was 
less  abrupt  than  usual,  and  the  relapse  lasted  less  than  five  days.  It  was 
quite  severe,  however,  so  that  it  is  doubtful  whether  the  apparent  modifi- 
cation was  anything  more  than  is  frequently  observed  in  cases  where  no 
quinine  has  been  administered. 

In  another  case  the  fall  in  temperature  at  the  end  of  the  first  paroxysm 

1  Op.  cil.,  p.  408. 


TREATMENT.  427 

was  from  105.5°  to  97°  on  March  26th :  35  to  40  grains  of  sulphate  of 
quinine  were  given  daily  on  April  4th,  5th,  6th,  7th,  and  8th ;  the  tem- 
perature began  to  rise  on  the  3d,  but  the  severe  pyrexia  and  the  usual 
symptoms  of  the  relapse  were  limited  to  a  period  of  less  than  thirty-six 
hours.  This  is  a  less  common  irregularity,  and  yet  does  not  afford  suf- 
ficient evidence  of  the  efficiency  of  quinine.  In  other  cases,  however,  as 
already  stated,  no  appreciable  effect  followed  its  administration  in  this 
manner. 

To  illustrate  the  other  method  of  giving  quinia,  a  case  may  be  quoted 
in  which  20-grain  doses  every  three  or  four  hours  were  giveu  from 
April  25th  to  April  29th,  so  that  in  four  days  575  grains  were  taken. 
The  initial  paroxysm  was  of  average  severity,  and  terminated  at  the  end 
of  the  seventh  day,  April  20th.  The  quinine  did  not  postpone  the 
relapse,  which  occurred  on  April  28th,  but  was  of  much  less  than  the 
usual  duration. 

In  no  other  case  in  which  these  large  doses  were  given  was  there  even 
as  much  reason  as  in  the  above  instance  to  attribute  to  quinine  any  posi- 
tive influence  upon  the  course  of  the  disease. 

In  order  to  demonstrate  that  the  failure  of  quinine  was  not  dependent 
upon  a  want  of  absorption,  Muirhead  injected  large  amounts  subcutane- 
ously  with  no  better  results. 

In  conclusion,  it  may  be  said  that  the  evidence  shows  positively  that 
quinine  possesses  no  specific  influence  whatever  upon  relapsing  fever; 
that  in  only  occasional  cases,  if  at  all,  will  eVen  enormous  doses  given 
during  the  intermission  postpone  or  modify  the  subsequent  relapse  ;  and 
that  it  is  not  effective  in  reducing  the  temperature.  In  view,  therefore, 
of  the  usual  gastric  irritability  and  tendency  to  vertigo  and  headache, 
which  seem  to  be  increased  by  large  doses  of  quinine,  and,  further,  in 
view  of  the  small  mortality,  and  of  the  fact  that  when  death  occurs  it 
usually  comes  from  causes  over  which  large  doses  of  quinine  could  exert 
no  influence,  it  seems  clear  that  this  drug  should  be  prescribed  only  in 
tonic  doses  and  only  in  cases  where  it  is  well  tolerated  by  the  stomach. 

Arsenic  was  used  in  a  considerable  number  of  our  cases  with  the  view  of 
determining  if  it  possessed  any  power  of  relieving  the  severe  pains  or  of 
influencing  the  relapse.  It  was  administered  in  the  form  of  Fowler's 
solution  (Liq.  potassii  arsenitis),  and  was  given  exclusively  by  the  mouth. 
If  given  during  the  intermission,  it  was  well  borne  in  doses  of  five  to  ten 
drops  every  four  or  even  every  three  hours,  given  freely  diluted  with 
water  and  immediately  after  food.  In  several  cases  it  quickly  induced 
puffiness  about  the  eyes,  but  no  effect  whatever  was  produced  on  the  pains 
or  on  the  succeeding  relapse.  In  more  than  one  such  case  there  was  an 
unusually  profuse  crop  of  sudamina  during  the  relapse,  many  of  the 
vesicles  breaking  and  being  followed  by  brownish  stains.  When  given 
during  the  pyrexia  it  aggravated  the  nausea  and  vomiting,  so  that  it  had 
to  be  suspended.  In  one  unfortunate  case,  indeed,  although  promptly 
suspended,  the  arsenical  solution  seemed  to  have  assisted  in  the  establish- 
ment of  vomiting  and  purging,  which  proved  uncontrollable  and  con- 
tributed greatly  to  the  fatal  result.  Hypodermic  injections  of  arsenic 
have  been  used  considerably  with  no  better  results.  There  seems,  there- 
fore, to  be  no  reason  whatever  for  any  further  use  of  this  drug  in  relaps- 
ing fever. 


428  RELAPSING  FEVER. 

The  high  pyrexia  and  the  severe  rheumatoid  pains  have  naturally  sug 
gested  the  use  of  salicylic  acid  and  the  salicylate  of  soda.  We  were  not 
sufficiently  aware  of  their  antipyretic  properties  in  1869-70  to  have 
recourse  to  them,  but  in  more  recent  epidemics  Uuterburger 1  and  Riess 2 
have  found  that  large  doses  of  the  latter  substance  (one  hundred  grains 
or  more  daily)  will  reduce  the  temperature  either  in  the  initial  paroxysm 
or  in  the  relapse,  but  that  the  disease  is  not  cut  short  nor  are  the  lesions 
of  the  blood  or  solids  prevented. 

It  must  be  borne  in  mind  here,  as  in  connection  with  the  action  of 
quinine,  that  apparent  modifications  of  the  relapse  are  to  be  viewed  with 
great  distrust,  since  such  great  irregularities  therein  naturally  present 
themselves.  Care  must  further  be  taken  lest  such  attempts  to  reduce  the 
temperature  aggravate  the  irritation  of  the  stomach,  and  by  lessening  the 
power  of  taking  food  induce  more  serious  exhaustion  than  would  have 
resulted  from  the  unchecked  pyrexia.  The  evidence  in  our  possession  is 
not  sufficient  to  justify  a  positive  decision  as  to  the  therapeutic  value  of 
the  salicylates  in  relapsing  fever,  but,  apparently,  they  are  applicable  to 
only  a  portion  of  the  cases,  and  in  these  are  of  but  limited  utility. 

The  same  failure  which  has  followed  the  use  of  quinine,  of  arsenic,  and 
of  saliciu  and  the  salicylates  has  attended  the  effort  to  prevent  the  relapse 
by  berberine,  benzoate  of  soda,  tincture  of  eucalyptus,  and  other  reputed 
antiperiodics. 

Digitalis,  veratrum  viride,  and  aconite  were  used  by  us  quite  freely 
as  antipyretics.  The  first  t\vro  of  these  were  often  suspended  on  account 
of  the  irritability  of  the  stomach,  and  no  valuable  results  followed  their 
use  when  well  tolerated.  Aconite  in  small  doses,  frequently  repeated,  as 
one  drop  every  two  hours,  seemed  to  aid  in  allaying  nausea  and  to  exert 
some  slight  influence  upon  the  fever.  In  cases  where  there  was  a  distinct 
tendency  to  heart-failure,  digitalis  was  given  freely  with  a  Ivantage. 

Cold  baths  were  not  used  to  reduce  the  temperature  in  a~i  v  of  the  cases 
under  our  observation.  They  have  been  employed  in  other  epidemics, 
but,  as  far  as  we  know,  with  no  other  effect  than  to  cause  merely  tempo- 
rary lowering  of  temperature,  without  any  decided  relief  to  the  other 
symptoms  and  without  any  apparent  influence  upon  the  course  of  the 
disease.  Frequent  spongiugs  with  cool  water  and  the  application  of  ice 
to  the  head  gave  only  slight  and  temporary  relief. 

Simple  febrifuge  remedies,  such  as  effervescing  draught  or  spirit  of 
nitrous  ether  with  solution  of  acetate  of  ammonium,  were  well  received  by 
the  stomach,  and  appeared  to  promote  perspiration  and  the  more  free 
secretion  of  urine. 

Finding  all  our  efforts  to  control  the  pyrexia  so  unsuccessful,  recourse 
was  had  in  a  large  proportion  of  our  cases  to  the  hyposulphite  of  soda, 
given,  dissolved  in  two  ounces  of  water,  in  doses  of  twenty  grains  every 
two  or  three  hours.  In  two  cases  it  seemed  to  increase  nausea,  and  at 
times  it  caused  some  purging,  but  otherwise  it  was  well  borne  by  the 
stomach,  and,  indeed,  frequently  appeared  to  aid  in  controlling  vomiting. 
The  records  show  that  this  drug  was  given  in  only  two  or  three  of  the 
fatal  cases,  so  that  although  the  patients  who  took  it  regularly  presented 
every  grade  of  severity  of  the  disease,  they  did  well  uniformly.  It  is 
certain,  however,  that  the  hyposulphite  of  soda  exerted  no  specific  effect 

1  Jahrb.  f.  Kinderheilk.  v.  x.,  1876.  J  Deutsch.  Med.  Wochnsch.,  Dec.,  1879. 


TREATMENT.  429 

upon  the  disease ;  it  did  not  reduce  temperature,  it  did  not  prevent  or 
modify  the  relapses  nor  relieve  the  severe  pains ;  it  may  have  promoted 
more  free  and  healthy  secretions,  and,  by  tending  to  prevent  vomiting, 
may  have  aided  in  maintaining  nutrition ;  but,  on  the  whole,  it  may 
fairly  be  doubted  whether  this  remedy  merits  any  more  extended 
trial. 

One  chief  reason  of  the  failure  of  antipyretics  in  relapsing  fever  is  to 
be  found  in  the  existence  of  widespread  irritative  lesions  of  the  glandular 
and  mucous  tissues,  which  combine  with  the  specific  blood-changes  in 
causing  and  maintaining  the  high  temperature.  It  is  not  surprising, 
therefore,  that  the  remedies  which  afford  the  greatest  relief  in  this  dis- 
ease are  opiates  and  sedatives  to  the  gastro-intestinal  mucous  membrane. 
Opium,  or  morphia,  must  indeed  be  regarded  as  the  basis  of  the  rational 
treatment  of  relapsing  fever.  It  is  called  for  by  the  insomnia,  the  severe 
headache  and  the  pains  in  various  parts  of  the  body,  the  nausea  and  vom- 
iting, and  the  pyrexia.  It  does  not  appear  to  have  been  as  prominent  a 
feature  in  the  treatment  of  other  epidemics  as  we  found  it  necessary  to 
make  it  in  Philadelphia.  Parry *  used  it  very  freely,  chiefly  in  the  form 
of  opium,  by  the  mouth,  and  found  a  singular  tolerance  exhibited  by  his 
patients,  several  of  whom  took  as  large  a  dose  as  three  grains  every  two 
hours  during  the  afternoon  and  night  without  producing  any  sleep  or  even 
any  contraction  of  the  pupils.  This  resistance  to  the  action  of  opium 
was  observed  chiefly  in  the  early  part  of  the  epidemic,  and  we  may  add 
that  it  was  exhibited  chiefly  when  opium  was  given  by  the  mouth.  When 
morphia  was  used  hypodermically  we  found  that  one-fourth  of  a  grain, 
given  at  intervals  of  six  to  twelve  hours,  afforded  very  great  relief  to 
the  pains,  aided  and  relieved  vomiting,  and  often  induced  quiet,  refresh- 
ing sleep.  Its  use  was  not  contraiudicated  by  jaundice,  by  cough  or  pul- 
monary congestion,  or  by  moderate  contraction  of  the  pupils.  It  was 
frequently  given  so  as  to  maintain  decided  drowsiness  throughout  the 
pyrexia.  When  the  pains  persisted  during  the  intermission  the  morphia 
was  continued  in  smaller  doses  or  at  longer  intervals.  It  occasionally 
happened  that  when  patients  were  thus  kept  continuously  under  opium 
influence  no  relapse  occurred ;  but  here,  as  in  regard  to  the  action  of 
quinine,  it  may  safely  be  asserted  either  that  what  was  regarded  as  the 
initial  paroxysm  was  in  reality  the  relapse,  or  else  that  the  absence 
of  a  relapse  was  a  mere  irregularity,  and  in  no  way  to  be  attributed  to 
the  action  of  the  opium.  On  the  other  hand,  in  cases  presenting  a 
tendency  to  the  typhoid  state,  with  a  disposition  to  stupor,  or  where 
the  urine  was  scanty  and  albuminous,  no  opiate  was  administered. 

We  have  already  stated  that  in  our  cases  quinine  in  acid  solution  was 
frequently  ordered,  and  it  answered  very  well  to  add  to  each  dose  of  this 
a  suitable  amount  of  morphia. 

Atropia,  in  the  dose  of  gr.  -fa  to  gr.  •£$,  was  usually  associated  with 
the  hypodermic  injections  of  morphia.  This  was  done  particularly  in 
cases  where  the  pains  were  very  severe,  when  the  pupils  were  disposed 
to  be  contracted,  or  when  there  was  continued  profuse  sweating.  In 
addition  to  this,  atropia  was  continued  without  morphia  during  the  inter- 
mission in  a  few  cases.  The  patients  proved  susceptible  to  its  influence, 
and  dryness  of  the  mouth  with  dilatation  of  the  pupils  was  readily 

1  Loc.  cit. 


430  RELAPSING  FEVER. 

produced  by  gr.  -^  every  six  hours.  In  one  case  gr.  -fa  every  four  hours 
for  two  days  caused  delirium,  with  the  usual  symptoms  of  belladonna 
action,  all  of  which  passed  away  quickly  after  withdrawal  of  the  drug. 
But  in  none  of  these  cases  was  the  relapse  influenced  in  the  least. 

Other  remedies  may  be  used  for  the  relief  of  the  insomnia,  which  is 
always  one  of  the  most  distressing  symptoms.  Chloral  and  bromide  of 
potassium  have  been  found  serviceable  in  various  epidemics,  and  some 
observers  have  preferred  them  to  opium  for  the  relief  of  headache  and 
insomnia.  They  did  not  prove  reliable  in  the  Philadelphia  epidemic  of 
1869-70.  Bromide  of  potassium,  even  in  large  doses,  produced  scarcely 
any  effect,  and,  while  in  a  few  cases  chloral  in  doses  of  gr.  xx.  gave  posi- 
tive relief,  in  the  majority  of  instances  40  grains  failed  to  cause  sleep  or 
relieve  suffering.  It  must  not  be  forgotten  also  that,  as  there  is  a  special 
tendency  to  cardiac  failure  in  this  affection,  the  action  of  chloral  must  be 
closely  watched. 

In  a  small  series  of  our  cases  where  muscular  pains,  hyperasthesia, 
and  twitching  were  marked  succus  couii  was  given  quite  freely,  but  with- 
out any  apparent  benefit. 

The  condition  of  the  stomach  required  attention  in  almost  every  case. 
Nausea,  vomiting,  and  epigastric  and  hypochondriac  soreness  were  the 
prominent  symptoms.  Anorexia  was  usually  complete  during  pyrexia, 
and  not  rarely  patients  were  admitted  to  the  hospital  who  asserted  that 
for  one  or  more  days  they  had  not  taken  any  nourishment  whatever. 
Under  such  circumstances,  and  in  a  disease  where  the  tendency  to  pros- 
tration and  cardiac  failure  calls  for  stimulants  and  food,  it  is  evident  that 
strict  care  must  be  given  to  the  diet.  In  many  cases  skimmed  milk  with 
lime-water,  meat  broths,  arrowroot,  or  gruel,  could  be  taken  in  small 
amounts  at  short  intervals,  and  retained.  But  whenever  these  are 
rejected,  no  attempt  should  be  made  to  persist  in  their  use,  but  koumiss, 
whey,  or  chicken-water  should  be  substituted,  and  continued  until  the 
stomach  grows  retentive.  Equal  care  must  be  paid  to  the  selection  of  a 
suitable  form  of  stimulus.  It  may  be  proper  to  employ  a  mild  and 
relaxing  emetic  if  the  patient  be  seen  at  the  onset  of  the  disease  and  if 
there  is  reason  to  suspect  the  presence  of  indigested  food  in  the  stomach, 
but  under  any  other  circumstances  there  seems  no  reason  for  its  use  in  a 
disease  where  vomiting  is  so  common  and  gastric  irritability  one  of  the 
most  troublesome  symptoms.  Nor  should  purgatives  be  given  save  when 
very  positive  indications  exist  for  their  use. 

Constipation  is  rarely  obstinate ;  the  amount  of  nourishment  taken  is 
very  small ;  in  a  considerable  proportion  of  cases  there  is  diarrhoea,  or  at 
least  a  sensitive  state  of  the  bowels ;  and  as  a  consequence  it  is  preferable 
in  nearly  every  case  to  dispense  with  laxatives  entirely,  and,  if  the 
bowels  must  be  opened  by  assistance,  to  administer  a  simple  enema. 

When  irritability  of  the  stomach  is  marked,  benefit  may  be  derived 
from  very  small  doses  of  calomel  frequently  repeated,  as,  for  example, 
gr.  |  or  ^  every  one  or  two  hours.  Subnitrate  of  bismuth  may  be  used 
in  combination  with  this  or  as  a  substitute  for  it.  In  several  instances 
more  prompt  relief  was  obtained  from  nitrate  of  silver  given  in  the  dose 
°f  £r<  lV  every  three  or  four  hours,  dissolved  in  thin  mucilage  of  acacia. 

Stimulants  were  remarkably  well  borne,  and  their  administration  in 
such  form  as  was  acceptable  to  the  stomach  was  clearly  of  service, 


TREATMENT.  431 

even  from  an  early  period  of  the  disease.  As  a  rule,  whiskey  was 
employed,  given  in  the  form  of  milk  punch.  By  carefully  grad- 
uating the  amount  of  alcohol,  and  when  necessary  diluting  the  milk 
freely  with  lime-water,  the  stomach  usually  received  it  well.  If 
circumstances  favored,  dry  champagne,  or  brandy  or  sherry  in  carbon- 
ated water  would  often  prove  preferable.  The  exhausting  nature  of 
the  disease,  the  marked  tendency  to  cardiac  failure,  and  the  inability  to 
digest  an  adequate  amount  of  nourishment,  ail  indicate  the  early  use  of 
stimulants.  In  cases  where  a  tendency  to  the  development  of  the 
typhoid  state  existed  alcohol  was  freely  given,  even  to  the  extent  of  six- 
teen ounces  of  whiskey  in  twenty-four  hours.  Other  stimulants  were 
usually  given  in  these  cases,  such  as  carbonate  of  ammonium,  especially 
if  pulmonary  congestion  existed ;  turpentine,  especially  if  tympany  was 
marked ;  or  Hoffmann's  anodyne  or  spirit  of  chloroform,  if  muscular 
twitchings,  hiccough,  or  insomnia  with  wandering  delirium  were  promi- 
nent symptoms.  In  all  cases  of  severity  the  use  of  tonics  and  stimu- 
lants should  be  maintained  in  reduced  doses  during  the  intermission  and 
for  some  days  after  the  final  fall  of  temperature. 

It  remains  to  allude  briefly  to  certain  special  remedies  and  to  certain 
symptoms  requiring  special  treatment.  Formerly,  much  diversity  of 
opinion  existed  as  to  the  propriety  of  venesection  or  local  depletion  in 
relapsing  fever,  but  Murchison  concluded,  after  a  careful  examination 
of  the  evidence,  that  it  had  not  been  shown  to  be  of  service ;  and 
certainly  the  disease  as  it  occurred  in  PhUadelphia  in  1869—70  presented 
no  indication  whatever  for  even  the  mildest  depletory  measures.  This 
corresponds  with  the  recognized  plan  of  treatment  in  all  the  specific 
fevers. 

Blisters  are  not  so  objectionable  in  relapsing  fever  as  in  either  typhus 
or  typhoid,  and  there  are  several  conditions  in  which  they  have  been 
found  decidedly  useful.  In  cases  where  the  headache  has  obstinately 
resisted  cold  applications,  bromide  of  potassium,  and  opiates,  a  blister  to 
the  back  of  the  neck  has  afforded  marked  relief,  with  no  unfavorable 
result.  Again,  in  cases  where  the  vomiting  and  epigastric  distress  were 
severe  and  obstinate  the  application  of  a  blister  three  inches  square  to 
the  epigastrium  is  to  be  recommended. 

Chloroform  has  proved  of  value  for  the  relief  of  various  symptoms  in 
relapsing  fever.  As  already  stated,  it  was  found  the  most  useful  remedy 
for  the  hiccough  which  was  so  troublesome  in  a  number  of  our  cases,  and 
especially  in  those  where  jaundice  was  pronounced.  It  also  seemed  ser- 
viceable in  controlling  the  peculiar  chills  which  in  varying  degrees  of 
severity  were  present  in  a  few  cases,  recurring  at  about  the  same  hour  on 
successive  days.  These  rigors  or  chills  were  uninfluenced  by  very  large 
doses  of  quinine  or  other  antiperiodics,  but  were  apparently  controlled 
by  full  doses  of  chloroform  given  in  advance  of  the  expected  hour  of 
recurrence. 

Jaundice,  which,  as  has  been  stated,  is  partly  of  hsemic  origin,  but  is  prob- 
ably also  due  in  part  to  obstruction  from  catarrhal  swelling  of  the  mucous 
membrane  of  the  bile-ducts,  is  not  influenced  by  mineral  acids,  and  still  less 
should  mercurials  or  purgatives  be  administered  for  its  relief.  It  would 
seem  proper,  in  cases  where  this  symptom  is  marked,  to  observe  special 
care  in  diet,  and  the  use  of  stimulants,  and  to  employ  local  sedative 


432  RELAPSING  FEVER. 

astringents,  such  as  small  doses  of  nitrate  of  silver  combined  with  opium 
and  belladonna. 

Muscular  soreness,  pains,  and  tremor  may  call  for  special  treatment  on 
account  of  their  severity.  The  only  remedy  which  has  proved  useful  in 
relieving  the  first  two  of  these  symptoms  is  opium,  conjoined  with  the 
external  use  of  anodynes.  Iodide  of  potassium  fails  even  in  doses  as 
large  as  can  be  borne,  and  the  same  is  true  of  muriate  of  ammonium  and 
cimicifuga,  which  we  used  thoroughly  without  any  effect.  In  the  mus- 
cular pains,  however,  which  torment  the  patient  during  convalescence, 
the  ammoniated  tincture  of  guaiacum  was  found  of  service.  Atropia 
hypodermically  and  chloroform  internally  have  been  found  useful  for  the 
relief  of  severe  muscular  twitchings. 

Upon  the  whole,  therefore,  it  will  be  seen  that  in  ordinary  cases  a  sup- 
porting and  expectant  plan  of  treatment  is  all  that  is  required.  Aban- 
doning the  idea  of  forcibly  controlling  the  fever  or  of  preventing  the 
relapse,  care  should  be  given  in  the  first  place  to  the  diet  and  to  judicious 
stimulation. 

Opium  or  morphia  should  be  used  to  control  pain,  excitement,  and 
insomnia,  aided,  as  far  as  the  latter  is  concerned,  by  bromide  of  potas- 
sium or  the  cautious  use  of  chloral.  Cooling  drinks  should  be  allowed, 
cool  applications  made  to  the  head,  and  the  body  should  be  repeatedly 
sponged  with  cooling  and  disinfecting  lotions.  If  the  stomach  is  reten- 
tive, quinine  in  moderate  doses  may  be  given  in  acid  solution,  alternating 
with  a  simple  fever  mixture ;  but  if  nausea  and  vomiting  are  present, 
the  first  purpose  will  be  to  allay  them  by  the  appropriate  measures 
already  discussed. 

Epistaxis  is  a  frequent  symptom,  but  usually  requires  no  special  atten- 
tion. Occasionally  it  is  profuse,  and  then  should  be  promptly  checked, 
since  serious  exhaustion  may  follow  its  continuance.  If,  therefore,  mild 
astringent  applications  do  not  arrest  it,  recourse  must  be  had  to  the  tam- 
pon saturated  with  diluted  Monsell's  solution. 

The  urine  must  be  closely  watched  and  frequently  analyzed  in  relaps- 
ing fever.  In  some  epidemics  serious  alterations  in  this  secretion  are 
rare ;  in  others  it  is  not  uncommon  for  the  urine  to  be  scanty,  and  to 
contain  albumen  or  blood  When  this  latter  condition  is  presented,  espe- 
cially if  at  the  same  time  ursemic  symptoms  exist,  dry  cups  should  be 
applied  over  the  kidneys,  to  be  followed  by  the  use  of  dry  heat,  and  free 
perspiration  should  be  promoted  by  hot-air  baths  or  by  the  hot  wet  pack. 
It  is  probable  that  jaborandi  given  in  repeated  small  doses,  so  as  to  avoid 
any  depressing  effect  on  the  heart,  will  be  found  valuable  in  such  cases. 
Infusion  of  digitalis,  with  spirit  of  nitrous  ether  or  with  acetate  of 
potassium,  may  also  be  used  with  advantage. 

Absolute  rest  must  be  insisted  on  throughout  the  entire  period  of 
paroxysm  and  relapse.  The  records  of  every  epidemic  present  instances 
of  sudden  death  from  cardiac  syncope  following  trifling  exertions.  The 
patients  should  therefore  be  kept  strictly  quiet  in  bed  from  the  initial 
rigor  until  their  strength  is  fully  restored  after  the  relapse.  As  the 
danger  of  collap.se  is  especially  great  at  the  time  of  the  critical  fall  in 
temperature,  the  patient  should  be  closely  watched  as  the  end  of  the 
initial  paroxysm  and  of  the  relapse  approaches.  If  there  is  any  sudden 
rise  of  temperature,  with  head  symptoms  due  to  hyperpyrexia,  large  doses 


TREATMENT.  .  433 

of  quinine,  ice  to  the  head,  cold  spraying,  or  the  cold  bath  must  be 
promptly  used.  As  sweating  begins  the  body  must  be  covered  with  a 
warm  blanket  and  warm  stimulating  drinks  be  administered.  If  any 
marked  tendency  to  collapse  is  observed,  the  subcutaneous  injection  of 
strychnia  or  of  ether  and  digitalis,  conjoined  with  diffusible  stimulants 
internally  and  hot  applications  externally,  are  to  be  employed  immedi- 
ately. The  special  remedies  required  for  the  various  complications  and 
sequelae  have  already  been  sufficiently  indicated. 

I  desire  in  conclusion  to  acknowledge  the  important  assistance  received 
from  Drs.  Geo.  S.  Gerhard,  Louis  Starr,  Charles  Shaffner,  and  R.  G. 
Curtin,  who,  under  the  supervision  of  my  colleague,  the  late  Dr.  Edward 
Rhoads,  and  myself,  recorded  the  histories  of  most  of  the  cases  which 
serve  as  the  basis  of  this  article,  and  also  tabulated  them  for  statistical 
purposes.1 

1  Reference  must  also  be  made  to  the  interesting  observations  on  spirilla  published  by 
Miilhauser  in  Virckoufs  Archiv  for  July  9,  1884,  after  this  article  had  been  printed.  Ilia 
results  go  to  confirm  the  view  that  the  spirillum  of  Obermeier  is  the  essential  cause  of 
relapsing  fever. 

VOL.  I.— 28 


VARIOLA. 

BY  JAMES   NEVINS   HYDE,  M.D. 


VARIOLA  is  an  acute,  febrile,  contagious,  and  systemic  aflection,  pre- 
ceded by  an  incubative  period,  characterized  by  the  evolution  of  symp- 
toms in  a  relatively  determinate  order,  with  a  cutaneous  efflorescence 
successively  papular,  vesicular,  and  pustular  in  type,  followed  by  crust- 
ing, and  terminating  either  fatally  or  by  complete  convalescence,  with 
or  without  sequelae  in  the  form  of  multiple,  circumscribed,  and  super- 
ficial cicatrices. 

SYNONYMS. — Lai.,  Variola;  Eng.,  Small-pox;  Fr.,  Petite  VSrole; 
Get:,  Pockeu ;  ItaL,  Vajuolo. 

HISTORY. — -Small-pox  is  a  disease  which,  there  is  reason  to  believe, 
was  first  developed  in  the  earliest  ages  of  which  the  human  family  has 
record.  Originating  probably  in  China,  India,  and  the  adjacent  countries 
of  the  Asiatic  continent,  its  extension  over  Europe  and  America  was, 
without  question,  in  the  line  of  progress  pursued  by  the  advancing  cen- 
tres of  traffic  and  population.  The  earliest  traces  of  its  ravages  can  be 
dimly  recognized  in  the  descriptions  of  writers  in  the  middle  and  latter 
parts  of  the  sixth  century.  In  the  early  years  of  the  tenth  century, 
however,  a  remarkably  accurate  picture  of  the  disease  was  drawn  by 
Rhazes,  a  physician  of  Bagdad.  His  treatise,  translated  by  Greenhill 
for  the  London  Pathological  Society,1  sets  forth  the  views  of  an  Egyp- 
tian physician  named  Ahron,  who  wrote  in  the  sixth  century.  After 
these  dates  the  remarkable  political  and  social  changes  in  Europe,  which 
are  to  be  attributed  either  directly  or  remotely  to  the  Crusades,  contrib- 
uted largely  to  the  opportunities  for  the  spread  of  the  disease  and  to  the 
occurrence  later  of  those  decimating  epidemics  which  became  veritable 
scourges.  In  the  last  century  the  resulting  mortality  in  some  of  the 
countries  of  Europe  was  often  equal  to  the  entire  population  of  one  of 
their  largest  cities.  If  a  modern  traveller  could  find  himself  transported 
to  the  streets  of  the  city  of  London  as  they  appeared  in  the  early  part 
of  the  present  century,  it  is  probable  that  no  peculiarities  of  architecture, 
dress,  or  behavior  would  be  to  him  so  strikingly  conspicuous  as  the  enor- 
mous'number  of  pock-marked  visages  he  would  encounter  among  the 
people  at  every  turn.  In  the  face  of  all  cavil  and  sophistry,  medical 
science  will  alwavs  count  among  its  greatest  triumphs  the  modifications 

I'l  ••"!.  1  •  .  &  * 

wnicn  variola  Has  undergone  since  its  preventive  treatment  was  estab- 
lished upon  a  satisfactory  basis  by  the  discovery  of  the  immortal 
Jenner. 

1  A  Treatise  on  the  Small-pox  and  Measles,  by  Abu  Beer  Mohammed  Ibn  Zacarfj-a  Ar- 
riizf,  London,  1848. 

434 


ETIOLOGY.  435 

The  bibliography  of  the  disease  is  extensive,  and  the  list  of  authors 
contributing  to  the  subject  is  enriched  by  the  names  of  such  men  as 
Boerhaave,  Van  Swieten,  Sauvages,  "NVillan,  E.  Wagner,  Johanuy 
Rendu,  Hebra,  and,  more  lately,  Kaposi. 

ETIOLOGY. — Respecting  the  etiology  of  variola,  it  can  scarcely  be 
affirmed  that  our  knowledge  has  been  greatly  extended  since  the  date  of 
the  experiments  of  Jeuuer.  There  is  no  historical  knowledge  of  its 
generation  de  uovo ;  and  the  earliest  cases  of  the  malady  must  therefore 
be  classed  with  the  exceedingly  rare  instances  of  spontaneous  cow-pox 
which  have  proved  such  a  boon  to  the  vaccini-culturists.  To-day  every 
case  of  small-pox  is  justly  regarded  as  having  been  directly  or  indirectly 
transmitted  from  one  or  more  individuals  affected  with  a  similar  disorder. 
It  is  thus  recognized  as  specifically  infectious,  contagious,  and  iuoculable, 
its  transmission  occurring,  first,  without  contact,  by  atmospheric  conduc- 
tion of  a  volatile  contagious  principle  of  unknown  nature ;  second,  with 
contact  either  by  (a)  actual  transference  of  dry  or  moist  infectious  secre- 
tions deposited  upon  a  susceptible  surface,  immediately  or  through  the 
medium  of  garments,  bed-clothing,  paper  money,  and  similar  material 
substances ;  or  (6)  by  inoculation  of  unprotected  persons  with  the  path- 
ological product  of  an  infected  organism.  There  is  no  doubt  but  that 
the  contagious  principle  displays  its  greatest  activities  in  connection  with 
the  contents  of  the  lesions  undergoing  a  change  from  the  vesicular  to  the 
pustular  phases,  though  from  the  beginning  to  the  end  of  the  disease  it 
is  probable  that  all  the  tissues  and  fluids  of  the  infected  body  are  in 
various  degrees  capable  of  producing  the  malady  in  those  who  are  unpro- 
tected. Furthermore,  whether  associated  or  not  with  an  organic  sub- 
stance, the  coutagium  of  the  disease  is  known  to  preserve  the  power  of 
reproducing  itself  for  a  period  lasting  for  weeks,  mouths,  and  even  a 
longer  time.  A  field  for  its  activities  once  secured,  there  is  a  period  of 
time  during  which  few  if  any  evidences  of  its  progress  are  declared,  this 
period  being  abruptly  terminated  by  distinct  and  characteristic  symptoms. 
This  is  known  as  the  period  of  incubation. 

The  nature  of  the  contagium  in  small-pox  has  been  the  subject  of 
much  speculation,  careful  investigation,  and  experiment,  the  results  hav- 
ing established  but  few  facts  of  any  practical  value.  There  is  at  present 
no  proof  that  any  bacteria,  vegetable  germs,  or  other  minute  organisms 
foreign  to  the  human  body  are  the  essential  causes  of  the  disease.  It  is 
certain  that  iu  health  the  human  body  is  completely  enveloped  in  a  vola- 
tile medium  emanating  from  the  secretions  of  the  glands  of  the  skin, 
which  can  be  recognized  by  some  of  the  keen-scented  lower  animals  when 
it  is  wafted  through  the  air  at  a  distance  of  several  hundred  feet  from  a 
single  individual.  It  is  reasonable  to  conclude  that  not  only  in  small- 
pox, but  in  other  contagious  and  infectious  diseases,  these  emanations 
possess  a  pathological  character,  and  become  capable  of  transmitting  such 
maladies  from  diseased  to  healthy  organisms.  Certain  also  it  is  that 
when  the  subjects  of  these  diseases  are  crowded  together,  as  in  prisons, 
•hospitals  and  camps,  this  contagious  element  gathers  an  unwonted  inten- 
sity. By  far  the  larger  number  of  all  transmissions  of  variola  occur 
after  inhalation  of  the  infective  medium — in  other  words,  by  the  avenue 
of  the  lungs.  It  is  probably  for  the  same  reason  that  the  disease  spreads 
more  \videly  and  with  greater  virulence  during  the  cold  seasons  of  the 


436  VARIOLA. 

year,  in  this  latitude  especially  from  December  to  February — a  time 
when  the  veutilation  of  inhabited  dwelling-houses  is  usually  much  less 
perfect  than  in  warmer  weather. 

The  disease  affects  individuals  of  all  ages  and  both  sexes,  not  sparing 
the  foetus  in  utero,  and,  in  the  case  of  the  latter,  occurring  both  with  and 
without  previous  infection  of  the  mother  of  the  unborn  child.  Nowhere 
are  its  ravages  so  extensive  and  followed  by  such  fatal  results  as  among 
those  who  have  long  been  unprotected  by  previous  vaccination.  Among 
the  debilitated,  as  also  among  the  very  young  and  the  very  old,  small- 
pox is  liable  to  be  followed  by  severe  complications  and  a  fatal  result. 
Negroes,  possibly  in  consequence  of  tendencies  inherited  through  genera- 
tions of  unvaccinated  ancestors,  are  particularly  prone  to  the  disease. 
Lastly,  there  is  occasionally  noted  an  individual  idiosyncrasy,  in  conse- 
quence of  which  either  a  remarkable  susceptibility  to  the  disease  exists 
or  a  no  less  singular  immunity  against  its  encroachment  is  conferred. 

Thus,  physicians,  much  exposed  to  its  influences  in  the  discharge  of 
their  professional  duties,  are  known  to  be  relatively  exempt,  while  other 
individuals,  few  in  number  it  must  be  admitted,  have  either  had  repeated 
attacks  of  the  malady  itself,  or,  after  each  exposure  to  its  contagious 
principle,  a  recurrent  illness  of  variable  type.  In  the  immense  majority 
of  all  cases,  however,  one  attack  confers  immunity  upon  the  sufferer 
against  subsequent  invasion  of  the  disease  for  the  remainder  of  life. 
Upon  a  few  occasions  I  have  known  variola  to  occur  in  individuals  pre- 
viously affected  with  cutaneous  diseases,  especially  the  eczematous — a  fact 
which  merely  suggests  that  such  pre-existing  disorder  of  the  integument 
conferred  no  immunity  against  infection. 

SYMPTOMATOLOGY. — The  earliest  symptoms  of  small-pox  may  be  occa- 
sionally recognized  during  the  stage  of  incubation,  which,  as  described 
above,  embraces  a  period  of  from  ten  to  fifteen  days,  though  these  limits 
are  not  absolutely  fixed,  since  both  shorter  and  longer  incubative  periods 
have  been  at  times  established.  During  the  interval  the  patient  may 
appear  to  enjoy  perfect  health,  or,  on  the  other  hand,  suffer  from  an  ill- 
defined  malaise,  with  anorexia,  languor,  insomnia,  and  allied  symptoms. 
Close  observation  of  the  patient  thus  affected  will  often  reveal  the  exist- 
ence of  a  peculiar  pallor  of  the  face,  accompanied  by  a  skin-color  which 
suggests  a  slight  degree  of  sallowness  of  the  complexion.  These  rather 
indeterminate  symptoms  are  naturally  most  marked  toward  the  comple- 
tion of  the  period  of  incubation. 

The  latter  terminated,  the  period  of  invasion  follows,  and  extends  from 
the  conclusion  of  the  incubative  stage  to  the  moment  when  the  first 
cutaneous  lesions  of  variola  appear  upon  the  surface.  The  symptoms 
which  characterize  the  onset  of  this  period  of  invasion  are  conspicuous 
and  characteristic.  There  is  often  a  sharp  vespertine  rigor  or  a  more  or 
less  continuous  chilliness,  accompanied  by  sensations  of  "  creeping  "  over 
the  surface,  lasting  even  for  several  hours.  Meantime,  the  temperature 
rises  to  103°  or  105°  F.,  the  pulse  running  up  to  120  or  130  beats  per 
minute.  In  this  febrile  condition  there  is  commonly  complaint  of  a 
characteristic  aching  in  the  head  and  back,  intense,  scarcely  intermittent, 
and  so  peculiar  as  to  have  frequently  furnished  a  clue  to  the  diagnosis  of 
the  approaching  malady.  These  sensations  are  quite  analogous  to  the 
substernal  and  other  pains  which  frequently  precede  the  first  explosions 


SYMPTOMA  TOLOG  Y.  437 

of  syphilis,  and  are  all,  without  question,  due  to  the  circulation  of  a 
poisoned  blood,  the  influence  of  which  is  in  this  manner  confessed  by  the 
nervous  system.  In  the  case  of  infants  and  young  children  the  invasion 
of  small-pox  is  frequently  ushered  in  by  delirium  and  convulsions — 
symptoms  which  are  to  be  explained  by  the  facts  just  named. 

This  complexus  of  febrile  and  nervous  symptoms,  varying  somewhat 
in  intensity  and  possibly  interrupted  by  sensations  of  chilliness,  may  be 
recognized  as  continuing  on  the  second  and  third  days  of  the  period  of 
invasion.  Meantime,  there  may  be  noted  a  dusky  hypersemia  of  the 
pharnyx  and  tonsils,  the  surface  of  which  may  even  display  elevated 
points  which  develop  later  into  papules.  In  exceptional  instances  the 
intensity  of  the  poison  is  such  that  the  system  fails  to  rally  before  the 
violence  of  the  onset,  and  a  fatal  result  ensues  before  the  characteristic 
exanthem  appears  upon  the  skin. 

On  the  second  and  third  days  of  the  invasion  stage  of  the  disease,  if 
they  are  displayed  at  all,  the  variolous  rashes  appear.  Too  much  atten- 
tion can  scarcely  be  paid  to  the  importance  of  their  recognition  on  the 
part  of  the  diagnostician.  Often  indeed  have  practitioners  been 
deceived  by  their  occurrence,  having  been  either  completely  blinded  to 
the  serious  nature  of  the  malady  in  progress,  or,  as  Bartholow  l  has  well 
shown,  having  supposed  that  they  were  dealing  with  a  concurrence  of 
variola  and  scarlatina  or  rubeola. 

Hebra  was  the  first  to  point  out  the  significance  of  the  rash  known  as 
roseola  variolosa  or  erythema  variolosa.  Occurring  at  about  the  dates 
named  above,  it  is  in  a  few  patients  pronounced  and  vivid,  even  in  soli- 
tary instances  rivalling  in  severity  the  exanthem  which  succeeds  it.  In 
others,  the  majority  of  all  patients  in  some  epidemics,  it  may  be  entirely 
wanting.  The  writer  has  certainly  observed  its  most  typical  develop- 
ment in  women  who  were  either  menstruating  or  in  the  puerperal  state. 
It  is  said  also  to  be  relatively  frequent  in  subjects  of  a  tender  age.  Ka- 
posi2  has  recognized  it  in  all  its  manifestations  at  every  age. 

It  appears  in  the  form  of  puncta,  striae,  or  diffuse  and  uniform  blushes 
covering  extensive  areas  of  the  integument,  livid  red,  purplish,  or 
brownish-red  in  hue,  paling  under  pressure,  but  never  leaving  upon  the 
skin  over  which  the  finger-nail  is  quickly  drawn  the  characteristic  whitish 
streak  by  which  many  practitioners  test  the  scarlatinal  rash.  The  sur- 
faces involved  may  be  either  not  raised  or  slightly  elevated  above  the 
general  level  of  the  skin,  and  are  usually  circumscribed.  The  regions 
chiefly  involved  have  been  carefully  described  by  Th.  Simon,  a  ad  are 
hertce  sometimes  called  Simon's  triangles.  Thus  the  groin,  the  internal 
face  of  the  thighs,  and  the  hypogastric  region  may  be  involved  at  once 
(femoral  triangle  of  Simon)  ;  the  surface  of  the  axilla,  the  pectoral  region, 
and  the  inner  face  of  the  arm  (brachial  triangle  of  Sirnon),  as  also  the 
extensor  faces  of  the  knees  and  the  elbows,  the  dorsum  of  the  feet,  and 
indeed  every  portion  of  the  surface  of  the  body. 

In  the  midst  of  these  rash-covered  areas  may  also  appear  petechial  or 
hemorrhagic,  dark-red,  pin-head  to  bean-sized  maculae,  which  undergo 
color-changes  both  in  lighter  and  deeper  shades  as  the  invasion  period 

1  "The  Variolous  Diseases,"  Med.  News,  Mar. 4,  1882,  p.  232. 

*  Consult  the  admirable  chapter  on  variola  in  his  treatise,  Path.  u.  Therap.  der  Haut- 
krankt,  Wien,  1882. 


438  VARIOLA, 

lapses.  In  lieu  of  these,  however,  transient  wheals  may  come  and  go 
over  the  surface,  and  even  the  erythema  described  above  may  assume  an 
erratic  phase  and  appear  in  one  part  only  to  disappear  and  recur  at 
another.  None  of  these  flash-light  warnings  of  the  oncoming  exanthem 
are  proportioned  to  the  latter  in  the  matter  of  extent  and  intensity  of 
development.  They  may  be  followed  by  grave  or  mild  manifestations  of 
the  disease.  The  subsequent  eruption  may  also  be  much  more  abundantly 
developed  in  regions  where  the  invasion  rashes  have  not  appeared,  and 
the  latter  completely  fade  before  the  former  have  advanced  to  occupy  the 
field  thus  deserted. 

The  invasion  stage  of  variola  commonly  occupies  three  days.  Rarely 
it  extends  into  the  fourth,  fifth,  and  even  the  sixth,  day  after  the  pre- 
monitory chill  and  fever. 

Upon  its  subsidence  the  exanthem  of  the  disease  as  a  rule  promptly 
appears.  Simultaneously,  the  temperature  abates,  the  rapidity  of  the 
pulse  diminishes,  and  there  is  marked  amelioration  of  the  general 
symptoms.  The  patient,  frequently  deceived  by  the  completeness  of  this 
defervescence,  is  apt  to  conclude  that  he  is  convalescent  from  his  disorder, 
and  is  thus  often  astonished  at  the  discovery  of  the  exanthem  upon  the 
person,  usually  the  face.  In  other  cases,  more  commonly  those  of  a 
a  grave  character,  there  is  failure  of  this  defervescence,  the  febrile  symp- 
toms continuing  or  even  increasing  in  severity. 

The  eruption  first  appears  in  the  form  of  pin-head  sized  and  larger, 
firm,  conical,  discrete,  coherent  or  confluent,  reddish  papules,  sometimes 
accompanied  by  mild  sensations  of  a  pricking  or  painful  character,  often 
exciting  no  subjective  symptoms  by  which  their  presence  could  be  declared. 
To  the  touch  they  are  characteristically  indurated,  and  suggest  the  hard- 
ness of  small  shot  imbedded  in  the  skin.  They  appear  first  and  in  great- 
est abundance  upon  the  face  and  scalp,  involving  later  and  progessively 
the  trunk,  the  extremities,  and  the  palmar  and  plantar  surfaces.  It  is  at 
this  moment  that  the  eruption  most  resembles  that  to  be  recognized  in 
measles  (the  distinction  between  the  eruptive  symptoms  of  the  two  diseases 
will  be  considered  later).  At  times  a  reddish  areola  surrounds  each  lesion, 
especially  those  appearing  upon  the  trunk.  All  are  situated  about  the 
orifices  of  the  follicles  and  glands  of  the  skin. 

On  the  first  and  second  days  of  the  eruption  the  papular  lesions  mul- 
tiply in  number,  involve  an  increasingly  large  area,  and  individually  aug- 
ment in  size ;  so  they  appear  first  upon  the  head,  and  are  successively 
presented  to  the  eye  upon  the  lower  portions  of  the  body.  The  older 
lesions  are  usually  recognized  upon  the  scalp,  face,  neck,  and  shoulders ; 
the  more  recent  upon  the  extremities.  By  the  third  day  of  the  eruptive 
stage  there  is  usually  evident  at  the  apex  of  the  older  lesions  a  minute 
vesicle  containing  a  drop  of  pellucid  serum,  which  rapidly  changes  in 
character  and  size  till  a  distinct  vesicle  is  formed  with  cloudy  or  lactescerit 
contents.  Early  in  their  career  an  apicial  depression  can  be  seen,  which 
later  deepens  into  a  characteristic  umbilication.  This  umbilication  in  the 
vesicular  stage  is  somewhat  peculiar.  It  is  more  than  a  mere  depression 
of  the  summit,  such  as  might  be  made  by  thrusting  a  blunt-pointed  pin 
centrally  and  downward  so  as  to  carry  the  roof-wall  before  it.  It  is  made 
clinically  most  distinct  by  the  fluting  or  puckering  of  the  peripheral  part 
of  the  roof-wall,  giving  the  lesion  a  crenated  appearance  which  is  not 


SYMPTOMATOLOGY.  439 

assumed  by  any  other  cutaneous  efflorescence  of  multiple  development.    It 
may  be  regarded  as  pathognomonic  of  variola. 

The  pock  is  usually  mature  by  the  sixth  day  of  the  eruption.  It  is 
pea-sized  and  globular  in  shape ;  its  umbilication  has  been  usually  quite 
removed  by  the  complete  filling  of  its  chamber  with  distinctly  purulent 
contents ;  it  is  often  surrounded  by  a  halo  due  to  hypersemia  or  exuda- 
tion ;  and,  the  total  number  of  individual  lesions  being  then  fairly  deter- 
mined, it  is  often  closely  set  against  its  fellows,  islets  of  unaffected  integu- 
ment having  meantime  become  i'ewer  and  more  contracted.  The  face, 
covered  with  this  eruption,  then  exhibits  a  typical  aspect.  The  entire 
integument  becomes  swollen  and  brawny  or  cedematous.  The  eyes  are 
thus  closed  by  the  tumid  lids,  which  are  separable  with  difficulty,  arid 
this,  too,  even  though  they  be  the  seat  of  comparatively  few  lesions.  The 
nose,  lips,  cheeks,  and  ears  are  by  similar  processes  deformed  and  given  a 
most  repulsive  unsightliness.  Mucus  and  puriform  secretions  gather  and 
dry  about  the  mucous  outlets.  The  skin  of  other  parts  of  the  body 
(hands,  feet,  genitalia,  and  the  entire  extremities)  is  in  a  similar  condition, 
merely  most  noticeable  in  the  exposed  and  disfigured  visage. 

The  fever  of  maturation  or  suppuration,  or,  as  it  is  often  called,  the 
secondary  fever,  is  lighted  to  activity  with  the  onset  of  the  suppurative 
process.  The  temperature  rises  to  a  point  ranging  between  101°  and 
105°  F.,  the  pulse-rate  simultaneously  rising  to  100  and  even  150  in  the 
minute,  varying  of  course  with  the  age  of  the  patient  and  the  severity 
of  the  attack.  During  its  continuance,  from  the  eighth  or  ninth  to  the 
eleventh  or  twelfth  day  of  the  disease,  the  victim  of  the  malady  is  in  a 
deplorable  and  critical  condition.  The  intense  grade  of  cutaneous  inflam- 
mation, with  its  resulting  subjective  sensations  of  burning  pain  and  ten- 
sion, the  soreness  of  the  mouth  (tongue,  pharynx,  inside  of  lips,  and 
palate),  due  to  the  existence  of  pus-filled  pocks  upon  the  buccal  mem- 
brane, and,  for  similar  reasons,  the  dysphagia  and  irritation  of  the  larynx 
and  tracheal  membrane,  are  all  sufficient  to  account  for  the  general  condi- 
tion. In  cases  of  mild  grade  the  patient  lies  conscious,  but  in  a  stolid 
apathy,  listlessly  accepting  the  services  of  his  attendants.  In  others  there 
is  delirium  of  low  or  high  grade,  often  sufficient  to  demand  constant  sur- 
veillance, lest  in  consequence  the  patient  do  serious  injury  to  himself. 

The  behavior  of  the  pustules  which  appear  upon  the  mucous  surfaces 
accessible  to  the  eye  is  modified  somewhat  by  the  heat,  moisture,  and  fric- 
tion to  which  these  surfaces  are  exposed.  Typical,  fully-distended  pustules 
occasionally  persist  upon  the  soft  palate  and  the  inside  of  the  lips.  Soon, 
however,  the  macerated  roof-wall  yields,  leaving  a  reddish  floor  where 
the  mucous  membrane  is  exposed,  denuded  of  its  epithelial  layer  or 
covered  with  a  new  tender  and  hyperaemic  pellicle.  In  grave  and  severe 
cases  these  pustular  lesions  may  extend  deeply  into  the  mucous  tracts, 
involving  the  trachea,  bronchi,  or  alimentary  canal.  In  an  autopsy  made 
by  the  writer  on  the  body  of  a  male  subject  dead  of  unmodified  variola, 
there  was  no  portion  of  the  alimentary  canal  from  the  mouth  to  the  anus 
which  was  not  studded  by  thickly-set  pustules.  The  urethra,  vagina, 
vulva,  external  auditory  canal,  and  conjunctiva?  are,  in  severe  cases, 
similarly  involved.  According  to  Kaposi,  the  tympanum  is  usually 
exempt. 

The  period  of  desiccation  begins  usually  on  the  thirteenth  or  fourteenth 


440  VARIOLA. 

day  of  the  disease,  and,  according  to  the  severity  of  the  previous  path- 
ological processes,  requires  for  its  completion  from  one  week  to  a  fort- 
night. Its  onset  is  characterized  by  a  second  marked  but  gradually 
developed  defervescence.  With  a  diurnal  temperature  successively  less 
elevated  above  the  normal  standard  there  is  a  corresponding  fall  of  the 
pulse-rate.  As  the  disease  has  by  this  date  taxed  the  vital  resources  of 
the  system  to  the  utmost  limit,  the  exhaustion  resulting  may  be  declared 
by  a  pulse  which  is  flagging,  weak,  and  even  in  the  matter  of  frequency 
much  below  the  standard  of  health. 

The  cutaneous  lesions  now  again  undergo  a  change.  Some  of  the 
pustules  rupture,  and  their  viscid  contents,  oozing  forth,  concrete  into  a 
yellowish  crust  which  gradually  assumes  a  brownish  hue.  Others  desic- 
cate en  masse,  the  roof-wall  first  collapsing  upon  the  contents,  thus  pro- 
ducing an  appearance  which  again  suggests  umbilication  of  the  lesions. 
This  is  sometimes  termed  a  secondary  umbilication.  The  desiccation  en 
masse  is  doubtless  due  to  the  evaporation  of  a  portion  of  the  fluid  exuded 
into  the  superficial  strata  of  the  integument,  and  the  consequent  inspissa- 
tion  of  the  pus.  Often  the  face  at  this  moment  is  totally  concealed  by  a 
dense,  dry,  brownish  or  even  blackish  mask,  composed  of  the  crusts  fur- 
nished by  numerous  individual  lesions.  At  the  same  time  the  tumefac- 
tion of  the  skin  subsides,  and  the  subjective  sensations  to  which  it  gave 
rise  gradually  disappear.  Beneath  the  crusts  cicatrization  advances  till 
the  former  are  lessened,  and  finally,  becoming  detached,  fall  in  quantity 
from  the  surfaces  subjected  to  friction.  Beneath  them  are  seen  brownish 
and  violaceous  blotches,  the  integument  thus  stained  slowly  losing  its 
abnormal  color.  It  is  thus  seen  to  be  the  seat  of  multiple,  slightly  de- 
pressed, shining  scars  of  a  dead  white  color,  which  in  the  course  of  time 
lose  somewhat  of  their  disfiguring  prominence,  but  which  when  typically 
distinct  persist  for  a  lifetime.  This  exfoliation  of  crusts  continues  till 
the  skin  is  completely  rid  of  its  pathological  products,  the  process  being 
completed  with  entire  restoration  to  health  about  the  conclusion  of  the 
fourth  or  fifth  week  of  the  disease.  Meantime,  in  favorable  cases,  con- 
valescence progresses  pari  passu.  The  patient  has  a  returning  appetite, 
decadence  of  symptoms  originating  in  impairment  of  function  of  the 
mucous  membranes,  and  gains  in  weight  till  the  restoration  to  sound 
health  is  complete. 

Such  is  the  history  in  outline  of  what  may  be  regarded  as  a  typical 
form  of  uncomplicated  variola.  It  should  not  be  forgotten,  however, 
that  in  different  epidemics  there  are  marked  differences  in  the  career  and 
manifestations  of  the  malady,  and  that  even  among  the  cases  observed  in 
a  single  locality  visited  by  the  disease  the  same  divergence  of  symptoms 
is  no  less  conspicuous.  This  diversity  is  due  to  several  causes,  irrespec- 
tive of  the  remarkable  modifications  displayed  in  the  variolous  who  have 
been  previously  vaccinated.  Individual  susceptibility  is  doubtless  to  be 
considered  in  this  connection,  as  also  the  temperament,  bodily  vigor,  and 
hygienic  surroundings  of  those  who  are  infected.  It  is  possible  also  that 
the  intensity  of  the  poison  may  be  subjected  to  occasional  modifications 
in  its  transmission  from  individual  to  individual.  In  this  way  the  follow- 
ing types  of  variola  present  themselves  in  clinical  forms  with  divergent 
features : 

CONFLUENT  VARIOLA  (variola  confluens). — This  virulent  form  of 


CONFLUENT  VARIOLA.  441 

small-pox  is  ushered  in  by  a  relatively  short  incubative  period,  followed 
by  a  severe  invasion  of  the  disease.  The  premonitory  chill  is  violent ;  the 
cephalic  and  lumbar  pains  are  excruciating ;  the  fever,  rising  to  a  high 
grade,  106°  to  110°  F.,  with  few  and  slight  remissions,  scarcely  subsides, 
if  at  all,  with  the  appearance  of  the  eruption,  the  latter  developing  early, 
and,  to  borrow  an  expression  from  syphilographers,  exploding  with  vio- 
lence over  large  areas  of  the  surface  of  the  body.  The  initial  lesions  of 
the  exanthem  are  dense  and  deeply-set  papules,  so  closely  coherent  even 
at  this  moment  that  they  scarcely  leave  between  them  interspaces  of  sound 
skin.  During  the  vesiculo-pustular  transformation  which  they  promptly 
undergo  on  the  second  day  there  is  a  more  or  less  complete  coalesence  of 
the  elements  of  the  eruption,  which  circumstance  has  given  this  form  of 
the  disease  its  name,  confluent  variola.  This  confluence  is  most  conspicu- 
ous upon  the  face  and  hands,  where  large  flat  vesicles  run  together,  form 
pus-filled  bulla?,  and  finally  convert  the  surface  on  which  they  rest  into  a 
single,  large,  many-chambered  pustule.  All  this  occurs  upon  an  enor- 
mously swollen  and  inflamed  skin,  disfiguring  every  feature  of  the  face 
and  wellnigh  obliterating  every  external  distinction  between  the  scalp, 
nose,  eyes,  and  mouth.  Here  and  there  the  mass  is  elevated  by  the 
quantity  of  exuded  pus  to  a  more  notable  projection  from  the  surface. 
Pustules  filled  with  blood  may  appear  at  several  points.  At  others,  the 
suppurative  inflammation  may  be  seen  to  have  eroded  the  derma,  which 
is  covered  with  a  diphtheritic  membranous  exudation  similar  to  that 
covering  the  mucous  membranes  lining  the  mouth,  nose,  and  ears.  Natu- 
rally, the  skin  in  its  totality  often  yields  to  these  destructive  processes 
and  in  large  patches  falls  into  gangrene. 

The  confluence  of  the  lesions  is  less  marked  in  other  parts  of  the  body 
than  the  face  and  hands,  yet  the  entire  surface  may  be  covered  with  a 
coherent  exanthem  which  becomes  elsewhere,  in  large  areas,  confluent. 
The  writer  has  seen  patients  in  whom  the  head  of  a  pin  could  not  be 
placed  upon  an  unaffected  patch  of  skin  in  any  portion  of  the  body. 
The  parts  subjected  to  pressure  in  the  reclining  posture,  such  as  the  back, 
shoulders,  and  buttocks,  are  especially  liable  to  this  coalescence  of  the 
pustular  lesions. 

In  confluent  variola  too,  as  already  intimated,  the  mucous  surfaces 
suffer  proportionately.  Pasty  accumulations  of  muco-pus  and  diphthe- 
ritic exudation,  like  macerated  chamois  leather,  cover  the  tongue,  which 
is  often  so  enormously  swollen  as  to  bulge  between  the  teeth  and  project 
from  the  mouth.  These  exudations  line  the  mouth,  pharynx,  larynx, 
and  even  the  bronchi.  Beneath  these  masses  the  eroded  mucous  surface 
is  dry,  livid  red  in  color,  and  has  a  varnished  aspect.  Gangrene  here 
may  lead  to  necrosis  of  the  cartilages  of  the  larynx.  Aphonia  is  often 
complete,  deglutition  impossible,  respiration  difficult.  The  stench 
arising  from  the  patient  is  intolerably  fetid  and  pervading,  and  a 
single  exhalation  will  poison  the  best-ventilated  apartment.  The  sub- 
maxillary  and  sublingual  glands  are  enlarged  and  the  neighboring 
lymphatics  swollen. 

The  patient  who  is  plunged  into  this  grave  condition  is  the  victim  of  a 
fever  which  is  unquestionably  septicsemic  in  character ;  he  has  a  small, 
frequent,  and  often  fluttering  pulse ;  his  mental  condition  is  betrayed  by 
a  delirium  of  varying  grade  or  he  lies  comatose.  In  this  state  a  fatal 


442  VARIOLA. 

result  is  often  induced  by  either  exhaustion  of  the  vital  forces  or  an 
mtercurrent  malady,  such  as  pleurisy,  pneumonia,  cardiac  inflammation, 
oedema  of  the  glottis,  or  an  uncontrollable  diarrhoea.  In  yet  other  cases 
the  patient  falls  into  a  typhoid  state,  and,  after  surviving  for  a  fortnight 
or  more  with  a  low  fever,  a  broncho-pneumonia,  or  a  diarrhoea,  succumbs 
to  an  inevitable  exhaustion,  the  surface  of  his  body  being  yet  covered 
with  a  dry,  blackish,  and  fetid  crust. 

The  expression  of  an  intense  variolous  poison  is  known  as  hemor- 
rhagic  variola ;  also  as  purpura  variolosa  and  black  pox.  A  large  num- 
ber of  such  cases  have  been  designated  and  treated  as  black  measles,  the 
real  nature  of  the  malady  having  been  mistaken. 

The  law  readily  observed  by  the  diagnostician  of  diseases  in  general 
must  here  be  recognized.  There  are  no  hard  and  fast  lines  in  nature. 
Hemorrhagic  variola  occurs,  without  question,  in  different  types.  At 
the  one  extreme  are  classed  the  inevitably  fatal  cases,  where  the  patient 
sinks  smitten  by  the  malady  even  before  the  exanthem  is  developed ;  at 
the  other  are  found  the  cases  of  confluent  variola,  not  necessarily  fatal, 
in  the  course  of  which  hemorrhagic  lesions  appear  in  variable  number, 
blood  either  filling  the  pustules  after  the  latter  have  arrived  at  maturity,' 
or  forming  ab  initio  purpuric  pocks  intermingled  with  the  typical  lesions 
of  the  variolous  exanthem.  However  ill-defined  the  limits  between  these 
classes  may  be,  the  symptoms  of  hemorrhagic  variola  are  sufficiently 
characteristic  to  require  separate  description.  According  to  Kaposi,  it 
occurs  in  the  two  following  types  : 

The  first  form  is  termed  variolic  purpura.  Its  incubative  period  is 
brief  and  distinguished  by  unusual  conditions  of  malaise  and  lumbar 
pain.  On  the  fourth  day  there  is  an  intense  fever  with  rapid  pulse, 
and  this  is  speedily  followed  by  a  deep  purplish-red  staining  of  the 
face,  neck,  trunk,  and  extremities,  the  skin  thus  affected  being  slightly 
tumid  and  quite  dry.  Minute  maculo-papules  can  be  distinguished  here 
and  there  over  the  surface,  often  closely  set  together,  and  presenting 
the  characteristic  color  described  above.  At  this  stage  of  the  disease 
the  eruption  greatly  suggests  an  intense  rubeolous  exanthem,  and  has 
been,  as  a  result,  repeatedly  mistaken  for  the  so-called  black  measles. 
But  the  excruciating  pains  persist,  there  is  often  coincident  delirium, 
and  the  pin-head  sized  maculo-papules  noted  above  become  lenticular  in 
shape,  cease  to  lose  their  color  under  the  pressure  of  the  finger,  extend 
peripherally  even  in  a  few  hours,  flatten  and  become  purpuric  patches  of 
a  bluish-black  shade,  palm-sized  and  even  larger,  covering  extensive 
areas  of  the  integument,  new  lesions  forming  in  unaffected  islets  of  the 
skin ;  conjunctival  ecchymoses  appear  at  the  angles  formed  by  the  lids, 
and  finally  encircle  the  cornea  with  an  annular  purplish-black  cushion. 
The  mucous  surfaces  become  dry,  crack,  and  bleed  where  the  epithelium 
is  torn,  and  become  covered  with  offensive  crusts.  The  odor  exhaled  by 
the  patient  is  intolerably  fetid.  He  lies  stupid  as  the  march  to  a  fatal 
issue  is  hourly  hastened.  Hemorrhages  occur  from  the  larynx,  bronchial 
membrane,  intestinal  surfaces,  and  even  into  the  parenchyma  of  the  viscera, 
the  muscles,  serous  membranes,  periosteum,  and  neurilemma.  The  urine 
is  retained  in  the  bladder ;  the  respirations  rapidly  increase  in  frequency ; 
1he  pulse  flutters;  and  death  closes  the  scene  between  one  and  two  days 
after  the  onset  of  the  malady.  In  several  cases  observed  by  the  writer, 


VARIOLOID.  443 

occurring  in  infants  and  children,  the  entire  course  of  the  malady  was 
completed  in  twelve  hours. 

In  the  second  and  much  rarer  form  of  hemorrhagic  variola  there  are 
the  usual  unfavorable  portents  of  intense  prodromic  symptoms.  On  the 
fourth  day  the  skin  is  swollen  and  indurated  in  consequence  of  the 
development  within  its  structure  of  numerous  firm,  roundish,  slightly 
acuminate  papules,  so  thickly  set  together  that  it  is  wellnigh  impossible 
to  distinguish  between  them.  These  are  early  in  betraying  the  bluish- 
black  hue  significant  of  hemorrhage  into  their  mass.  They  multiply  in 
number  and  increase  in  size,  while  their  hemorrhagic  stains  widen  and 
sweep  from  each  as  a  centre,  like  the  waves  that  spread  from  a  pebble 
thrown  into  smooth  water.  In  these  cases,  more  often  than  in  those  first 
described,  pus-filled  pocks  may  develop  over  some  portions  of  the  surface, 
while  in  others  a  species  of  gangrene  occurs  in  consequence  of  the  sepa- 
ration of  the  derma  from  the  subcutaneous  tissues  by  effused  blood.  At 
times  pustules  of  somewhat  typical  aspect  are  formed  and  subsequently 
filled  with  blood  by  a  hemorrhage  from  below.  The  accompanying 
symptoms  are  grave,  but  less  rapidly  fatal  than  in  the  other  types  of  the 
disease.  Delirium,  stupor,  an  intense  fever,  and  a  rapid,  feeble  pulse  are 
commonly  noted.  A  fatal  result  is  usually  reached  in  from  four  to  five  days. 

Hemorrhagic  lesions,  isolated  or  confluent,  are  seen  also  in  severe 
forms  of  variola,  not  of  the  two  types  described  above.  Thus,  in  con- 
fluent small-pox,  especially  when  occurring  among  the  unvaccinated, 
some  of  the  pustules  on  the  face,  the  back,  or  possibly  the  legs,  where 
varicosities  of  the  veins  permit  a  passive  engorgement  of  the  tissues  with 
blood,  may  become  the  seat  of  a  hemorrhage.  For  these  local  causes  are 
often  etiologically  effective.  In  other  cases  the  appearance  of  the  hemor- 
rhagic lesions  seems  to  be  due  to  a  dyscrasia,  such  as  that  recognized  in 
phthisis,  chronic  alcoholism,  and  haemophilia. 

Aside  from  the  trivial  accidents  to  which  the  exanthem  may  be  sub- 
ject, the  hemorrhagic  types  of  variola  may  be  regarded  as  necessarily 
grave  and  in  a  large  proportion  of  cases  inevitably  fatal.  That  they  are 
all  truly  the  results  of  variolous  poisoning  is  shown,  first,  by  the  occur- 
rence of  intermediate  forms ;  second,  by  the  occasional  transmission  of 
the  disease  in  its  typical  aspects  to  the  partially  protected. 

VARIOLOID  is  that  form  of  variola  in  which  the  disease  is  modified, 
either  in  its  course,  duration,  or  intensity  of  symptoms,  such  modification 
usually  resulting,  directly  or  indirectly,  from  the  protective  influence  of 
vaccination  or  from  a  previous  attack  of  variola. 

The  symptoms  of  the  class  of  patients  commonly  regarded  as  suffering 
from  varioloid  are  all  those  of  variola,  modified,  however,  in  the  direc- 
tion of  a  mitigation  of  their  intensity  and  dangerous  character.  It  is 
thus  evident  that  there  is  no  strict  line  of  demarcation  between  the  very 
mildest  physical  expression  of  the  variolous  poison  and  that  variola  vera 
which  presents  atypically  benign  symptoms  in  any  stage  of  its  career. 
Within  this  wide  range  of  possibilities  cases  of  varioloid  occur  which  cer- 
tainly diifer  from  each  other  .by  very  marked  degrees. 

The  invasion  stage  of  varioloid  may  be  shorter  or  longer  than  that 
occurring  in  variola  vera,  and  may  be  insignificant  or  intensely  marked 
as  regards  the  severity  of  its  symptoms.  According  to  Bartholow1  the 

1  Loc.  cit. 


444  VARIOLA. 

invasion  rashes  are  here  of  common  occurrence ;  and  the  more  extensive 
the  latter,  the  less  copious  the  subsequent  eruption.  It  must  be  admitted 
that  a  personal  experience  has  not  confirmed  us  in  this  view. 

After  the  -high  fever  and  severe  cephalic  and  lumbar  pains  of  this 
stage  there  may  follow,  in  the  case  of  varioloid,  a  complete  deferves- 
cence and  the  appearance  of  a  very  copious  exanthem.  With  this,  how- 
ever, the  apogee  of  the  disease  may  be  reached,  and  the  subsequent 
symptoms  be  altogether  insufficient  in  comparison  with  those  which  have 
preceded.  Thus,  the  maculo-papules  may  never  reach  a  vesicular  stage, 
or,  having  attained  this,  the  vesicles  may  not  be  umbilicated,  or  may 
shrivel  after  their  contents  have  assumed  a  lactescent  color,  and  be  suc- 
ceeded by  light  superficial  crusts  which  in  a  few  days  fall.  Or,  again, 
the  pustular  stage  of  the  lesions  may  be  fully  developed,  even  with  the 
production  of  a  halo  about  the  pocks,  while  yet  there  is  no  swelling  of 
the  skin  and  but  trifling  subjective  sensations  experienced  by  the  patient. 
The  pustules  in  the  course  of  from  four  days  to  a  week  desiccate  and  are 
shed,  leaving  behind  them  violaceous  pigmentations  of  the  surface  with- 
out persistent  cicatricial  sequelae. 

Other  cases,  again,  instead  of  producing  the  impression  upon  an 
observer  of  being  illustrations  of  a  malady  aborted  or  cut  short  at  some 
period  of  its  career,  seem  to  exhibit  merely  a  modification  in  the  intensity 
or  distribution  of  symptoms  betrayed  in  a  wellnigh  typical  career. 
Thus,  there  may  be  a  total  absence  or  insignificant  reminder  of  the  sep- 
tic fever  usually  known  as  the  secondary  fever  of  variola,  and  the  ele- 
ments of  the  eruption  may  be  few  or  appear  in  scanty  number  upon  the 
face  and  more  copiously  elsewhere.  The  latter  may,  however,  pursue  a 
perfectly  typical  career  and  be  followed  by  characteristic  scars. 

There  is  yet  another  type  of  varioloid  with  which  many  practitioners 
become  familiar  who  have  experience  in  epidemics  of  small-pox.  The 
patient  exhibits  distinct  symptoms  of  malaise  in  the  period  of  incubation. 
The  fever  of  invasion,  with  its  characteristic  pains  and  nausea,  is  equally 
well  marked.  Defervescence  occurs  with  a  trifling  eruption  of  maculo- 
papules,  which  in  two  days  have  wellnigh  completely  disappeared. 
There  is  no  secondary  fever,  but  the  patient  is  far  from  well.  There  is 
a  period  of  anemia,  mental  depression,  marked  langour,  and  unmistaka- 
ble evidences  of  physical  prostration  out  of  all  proportion  to  the  prece- 
dent symptoms.  In  these  cases  it  may  well  be  believed  that  the  poison 
has  at  last  produced  a  strong  impression  upon  the  nervous  centres.  The 
most  characteristic  feature  of  these  cases  is  the  tedious  convalescence  from 
an  apparently  trifling  form  of  the  malady. 

The  identity  of  varioloid  with  variola  is  abundantly  shown — first,  by 
the  occurrence  of  intermediate  forms  of  every  grade,  from  the  mildest 
evidence  of  variolous  poisoning  to  typically  developed  cases  of  variola 
vera ;  second,  by  the  fact  that  patients  affected  with  varioloid  are  capable 
of  transmitting  variola  to  the  unprotected ;  third,  by  the  anatomico- 
pathological  fact  that  the  structure  of  the  pock,  when  it  appears,  is  the 
same  in  all. 

A  variation  as  to  the  form  and  contents  of  the  lesion  of  modified  vari- 
ola occasionally  occurs  as  a  consequence  of  individual  peculiarities  or  of 
the  special  surroundings  of  the  patient,  A  number  of  useless  terms 
have  been  employed  to  designate  these  peculiarities,  the  most  of  which 


COMPLICATIONS  AND  SEQUELS.  445 

are  relics  of  the  superstitions  of  the  past.  In  variola  siliquosa  the  pocks 
are  said  to  contain  air  only ;  in  v.  pemphicosa,  bullous  lesions  predomi- 
nate ;  in  v.  verrucosa,  the  papules,  after  partial  evolution  and  involution, 
leave  minute  wart-like  papillary  masses  upon  the  face  ;  in  v.  crystallina, 
there  are  superficial  vesicles  only  filled  with  clear  serum,  which  somewhat 
resemble  those  recognized  as  sudamina.  The  older  English  writers  with 
as  little  reason  described  cases  of  horn-pox,  swine-pox,  etc.,  differing 
only  from  those  of  variola  by  the  anomalous  behavior  of  the  exauthem 
in  the  course  of  its  evolution.1 

COMPLICATIONS  AND  SEQUELAE. — The  complications  and  sequelae  of 
variola  are  fewer  in  number  and  more  restricted  in  range  than  those  of 
many  other  maladies.  This  results  from  the  remarkable  unity  of  the 
disease  as  it  occurs  in  its  several  manifestations  among  the  unprotected, 
its  relatively  rapid  progress,  and  its  absolute  disappearance  on  the  com- 
pletion of  its  curriculum.  There  is  no  chronic  form  of  variola  lingering 
for  weeks  and  months  after  the  violence  of  the  fever  has  abated. 

Furuncles  and  abscesses  occasionally  result  during  or  after  the  pustular 
stage  of  the  disease  has  been  reached,  sometimes  of  such  extent  as  to 
give  exit  to  large  quantities  of  an  ill-conditioned  pus.  The  tissues, 
weakened  by  the  suppurative  process  which  the  skin  has  undergone, 
may  then  necrose,  and  thus  lay  bare  periosteum,  cartilage,  or  bone.  Ery- 
sipelas, especially  about  the  lace,  may  close  the  eyes,  encroach  upon  the 
scalp,  or  spread  extensively  over  other  regions.  Muscular  paralyses, 
hemiplegic  and  paraplegic  attacks,  albuminuria,  diarrhoaa,  and  the  inflam- 
mations of  chronic  type  affecting  the  thoracic  organs  may  each  supervene, 
and  either  greatly  prolong  convalescence  or  precipitate  a  fatal  issue. 
None  of  them  is  perhaps  more  common  than  a  low  typhoid  and  febrile 
state,  in  which  the  patient  lies  after  his  variola  is  practically  ended,  his 
skin  struggling  to  regain  its  normal  tone,  a  fever  of  remittent  type- 
taxing  his  energies,  his  bowels  in  frequent  movements  discharging  a  thin 
and  fetid  feculent  matter,  while  a  low  delirium  renders  him  insensible  to 
the  gravity  of  the  situation. 

Reference  has  been  made  above  to  the  implication  of  the  eyes  of  the 
variolous,  and  the  possibility  of  the  disorder  terminating,  after  an 
otherwise  favorable  convalescence,  in  total  blindness,  should  not  be 
forgotten.  The  cornea  may  be  the  seat  of  pustules  or  a  diffuse  puri- 
form  infiltration  resulting  in  ulceration,  and  eventually  perforation 
with  hernia  of  the  iris.  At  times  it  is  merely  macerated  by  the  pus 
continually  covering  it,  and  in  that  condition  yields  to  even  moderate 
pressure.  At  others  the  deeper  portions  of  the  globe  fall  into  inflam- 
mation, and  there  is  a  resulting  cyclitis,  irido-cyclitis,  or  parophthalmia. 

In  the  nose  severe  destructive  effects  may  follow  the  pustular  involve- 
ment of  the  Schneiderian  membrane,  including  necrosis  of  the  nasal  bones 
and  profuse  epistaxis. 

In  a  similar  way,  the  external  ear  may  be  involved,  the  tympanum 
disappear,  a  severe  otitis  media  supervene,  and  the  mastoid  cells  become 
filled  with  pus  and  detritus  of  necrosed  tissue. 

1  Besides  the  terms  given  above,  Hebra  gives  the  following  list  of  Latin  adjectives  which 
have  been  employed  to  describe  special  varieties  of  small-pox,  none  of  which  requires 
special  explanation :  variola  papnlosa,  conica,  acuminata,  globosa,  globulosa,  tuberculosa, 
cornea,  fimbriata,  miliaris,  lymphatica,  vesiculosa,  pustularis,  rosea,  morbillosa.  carbun- 
eulosa,  etc. 


446  VARIOLA. 

In  the  larynx,  which  may  be  well  lined  with  pustules,  as  indicated 
above,  complications  may  arise  in  the  shape  of  oedema  of  the  ary-epi- 
glottic  folds,1  Iaryugo-O2sophageal  abscess  and  various  diphtheritic  deposits 
lining  every  portion  of  the  mucous  membrane. 

Other  disorders  noted  as  complicating  variola  are  hydrocele  and  orchitis 
in  the  male,  ovaritis  in  the  female,  gangrene  of  scrotum  or  labia,  hsema- 
turia,  peritonitis,  adenopathy  and  lymphangitis  and  arthritis,  as  well  as 
peri-arthritic  suppurative  inflammation. 

PATHOLOGY  AXD  MORBID  AXATOMY. — Ours  is  a  day  in  which 
bacteria,  special  to  each  of  a  number  of  infectious  diseases  (lepra,  pem- 
phigus, tuberculosis,  etc.),  are  constantly  reported  as  coming  to  light 
under  the  persuasive  influence  of  modern  staining  solutions.  With 
respect  to  variola,  it  may  be  said  that  while  Cohn,  Klebs,  Weigert,  and 
others  have,  without  question,  recognized  microsphasra,  micrococci,  and 
similar  organisms  in  variolous  pus,  their  causative  relation  to  the  patho- 
logical process  has  certainly  not  yet  been  demonstrated. 

The  pathological  anatomy  of  the  cutaneous  lesions  of  variola  has  been 
very  carefully  studied  by  Auspitz  and  Basch,2  and  Heitzmann.3  The 
following  is  a  condensed  account  of  the  results  reached  by  these 
observers : 

First  appear  circumscribed  patches  of  hypersemia,  in  which  the  papil- 
lary layer  of  the  corium  is  concerned,  and  which  is  followed  by  some 
thickening  of  the  rete,  the  epithelia  involved  becoming  coarsely  granular. 
This  granular  condition  is  due  to  an  increase  of  living  matter  within  the 
protoplasmic  bodies,  evident  at  the  points  of  intersection  of  the  reticulum 
of  which  they  are  composed,  the  nuclei  becoming  solid  and  shining,  and 
the  threads  traversing  this  cement-substance  between  them  becoming  also 
increased  in  thickness.  The  papilke  beneath  increase  in  size  in  conse- 
.quence  of  their  vascular  engorgement,  and  in  consequence  of  the  change 
experienced  by  the  connective-tissue  bundles,  which  are  partly  trans- 
formed into  protoplasm,  while  the  protoplasm  between  them  increases 
also.  There  is,  in  brief,  a  liquefaction  of  the  glue-giving  basis-substance, 
which  makes  visible  the  reticulum  of  living  matter  formerly  hidden 
within  it.  In  this  way  the  epidermis  is  raised  into  the  flat  solid  papules 
which  are  the  early  lesions  of  the  disease. 

Then  follows  an  exudation  of  a  serous  fluid  at  one  or  more  points  in 
the  papule,  the  meshes  of  the  reticulum  being  so  stretched  and  torn  that 
small  chambers  are  formed  filled  with  the  liquid  exudate  containing 
granules.  Between  these  chambers  the  separating  strata  of  epithelia  are 
compressed  so  as  to  form  septa  or  partition  walls.  The  neighboring  epi- 
thelia become  granular,  divested  of  their  cement  envelope,  and  transformed 
into  protoplasmic  clusters  still  connected  with  the  living  reticulum  by 
slender  threads.  An  irregular  cavity  is  thus  formed  in  the  thickened 
rete  traversed  by  septa,  the  contained  exudation  being  filled  with 
granules,  coagulated  fibrin,  and  lymph.  A  few  protoplasmic  bodies 
are  here  also  distinguishable,  which  Heitzmaun  regards  as  either  debris 
of  destroyed  epithelia  or  colorless  blood-corpuscles. 

In  these  changes  the  connective-tissue  beneath  participates.  The  papillae 
eventually  disappear,  the  superior  portion  of  the  corium  being  replaced  by 

1  J.  William  White,  "  Surgical  Aspects  of  Small-Pox,"  Medical  News,  March  4,  1882, 
p.  241.  2  Virch.  Arckiv,  Bd.  28.  3  Trans,  of  Amer.  Derm.  Ass.,  Aug.,  1879. 


DIAGNOSIS.  447 

clusters  of  medullary  or  inflammatory  elements  uninterruptedly  connected 
by  threads  of  living  matter. 

The  pus-corpuscles  which  eventually  appear  originate  mainly  from 
transformed  epithelia.  In  the  process  of  transformation  the  increased 
protoplasm  of  the  epithelia  first  exhibits  shining  homogeneous  lumps, 
which,  after  an  intermediate  stage  of  vacuolation,  undergo  an  endogenous 
metamorphosis  into  nucleated  bodies  with  a  reticulum  in  each.  To  the 
number  of  these  there  is  possibly  an  addition  by  the  immigration  from 
below  (diapedesis)  of  leucocytes. 

The  question  of  repair  with  or  without  the  production  of  cicatrices 
rests  upon  the  behavior  of  the  connective-tissue  elements.  If  these  are 
not  torn  asunder,  but  remain  in  connection  with  each  other,  the  re-forma- 
tion of  a  glue-giving  basis-substance  is  possible,  and  new  bundles  of 
fibrous  connective-tissue  take  the  place  of  the  old.  If,  on  the  contrary, 
the  latter  are  completely  destroyed,  their  place  is  filled  with  the  cicatricial 
new  growth.  The  pigmentation,  which  is  such  a  common  transitory  sequela 
of  the  skin  lesions,  is  due  both  to  the  imbibition  of  the  coloring  matter 
of  the  blood  by  the  epithelia  and  by  direct  hemorrhagic  exudation  into 
both  the  rete  and  derma. 

The  umbilication  of  the  mature  pock  is  doubtless  due  to  the  situation  of 
such  lesions  at  the  orifices  of  the  excretory  ducts  of  the  skin-glands. 
The  epidermis,  in  one  or  more  of  its  'strata,  dips  downward  to  form  a 
living  investment  for  such  glands,  and  in  this  situation  ties  down  the 
centre  of  the  roof-wall  of  the  pustules.  Eventually,  it  too,  as  a  result 
of  the  maceration  and  tension  incidental  to  the  complete  filling  of  the 
pock  with  pus-elements,  is  ruptured  or  stretched,  and  the  umbilication  of 
the  pustule  disappears. 

The  anatomy  of  the  exanthematous  lesions  in  hemorrhagic  variola  is 
not  different  from  that  described  above.  The  pocks  in  such  cases  are 
merely  filled  with  blood  instead  of  with  pus  or  sero-pus.  In  some  forms 
of  hemorrhagic  variola,  as  indeed  would  be  suggested  by  their  clinical 
observation,  there  is  hemorrhage  directly  into  the  tissues  of  the  integu- 
ment, or,  more  probably  in  severe  cases,  a  mere  passive  leaking  of  the 
sanguineous  fluid  with  its  coloring  matter  through  the  relaxed  and  weak- 
ened vascular  walls. 

The  morbid  changes  occurring  in  the  viscera  are  described  by  Cursch- 
mann  as  follows :  The  mucous  surfaces  may  be  the  seat  of  pustules,  diffuse 
purulent  infiltration,  and  catarrhal,  croupous,  or  diphtheritic  inflammation. 
As  regards  the  extent  of  diffusion  of  the  pustular  lesions,  they  occur, 
according  to  Wagner,  in  bronchi  of  the  second  and  even  of  the  third  order, 
rarely  in  the  stomach  and  intestines,  and  in  the  rectum  only  in  its  lowest 
portion.  The  bladder,  urethra,  and  serous  surfaces  are  always  exempt. 
The  lungs,  breast,  liver,  spleen,  brain,  and  spinal  medulla  are  variously 
involved.  Often  the  tissues  of  these  organs  are  quite  unchanged  as 
regards  their  macroscopical  appearance.  At  other  times  the  tissues 
appear  swollen,  granular,  and  undergo  a  fatty  degeneration.  In  purpura 
variolosa  the  spleen  and  walls  of  the  heart,  however,  are  seen  to  be  firm, 
dark-red,  and  more  or  less  indurated. 

DIAGNOSIS.- — The  establishment  of  a  correct  diagnosis  where  there  is 
question  of  variola  is  one  of  the  most  critical  and  important  of  the  duties 
of  a  physician.  Upon  such  decisions  have  turned,  again  and  again,  pro- 


448  VARIOLA. 

fessional  success  or  disaster.  To  pronounce  that  case  to  be  variolous 
which  is  not  of  such  a  nature  is  to  subject  one  to  the  indignation  of  the 
few  and  the  ridicule  of  the  many.  On  the  other  hand,  to  be  guilty  of 
treating  a  patient  with  small-pox,  and  of  remaining  ignorant  of  the  nature 
of  the  malady,  is  to  subject  many  ignorant  people  to  the  danger  of  expo- 
sure to  the  disease  and  to  render  one's  self  liable  for  the  redress  sought 
by  recourse  to  the  civil  authorities  and  the  law.  It  is  difficult  to  decide 
which  predicament  is  the  graver. 

Typical  variola  vera  is  readily  recognized  by  its  characteristic  features. 
As  usual,  it  is  the  atypical  and  modified  forms  where  the  difficulty  most 
often  arises  and  where  the  danger  to  the  physician  is  proportionately 
increased. 

In  the  invasion  stage  of  the  disease  it  is  often  impossible  to  recognize 
any  symptoms  characteristic  of  variola.  High  fever  with  severe  lumbar 
pain,  considerable  gastric  distress,  and  the  appearance  of  one  of  the  inva- 
sion rashes  (roseola  variolosa)  would,  however,  put  the  observant  practi- 
tioner on  his  guard.  I  have  often  noticed  in  these  cases  a  symptom  which, 
apparently  insignificant,  has  on  more  than  one  occasion  preceded  the 
eruptive  period.  It  is  the  occurrence  upon  the  centre  of  the  two  cheeks 
of  a  vivid  damask-red  blush,  occasionally  having  a  purplish-red  hue,  and 
with  a  very  remarkable  circumscribed  area.  This  may  be  recognized  in 
children  and  adults  of  both  sexes  when  it  occurs  in  typical  aspect,  and  is 
undoubtedly  a  hypersernia  of  the  character  of  that  producing  the  rashes 
in  Simon's  triangles. 

When  the  variolous  exanthem  first  appears  the  practitioner  should 
secure  as  soon  as  practicable  a  history  of  the  invasion  stage  if  this  has 
not  been  subject  to  his  personal  observation.  He  should  then  make  care- 
ful inquiry  as  to  the  possibility  of  a  neighboring  source  of  contagion,  and 
ascertain  by  inspection  whether  the  person  of  the  patient  exhibits  the 
evidences  of  successful  vaccination.  In  this  connection  it  is  always  well 
to  estimate  the  value  of  the  elements  represented  by  (a)  the  period  ascer- 
tained as  having  elapsed  since  the  last  successful  vaccination ;  (6)  the 
typical  or  atypical  character  of  the  existing  cicatrices  of  vaccinia ;  (c)  the 
unicity  or  multiplicity  of  the  cicatrices  simultaneously  resulting  from 
vaccinations  performed  at  one  and  the  same  date. 

Without  question,  the  first  papular  lesions  of  variola  resemble  those  of 
rubeola  or  measles  to  an  extent  which  has  often  deceived  the  most  expert 
diagnosticians.  The  distinguishing  points  are — (1)  In  measles,  catarrhal 
symptoms  (conjunctival,  nasal,  laryngeal,  bronchial),  which  are  usually 
absent  in  the  early  stages  of  variola,  and  later  are  obviously  associated 
with  the  irritation  set  up  of  the  pustules  of  the  maturing  period.  (2) 
The  difference  in  the  temperature  record,  that  noted  in  the  invasion  stage 
of  variola  varying  from  104°  to  105°  F.,  Avhile  in  rubeola  it  is  rarely 
registered  above  103°  F.  Moreover,  in  typical  variola  the  defervescence 
is  marked  and  characteristic  on  the  appearance  of  the  exanthem,  while  in 
rubeola,  when  the  rash  appears,  the  temperature  is  usually  sustained  at  a 
maximum,  and  may  even  rise.  (3)  The  differences  in  the  rashes  of  the 
two  disorders.  The  papules  of  variola,  even  in  its  confluent  forms,  are, 
when  first  observed,  remarkably  discrete  and  exhibit  not  the  slightest 
tendency  to  grouping,  while  the  maculo-papules  of  rubeola  are  (a)  devel- 
oped simultaneously  on  the  face  and  trunk,  while  those  of  variola  com- 


DIAGNOSIS.  449 

mouly  appear  first  on  the  face  and  afterward  on  the  trunk,  the  older,  and 
larger  therefore,  in  the  site  of  earliest  appearance ;  (6)  are  set  in  clusters 
or  groups  having  a  distinct  tendency  to  crescentic  arrangement,  a  symptom 
decidedly  best  appreciated  by  the  eye  when  the  eruption  is  viewed  in 
totality  or  in  large  areas  with  the  eye  of  the  observer  somewhat  removed 
from  the  surface ;  (c)  are  often  made  to  disappear  or  pale  beneath  the 
pressure  of  the  finger,  while  there  is  greater  persistence  of  color  in  the 
variolous  papules ;  (d)  are  surrounded  by  little  or  no  halo,  each  element- 
ary lesion  of  the  eruption  being  abruptly  defined  upon  the  sound  skin, 
while  the  variolous  papule  is  apt  to  rest  upon  a  circlet  of  hypersernic 
integument. 

Even  with  careful  observation  of  all  the  specific  differences  between 
the  two  diseases,  they  may,  for  a  brief  time,  so  resemble  each  other  as  to 
defy  the  skill  of  the  expert.  In  all  doubtful  cases  the  physician  should 
invariably  admit  the  doubt  and  defer  an  exact  diagnosis  for  twenty-four 
hours.  During  the  delay  the  variolous  exanthem  should  betray  its  indi- 
viduality by  the  formation  of  a  minute  vesicular  apex  at  the  summit  of 
several  papules. 

In  scarlatina  the  uniform  diffusion  of  the  exanthematous  blush,  the 
absence  of  papules  and  vesico-papules,  the  continuance  of  the  fever  after 
the  rash  has  appeared,  the  characteristic  scarlet  or  boiled-lobster  color  of 
the  skin,  and  the  anginose  condition  of  the  throat,  are  all  significant 
symptoms.  In  hemorrhagic  small-pox  the  color  of  the  integument  is  a 
much  more  purplish  and  lurid-reddish  hue,  rapidly  reaching  that  stage 
where  it  refuses  to  pale  under  the  pressure  of  the  finger,  and  never  leav- 
ing in  the  track  of  the  finger-nail  quickly  drawn  over  its  surface  the 
peculiar  transitory  yellowish-white  line  which  can  be  usually  obtained  in 
the  skin  of  the  patient  with  scarlatina. 

The  pustular  stage  of  variola  might  be  confounded  with  the  pustular 
syphiloderm.  But  in  the  latter  there  should  be  a  history  of  a  chronic 
rather  than  of  an  acute  affection,  and,  as  a  result,  the  simultaneous 
appearance  of  lesions  in  very  different  stages  of  their  career,  some  dis- 
tended with  pus,  others  ruptured  and  crusted,  yet  others  which  have 
recently  formed  in  the  immediate  vicinity  of  the  oldest  lesions,  while  the 
latter  have  been  in  full  involution  or  have  been  replaced  by  superficial 
losses  of  tissue. 

The  resemblance  of  pustular  variola  to  certain  suppurative  and  other 
disorders  of  the  sebaceous  glands  is  well  attested  by  the  name  given  by 
certain  French  authors  to  molluscum  epitheliale  (M.  contagiosum,  IVf. 
sebaceum) — viz.  acne  varioliformis.  But  in  the  case  of  acneiform  dis- 
orders the  concurrence  of  comedones,  the  chronic  course  of  the  disease, 
the  absence  of  fever  and  systemic  disturbance,  and  the  particularly  irreg- 
ular distribution  of  the  lesions  upon  the  face,  with  failure  to  appear  else- 
where,— all  these  facts  forbid  the  confusion  of  the  affection  with  variola. 
In  medicamentous  acne,  accompanied  by  the  sudden  appearance  of  numer- 
ous pustular  lesions  symmetrically  displayed  upon  the  surface,  there  will 
indeed  be  a  source  of  error.  In  such  cases,  of  course,  a  history  of  the 
ingestion  of  a  medicament  capable  of  producing  a  rash  will  afford  valu- 
able aid  in  the  diagnosis.  In  pustular  forms  of  dermatitis  medicamen- 
tosa  there  will  usually  be  found  a  more  abundant  development  of  the 
pus-containing  lesions  upon  the  head  and  both  arms  and  forearms,  with 
VOL.  I.— 29 


450  VARIOLA. 

no  tendency  to  extension  over  very  large  areas  of  the  trunk  and  lower 
extremities — a  circumstance  which  a  delay  of  but  a  few  hours  will  often 
substantiate. 

The  absence  of  marked  defervescence  is  the  most  characteristic  differ- 
ence between  variola  in  its  eruptive  stage  and  typhus,  typhoid,  and 
relapsing  fevers.  Pneumonia,  cerebro-spinal  meningitis,  acute  miliary 
tuberculosis,  and  gastric  fever  are  all  to  be  differentiated  from  variola 
by  the  occurrence  of  symptoms  characteristic  of  the  involvement  of  the 
several  organs  which  in  these  diseases  respectively  are  more  particularly 
impaired. 

PROGNOSIS — The  prognosis  of  variola  is  wellnigh  inseparably  asso- 
ciated with  the  question  of  protection  by  vaccination.  Variola  vera  in 
the  unprotected  is  an  exceedingly  fatal  malady,  the  death-rate  varying  in 
different  epidemics  according  to  the  severity  of.  each  and  the  ages  and 
hygienic  surroundings  of  the  victims  of  the  disease.  Certainly,  from 
15  to  50  per  cent,  of  unprotected  individuals  affected  with  the  dis- 
ease occurring  in  epidemic  form  in  any  given  community  will  perish. 
This  number  may,  however,  be  enormously  increased,  as,  for  example, 
among  a  large  number  of  unprotected  negroes  crowded  together  in  a  filthy 
prison,  or  when  the  malady  makes  a  periodical  visitation  to  an  insular 
community  where  long  isolation  has  begotten  a  carelessness  with  respect 
to  vaccination. 

"With  respect  to  individual  cases  it  may  be  asserted,  first,  that  an  intense 
series  of  prodromic  symptoms,  followed  by  the  appearance  of  an 
unusually  large  number  of  cutaneous  lesions,  is  often  unfavorable.  Con- 
fluence of  the  latter  adds  to  the  gravity ;  hemorrhagic  and  purpuric 
symptoms  are  in  the  highest  degree  portentous,  and  commonly  indicate  a 
fatal  result.  Women  pregnant  or  in  the  puerperal  state,  infants  at  the 
breast,  and  persons  of  both  sexes  at  advanced  ages,  are  little  able  to 
resist  the  ravages  of  the  disease.  According  to  Kaposi,  women  recently 
delivered  prematurely  or  who  have  lately  suffered  from  an  abortion  suc- 
cumb more  often  than  others  of  their  sex.  Chronic  alcoholism  among 
male  subjects  and  the  cachexia  induced  by  all  chronic  visceral  and  sys- 
temic disorders  are  sources  of  weakness  which  largely  increase  the  death- 
list  by  adding  to  the  heavy  strain  upon  the  vital  energies.  The  prog- 
nosis is  rendered  uncertain  or  unpromising  by  extensive  involvement  of 
the  mucous  as  well  as  of  the  cutaneous  surfaces,  by  marked  visceral  com- 
plications, by  evidences  of  shock  or  exhaustion  before  the  apogee  of  the 
exanthem  is  reached,  by  grave  sequelfe,  and  even  by  simple  complications 
of  the  malady  when,  instead  of  entering  promptly  upon  convalescence, 
the  patient  lingers  for  weeks  in  a  typhoid  condition.  An  unfavorable 
symptom  in  any  case  is  the  sudden  cessation  of  the  processes  active-ly  pur- 
sued upon  the  surface  of  the  body.  The  swelling  of  the  integument  then 
suddenly  diminishes  and  the  crusts  by  which  it  was  covered  shrivel. 
The  eruption,  in  brief,  seems  to  undergo  what  may  be  described  as  a  col- 
lapse. The  pulse  at  such  moments  usually  flutters  feebly,  and  there  are 
other  portents  of  dissolution  which  the  eye  of  the  physician  will  hardly 
fail^  to  interpret  correctly.  The  fluids  in  such  instances  mechanically 
drain  away  from  the  surface  of  the  body  to  seek  the  deeper  parts.  This 
is  not  peculiar  to  small-pox.  Similar  phenomena  occur  even  in  the  case 
of  other  than  exudative  affections  of  the  skin.  In  pityriasis  rubra  the 


PROPHYLAXIS  AND   TREATMENT.  451 

patient  dies  leaving  an  integument  apparently  unaffected,  and  I  Lave 
seen  a  patient  dead  of  even  multiple  sarcoma  of  the  skin  when  the  tumors 
were  reduced  fully  one-half  in  bulk  as  the  result  of  a  similar  cause. 

On  the  other  hand,  the  practitioner  should  never  forget  that  even 
apparently  desperate  cases  of  variola  rally  and  are  wron  back  to  life. 
That  the  exudative  process  should  be  in  full  evolution  at  the  surface  of 
the  body  is,  cseteris  paribus,  certainly  so  far  a  good  omen.  The  most 
hideous,  extensive,  and  stench-emitting  crusts  have  hidden  for  a  time  the 
forms  that  have  for  many  subsequent  years  not  only  known  the  enjoy- 
ment of  life,  but  have  made  that  life  of  inestimable  value  to  others. 
The  physician  in  the  presence  of  this  most  loathsome  and  formidable  dis- 
ease should  never  despair. 

PROPHYLAXIS  AND  TREATMENT. — The  loftiest  end  to  be  reached  by 
the  physician  of  our  day  with  respect  to  variola  is  its  complete  removal 
from  all  civilized  countries,  and  indeed  from  the  face  of  the  earth,  by  the 
practice  of  universal  vaccination  and  revaccination.  The  evident  modifi- 
cations which  the  disease  has  undergone  in  late  years  as  a  consequence  of 
the  extraordinary  attention  given  to  this  subject  is  an  earnest  of  the 
future.  The  day  is  probably  not  far  distant  when  the  man,  woman,  and 
child  unprotected  by  vaccination  will  properly  be  regarded  as  an  enemy 
of  the  human  race,  and  treated  accordingly.  Evidences  of  the  most 
satisfactory  character  as  to  successful  vaccination  should  be  imperatively 
required  of  all  applicants  for  admission  to  schools,  academies,  colleges, 
charitable  institutions,  public  libraries,  art -galleries,  and  places  of  labor 
controlled  by  incorporated  institutions ;  of  all  members  of  conventions, 
legislatures,  political,  religious,  and  deliberative  bodies ;  of  every  pur- 
chaser of  a  ticket  for  purposes  of  travel ;  and  of  every  voter.  In  addi- 
tion, there  should  be  in  every  district  a  systematic  and  periodical  inspec- 
tion of  all  persons  registered  in  the  census  by  persons  qualified  and  com- 
petent to  perform  compulsory  vaccination.  This  is  the  scientific  treat- 
ment of  variola. 

Respecting  the  therapeutic  management  of  variola,  it  must  be  admitted 
that  there  are  no  remedies  known  to  exert  the  slightest  influence  in  either 
cutting  short  the  curriculum  of  the  disorder  or  in  checking  its  progress 
in  any  stage.  When  vaccination  is  practised  after  the  disease  is  fully 
developed,  the  two  disorders,  vaccinia  and  variola,  apparently  concur,  and 
proceed  pari  passu  to  the  evolution  peculiar  to  each.  Quinia,  the  sar- 
racenia  purpurea,  the  salicylate  of  sodium,  emetics,  diaphoretics,  purga- 
tives, and  other  remedies  and  methods  vaunted  as  efficacious,  have  again 
and  again  failed  to  establish  the  claims  which  have  been  put  forth  respect- 
ing the  value  of  each. 

The  most  important  of  the  considerations  to  be  regarded  at  the  outset 
of  the  management  of  the  small-pox  patient  relate  to  his  hygienic  sur- 
roundings and  nursing — considerations  which  scarcely  differ  from  those 
recognized  as  of  general  importance  in  the  case  of  all  septic,  contagious, 
and  filth-producing  diseases. 

The  timid,  the  fearful,  and  the  unprotected  are  to  be  at  once  dismissed 
from  the  bedside,  and  trustworthy  attendants  secured'  who  have  received 
protection  by  either  recent  vaccination  or  a  prior  attack  of  the  malady. 
The  sick  chamber  should  be  sufficiently  large  and  capable  of  the  most 
thorough  ventilation  by  free  access  of  air.  Solar  light  should  be  excluded 


452  VARIOLA. 

as  rigidly  and  completely  as  possible,  since  it  is  reasonably  certain  that 
its  access  to  the  face  has  an  etiological  relation  to  the  pitting  of  that  part, 
often  the  most  serious  sequel  of  the  affection.  It  is  an  interesting  fact 
that  pitting  is  much  less  frequently  noted  on  those  parts  of  the  body 
from  which  light  is  excluded  by  the  covering  of  the  clothing.  The 
temperature  of  the  sick  room  during  the  febrile  stages  of  the  disorder 
should  not  rise  above  70°  F.  nor  be  permitted  to  fall  below  60°  F. 
Between  these  extremes  a  variation  may  be  made  in  accordance  with  the 
sensations  of  the  patient. 

During  the  invasion  stage  of  the  disease  the  patient  can  rarely  assimi- 
late food,  but  if  this  be  possible  it  should  be  given  throughout  the  entire 
course  of  the  disease  in  the  form  of  animal  broths,  eggs,  nutritious  soups, 
and  milk.  Iced  and  acidulated  beverages  are  often  grateful  to  the  palate, 
and  small  lumps  of  ice  should  be  permitted  to  dissolve  slowly  in  the 
mouth.  Lime-water  may  be  required  by  unusual  gastric  irritability. 
As  the  disease  progresses  and  the  palate  and  buccal  membrane  become 
painful  and  sore  by  reason  of  the  localization  there  of  pustular  and  other 
lesions,  various  mouth-washes  and  gargles  may  be  ordered,  such  as  those 
containing  the  chlorate  of  potassium,  the  tincture  of  myrrh,  the  tincture 
of  cinchona,  or  even  the  milder  demulcent  fluids  made  by  the  addition 
of  flaxseed,  gum  acacia,  or  powdered  elm-bark  to  water.  In  almost  all 
such  cases  the  skilled  nurse  will  accomplish  a  grateful  result  by  fre- 
quently cleansing  the  mouth  of  the  sufferer  (especially  before  the  deglu- 
tition of  aliments)  by  covering  the  finger  with  a  soft  handkerchief, 
dipping  it  in  pure  hot  water,  and  then  thoroughly  and  gently  cleansing 
the  entire  buccal  cavity.  The  spray  of  a  saturated  solution  of  boracic 
acid  in  rose-water  may  then  be  directed  over  the  parts. 

Applications  of  cool  and  iced  water  to  the  skin  are  commonly  grateful, 
and,  as  a  rule,  are  accompanied  by  no  danger  to  the  patient,  though  in  the 
early  periods  of  the  disease  they  unquestionably  retard  the  full  evolution 
of  the  cutaneous  symptoms.  For  the  pain  in  the  back,  therefore,  which 
is  often  the  most  urgent  symptom  of  the  invasion  stage  of  the  disease,  it 
«s  usually  preferable  to  make  hot  applications.  The  large  rubber  bags 
now  in  common  use,  filled  with  hot  water  and  from  time  to  time  applied 
to  the  lumbar  region,  may  be  employed  with  good  effect  simultaneously 
with  iced,  spirituous,  or  camphorated  applications  to  the  head. 

Numerous  indeed  have  been  the  topical  applications  made  to  the 
surface  of  the  skin  in  the  pustular  stage  of  the  malady,  both  with  a 
view  to  assuage  the  soreness  and  pain  and  to  obviate  the  tendency  to 
pitting.  The  opening  of  the  pustules  and  the  evacuation  of  their  con- 
tents (practicable  only  in  other  than  confluent  forms  of  the  disease)  has 
been  practised  from  an  early  date,  but  is  ineffectual  from  the  standpoint 
of  any  practical  results  thus  obtainable.  The  same  may  be  said  of  the 
subsequent  cauterization  of  the  floor  of  the  pustular  chamber,  which  only 
adds  to  the  distress  experienced  by  the  sufferer  in  his  skin.  Medicated 
unguents,  applied  to  the  skin,  containing  mercury,  iodine,  and  other  sub- 
stances, are  not  known  to  be  followed  by  any  better  results.  It  may  in- 
deed be  laid  down  as  a  general  rule  that  fatty  applications  to  pus-producing 
surfaces  where  the  pathological  product  is  virulent  are  apt  to  undergo 
decomposition  and  otherwise  act  unfavorably  upon  the  tissues — a  fact 
first  pointed  out  by  Ricord  in  connection  with  the  treatment  of  the  chan- 


PROPHYLAXIS  AND  TREATMENT.  453 

croid.     Vaseline,  as  not  liable  to  undergo  chemical  decomposition,  is  not 
open  to  this  objection. 

Curschmann,  Kaposi,  and  other  authors  are  in  agreement  respecting 
the  value  of  water-compresses  over  the  surfaces  invaded  by  the  eruption 
— a  method  of  topical  treatment  which  I  desire  to  fully  endorse  after 
personal  observation  of  its  value.  Curschmann  recommends  compresses 
dipped  in  iced,  Kaposi  those  moistened  with  tepid  water.  The  sensation 
experienced  by  the  patient  will  prove  the  best  guide  to  the  temperature 
of  this  fluid.  I  prefer  a  solution  containing  one  drachm  of  boracic  acid 
to  the  pint  of  water  as  hot  as  can  be  discovered  to  be  productive  of  com- 
fort, a  drachm  or  two  of  glycerine  being  added  to  the  solution.  The 
compresses  dipped  in  this  (or  a  carbolated  solution,  if  the  latter  is  pre- 
ferred by  either  physician  or  patient)  should  be  assiduously  moistened 
and  changed  regularly  by  the  attendants  just  as  long  as  they  can  accom- 
plish good.  They  operate,  first,  by  protecting  the  part ;  second,  by  keep- 
ing it  moist ;  third,  by  maintaining  the  surface  temperature  at  the  point 
most  pleasant  to  the  patient ;  fourth,  by  exercising  the  gentlest  degree  of 
equable  compression  over  the  surface.  When  desired,  this  may  be  covered 
with  the  Lister  protective  material  or  a  piece  of  oiled  silk  to  prevent 
evaporation  at  the  surface. 

In  Vienna  warm  baths,  administered  either  by  the  process  of  continu- 
ous immersion  so  generally  practised  there  or  by  immersion  for  from  two 
to  three  hours  of  each  day,  have  been  found  to  furnish  the  greatest  amount 
of  comfort  to  the  patient.  The  skin  is  thus  speedily  relieved  of  its 
tension,  the  exfoliation  of  the  crusts  is  hastened,  and  the  time  required 
for  the  evolution  of  the  cutaneous  lesions,  if  not  shortened,  is  at  least  not 
retarded  by  the  accidents  of  exposure  to  the  desiccating  influences  of  the 
air — ends  which  for  the  patient  are  practically  one.  In  this,  country,  and 
especially  in  private  practice  outside  the  larger  charities  with  their  ampler 
provision  for  these  emergencies,  nearly  the  same  result  may  be  reached  by 
wrapping  the  patient  completely  in  sheets  wrung  out  of  water  of  the 
temperature  desired. 

From  first  to  last  in  the  treatment  of  variola,  all  indications  should  be 
made  subordinate  to  that  most  prominently  set  forth  by  the  general 
character  of  the  symptoms — viz.  the  conservation  by  every  possible 
means  of  the  vigor  of  the  patient.  The  tax  upon  all  reserves  of  vital 
energy  is  here  so  enormous  and  constant  that  he  will  gravely  err  who  for 
a  moment  loses  sight  of  this  fact.  Hence  it  is  that  anodynes,  chloral, 
opium  and  its  alkaloids,  the  bromide  of  potassium,  and  similar  medica- 
ments, introduced  either  by  tli£  stomach  or  by  hypodermic  injection,  are 
to  be  jealously  reserved  for  emergencies  when  it  would  seem  cruel  to 
withhold  the  temporary  comfort  they  may  impart.  Stimulants  are  of  course 
to  be  freely  employed  whenever  they  are  indicated  by  exhaustion  as  this 
may  be  shown  by  a  weak  pulse  and  other  failing  functions  of  the  body, 
but  are  certainly  best  reserved  for  such  emergencies.  In  general,  it  may 
be  remarked  that  the  fewer  the  medicaments  ingested  by  the  stomach,  and 
the  larger  the  restriction  of  the  labor  of  this  organ  to  the  task  of  sus- 
taining the  nutrition  of  the  body,  the  better  are  the  chances  of  a  favorable 
issue. 

It  is  unnecessary  to  add  that  all  other  indications  presented  in  any  given 
case  are  to  be  met,  subject  to  the  conditions  indicated  above.  Abscesses 


454  VARIOLA. 

are  to  be  opened  and  antiseptically  treated;  delirious  patients  are  to 
be  sedulously  prevented  from  doing  themselves  injury;  daily  move- 
ments of  the  bowels  are  to  be  secured;  while  the  diarrhoea  of  the 
typhoid  state,  occasionally  resulting  from  the  exhausted  condition  of  the 
system  when  the  force  of  the  disease  is  spent,  demands  proper  control. 

Cleanliness  is  to  be  enforced  by  every  judicious  measure.  The  skin  of 
the  patient  is  to  be  washed  in  tepid  water  and  soap  as  often  as  practicable 
in  the  course  of  the  disease,  and  under  no  circumstances  are  applications 
of  ointments,  washes,  or  lotions  to  be  allowed  to  collect  in  strata  upon  the 
surface  commingled  with  the  pus  and  crusts  of  the  disease.  At  the  time 
of  such  ablution,  and  occasionally  oftener,  the  linen  and  other  garments 
of  the  patient  are  to  be  changed.  When  the  crusts  are  regularly  exfoliat- 
ing from  the  surface  of  the  body  general  warm  baths  may  be  ordered, 
after  each  of  which  the  surface  of  the  body  may  be  anointed  with  vaseline 
or  covered  with  a  finely-sifted  dusting-powder,  such  as  the  corn-starch 
farina  sold  by  grocers. 

Inasmuch  as  hemorrhagic  variola  is  usually  hopeless  in  character,  and 
remedilessly  fatal,  Kaposi's  liberal  use  of  opiates  may  be  recommended 
when  euthanasia  is  all  that  can  be  expected.  So  long  as  there  is  the 
narrowest  chance  of  recovery  resort  may  be  had  to  ergot,  turpentine  and 
the  mineral  acids  internally,  combined  with  the  external  use  of  styptics 
and  ice.  But  little  confidence  can,  however,  be  placed  in  these  measures, 
which  will  prove  entirely  ineffective  in  the  great  majority  of  all  cases. 

In  all  fatal  cases  of  variola  the  duties  of  the  physician  are  not  ended  by 
the  death  of  the  patient.  It  is  for  the  benefit  of  the  living  that  he  should 
require  destruction  or  disinfection  and  long  disuse  of  all  domestic  articles 
that  were  employed  upon  or  about  the  patient.  The  lifeless  body  should 
be  disposed  of  by  cremation,  and  medical  men  should  exert  their  influ- 
ence in  favor  of  legal  enforcement  of  such  a  wholesome  practice. 


VACCINIA. 

BY  FRANK  P.  FOSTER,  M.  D. 


SYNONYMS. — Vaccina,  Variolas  vaccinae  (Jenner),  Cow-pox,  Cow- 
pock,  Kine-pox,  Kiue-pock;  Fr.  Vaccine;  Ger.  Kuhpocken,  Schutz- 
pocken,  Impfpocken,  Schutzblattern ;  It.  Vaccina ;  Sp.  Vacuna. 

DEFINITION. — An  eruptive  disease  characterized  by  a  cutaneous  lesion 
closely  resembling  that  of  small-pox,  going  through  the  stages  of  papu- 
lation,  vesiculation,  pustulation,  incrustation,  and  cicatrization ;  differing 
from  small-pox  in  the  mildness  or  almost  total  absence  of  the  constitu- 
tional symptoms,  by  being  communicable  only  by  inoculation,  and  by  the 
fact  that  the  lesions,  as  a  rule,  are  developed  only  at  the  points  of  inocu- 
lation and  in  their  immediate  neighborhood. 

This  definition  holds  good  for  the  great  majority  of  cases,  but  in  each 
of  its  parts  we  must  take  account  of  exceptions.  For  example,  the  lesion 
does  not  always  follow  the  regular  sequence  of  changes  described.  It 
may  stop  short  at  the  stage  of  papulation,  constituting  the  so-called 
raspberry  excrescence,  which  will  be  further  referred  to  hereafter ;  it  may 
pass  directly  from  the  stage  of  vesiculation  into  that  of  incrustation, 
without  any  such  change  in  its  liquid  contents  as  can  properly  be  said  to 
form  a  pustule ;  desquamation  may  take  the  place  of  incrustation ;  and, 
after  an  evolution  otherwise  normal,  there  may  be  no  formation  of  a  scar, 
simply  because  the  destructive  effect  of  the  lesion  has  not  extended 
deeper  than  the  epidermis.  The  constitutional  symptoms  are  sometimes 
severe,  but  they  are  always  of  very  short  duration.  The  disease  is  said 
to  have  been  communicated  otherwise  than  by  inoculation  in  the  case  of 
some  of  the  lower  animals.  Thus,  Chauveau  succeeded  in  producing 
some  of  its  phenomena  in  the  horse  by  causing  the  virus  to  be  inhaled  in 
the  form  of  spray.  It  is  doubtful,  however,  if  it  is  possible  to  eliminate 
all  sources  of  fallacy  in  such  experiments.  Finally,  a  generalized  erup- 
tion is  occasionally  observed,  although  with  great  rarity.  In  stating  these 
exceptions  no  reference  is  intended  to  cases  in  which  complications  occur. 

NATURE  OF  THE  DISEASE. — Many  considerations  warrant  us  in  class- 
ing cow-pox  among  the  varioliform  diseases — chiefly  its  general  resem- 
blance to  variola,  and  the  fact  that  individuals  who  have  been  affected  by 
it  are  thereby  more  or  less  fully  protected  against  small-pox.  It  has 
been  thought,  indeed,  that  cow-pox  was  in  reality  but  a  modified  form  of 
small-pox ;  and  this  idea  has  been  the  basis  of  one  of  the  theories  that 
have  been  held  as  to  the  origin  of  vaccinia.  Before  enumerating  and 
discussing  those  theories  it  will  be  well  to  mention  that  cow-pox  is 
spoken  of  as  spontaneous,  casual,  or  inoculated,  according  to  its  mode  of 
origin,  known  or  assumed,  in  individual  instances. 

455 


456  VACCINIA. 

Spontaneous  or  original  cow-pox  is  the  name  commonly  applied  to  the 
disease  as  it  is  met  with  in  the  cow  in  instances  in  which  its  mode  of  ori- 
gin is  unknown.  Strictly  interpreted,  this  expression  implies  a  belief 
that  the  affection  is  capable  of  being  developed  in  a  cow  independently 
of  contagion  or  infection — u  notion  that  seems  to  be  held  by  many  phy- 
sicians, but  not,  so  far  as  the  writer  is  aware,  by  those  whose  study  of 
the  subject  has  been  such  as  to  lend  any  considerable  weight  to  their 
opinions.  Ordinarily,  however,  the  term  spontaneous  cow-pox  is  em- 
ployed simply  as  a  convenient  expression  to  denote  the  disease  as  it 
occurs  naturally  in  cows,  without  implying  any  belief  or  theory  as  to  its 
mode  of  origin. 

Casual  cow-pox  is  the  term  applied  in  cases  that  have  been  contracted 
by  accidental  inoculation,  whether  in  the  cow  or  in  man.  It  is  manifest 
that  the  so-called  spontaneous  cases  are  really  casual,  unless  we  accept  the 
doctrine  that  infection  is  not  necessary  to  the  development  of  the  disease. 

The  term  inoculated  cow-pox  implies  that  the  affection  has  been  pro- 
duced by  intentional  inoculation.  Here,  again,  we  are  confronted  with 
an  illogical  expression,  for  a  disease  that  is  inoculated  accidentally  is  still 
inoculated,  as  much  as  if  it  had  been  conveyed  purposely.  It  may  be 
said,  indeed,  that  the  casual  disease  is  due  to  some  other  form  of  infection 
than  inoculation,  but  for  such  an  assertion  there  is  not  a  particle  of 
proof. 

Passing  from  this  unsatisfactory  nomenclature  to  a  consideration  of  the 
theories  that  have  been  held  as  to  the  nature  of  cow-pox,  we  are  first 
met  with  that  of  its  being  a  disease  sui  generis,  like  small-pox,  measles, 
scarlet  fever,  and  the  like,  and,  like  them,  originating  only  by  its  own 
specific  contagion,  not  being  capable  of  development  by  a  modification  of 
any  other  contagion,  however  closely  it  may  thus  be  counterfeited.  This 
seems  the  most  rational  theory  of  the  nature  of  cow-pox,  but  it  cannot 
be  demonstrated  except  by  disproving  all  opposing  theories;  and  that 
has  not  yet  been  accomplished. 

Another  theory  is,  that  cow-pox  is  really  small-pox  modified,  as  the 
phrase  runs,  "  by  passing  through  the  system  of  the  cow."  It  has  been 
thought  possible,  indeed,  to  specify  in  what  way  the  coVs  system  could 
impress  such  decided  changes  upon  the  virulent  disease  small-pox  as  to 
convert  it  into  the  mild  aifection  that  we  know  as  vaccinia ;  in  other 
words,  it  has  been  imagined  that  the  function  of  lactation  accomplished 
this  remarkable  result.  This  notion  may  have  been  due  to  the  observation 
that  so-called  spontaneous  cow-pox  is  met  with  only  in  cows  that  are  in  milk. 
The  significance  of  this  fact,  however,  is  really  nothing  more  than  that 
cows  in  milk  are  more  exposed  to  accidental  inoculation  than  other 
bovine  animals — namely,  at  the  hands  of  the  milkers.  The  fact  that  in 
such  cases  the  lesions  are  almost  always  confined  to  the  teats  and  the 
udder,  far  from  affording  any  ground  for  the  notion  that  there  is  some 
mysterious  connection  between  cow-pox  and  the  function  of  lactation,  is 
but  another  proof  that  the  disease  is  the  result  of  inoculation.  The 
lesions  appear  at  the  points  of  inoculation,  the  teats  and  the  udder  being 
the  parts  handled  by  the  milkers.  Moreover,  there  is  no  difficulty  in 
inoculating  young  calves  or  adult  bulls,  and  the  lesions  so  produced  do 
not  vary  in  a  single  particular  from  those  observed  in  so-called  spon- 
taneous cases. 


NATURE  OF  THE  DISEASE.  457 

Men  have  been  so  carried  away  with  this  milk  theory,  however,  as 
even  to  believe  that  the  virus  of  small-pox  might  be  shorn  of  its  dan- 
gerous properties,  so  that  it  would  produce  only  the  vacciual  lesion  when 
inoculated  simply  by  mechanical  mixture  with  milk.  During  the  late 
Civil  War  one  of  the  Confederate  Army  surgeons  actually  put  this  notion 
to  the  test  of  practice  on  quite  a  large  scale,  inoculating  large  numbers  of 
persons  with  a  mixture  of  small-pox  virus  and  milk,  terming  the  prac- 
tice mitigated  inoculation.  We  can  scarcely  suppose  that  he  did  any- 
thing else  than  variolate  these  persons,  just  as  he  would  have  done  had 
he  used  variolous  lymph  without  the  addition  of  milk.  His  experiments 
show  nothing  new ;  they  merely  furnish  a  recent  confirmation  of  the 
well-known  fact,  familiar  to  the  old  iuoculators,  that  inoculated  small- 
pox is  sometimes  exceedingly  mild  iu  a  series  of  cases. 

This  theory  of  the  variolous  origin  of  cow-pox,  and  of  the  practica- 
bility of  converting  small-pox  into  cow-pox  at  will  by  "passing  it 
through  the  system  of  the  cow,"  has  taken  deep  root  in  the  minds  of 
men,  especially  in  Great  Britain,  where  the  late  Mr.  Ceely's  experiments 
and  Mr.  Badcock's  experience  seemed  to  give  it  some  color,  Some  years 
ago,  however,  the  question  was  investigated  most  practically  and  thor- 
oughly by  a  commission  appointed  for  the  purpose  by  one  of  the  medical 
societies  of  Lyons,  Chauveau  being  the  recorder.  Their  conclusion 
was — and  their  reasoning  seems  to  the  present  writer  incontrovertible — 
that  small-pox  and  cow-pox  were  wholly  distinct  from  each  other  under 
all  circumstances,  and  that  it  was  impossible  to  convert  the  one  into  the 
other.  But  the  doctrines  of  the  English  investigators,  reinforced  as  they 
were  by  the  ingenious  arguments  of  the  late  Dr.  Seaton,  were  not  easily 
to  be  overturned  in  their  own  country  or  in  America ;  consequently,  the 
practice  of  variolating  cows  has  been  resorted  to  from  time  to  time  for 
the  purpose  of  obtaining  a  stock  of  vacciual  virus  of  unquestionable 
authenticity — the  so-called  variola  vaccine.  This  practice  is  utterly  falla- 
cious, and  it  is  also  dangerous,  since  the  disease  so  produced,  however 
mild  it  may  seem  to  be,  is  nothing  more  nor  less  than  small-pox,  with 
its  infectiousness  by  effluvium  and  its  liability  to  prove  serious  even 
when  carefully  inoculated. 

Quite  recently  the  experimental  investigation  of  the  question  has  been 
undertaken  de  novo  by  a  well-known  English  veterinarian,  Mr.  Fleming ; 
and,  since  his  conclusions  coincide  with  those  of  the  Lyonnese  commis- 
sion, it  is  to  be  hoped  that  we  have  seen  the  last  of  this  rough-and-ready 
method  of  improvising  a  case  of  genuine  cow-pox — a  method  that,  in  the 
light  of  our  present  knowledge,  can  only  be  characterized  as  downright 
malpractice. 

The  third  and  last  theory  we  have  to  consider  is  that  which  ascribes 
the  origin  of  cow-pox  to  infection  from  the  horse.  So  far  back  as  Jenner's 
time  it  was  conjectured  that  cow-pox  was  due  to  the  accidental  conveyance 
of  the  virus  of  the  grease  (the  eaux-aux-jambes  of  the  French)  by  reason 
of  the  cows  being  milked  by  persons  who  were  also  employed  in  the  care 
of  horses  affected  with  that  disease.  Grease  is  an  eruptive  disease  of 
horses'  heels.  Doubtless  it  has  often  been  confounded  with  a  mere 
eczematous  affection  by  those  who  have  repeatedly  failed  in  their  persist- 
ent attempts  to  inoculate  cows  with  it,  and,  on  the  other  hand,  a  localized 
eruption  of  horse-pox  may  have  been  mistaken  for  it  by  those  who  have 


458  VACCINIA. 

supposed  themselves  to  have  succeeded  in  producing  cow-pox  by  inocu- 
lating cows  with  the  virus  of  grease,  and  have  consequently  given  in  their 
adhesion  to  the  grease  theory  of  the  origin  of  cow-pox.  At  all  events, 
so  far  as  the  writer  is  aware,  that  theory  is  not  now  held  by  any  well- 
informed  writer. 

Still  regarding  the  horse  as  the  originator  of  cow-pox,  we  must  turn 
our  attention  to  horse-pox  (equinia).  Several  years  ago  Depaul  of 
Paris  took  great  pains  to  establish  the  fact  that  horse-pox  (an  affection 
totally  distinct  from  grease)  was  an  eruptive  febrile  disease  of  horses,  an 
exauthem ;  that  the  eruption  was  generalized,  and,  being  for  the  most 
part  concealed  by  the  hair,  generally  overlooked ;  and  that  it  was  capable 
of  being  conveyed  by  inoculation,  the  lesion  being  indistinguishable  from 
that  of  cow-pox.  He  believed  himself  to  have  demonstrated  also  that  it 
was  the  contagion  of  horse-pox  that  gave  rise  to  cow-pox  in  the  cow. 

Depaul's  investigations  were  very  keen  and  his  conclusions  were  exceed- 
ingly plausible,  but  they  cannot  be  called  convincing,  notwithstanding 
the  fact  that  Constantiu  Paul  succeeded  for  a  time  in  popularizing 
a  stock  of  horse-pox  virus  as  material  for  vaccination.  At  about  the 
same  time  the  Beaugency  case  of  cow-pox  was  discovered,  and  the  per- 
fectly satisfactory  use  that  has  been  made  of  that  stock  niay  have  thrown 
Depaul's  theories  and  Paul's  practice  undeservedly  into  the  back- 
ground. 

We  can  only  say,  in  summing  up,  that  the  small-pox  theory  is  utterly 
untenable,  that  the  horse-pox  theory  has  not  been  disproved,  and  that  the 
theory  that  regards  cow-pox  as  derived  neither  from  small-pox  nor  from 
horse-pox,  but  as  a  disease  sui  generis,  although  not  proved,  is  the  most 
rational  of  all,  and  the  most  in  keeping  with  known  facts. 

ETIOLOGY. — Nearly  everything  that  could  be  said  under  this  head  has 
already  been  considered.  It  may  be  added  that  meteorological  conditions 
have  been  supposed  to  favor  the  prevalence  of  the  disease  among  cows. 
More  precise  observations  are  needed  to  enable  us  to  determine  whether 
or  not  there  is  any  truth  in  this  supposition.  It  has  been  said  that  the 
affection  is  most  apt  to  prevail  during  warm  and  moist  seasons.  This  is 
contrary  to  what  we  might  have  imagined,  as  warmth  and  moisture  are 
quite  destructive  of  the  vaccinal  virus.  Under  ordinary  circumstances, 
however,  the  contagium  often  proves  wonderfully  tenacious  of  life,  and 
the  disease,  once  introduced  among  a  herd  of  cows,  is  prone  to  linger  for 
months,  or  even  years,  attacking  animals  recently  added  to  the  stock  and 
young  cows  during  their  first  lactation.  As  has  already  been  stated,  age, 
sex,  and  parturition  can  be  regarded  as  etiological  factors  only  in  so  far 
as  they  favor  the  occurrence  of  accidental  inoculation.  In  the  human 
subject  vaccinia  occurs  generally  as  the  result  of  intentional  inoculation, 
as  will  be  more  fully  referred  to  when  we  come  to  the  consideration  of 
vaccination.  Insusceptibility  is  occasionally  met  with,  both  in  the  cow 
and  in  man,  but  it  is  very  rare.  Perhaps  it  may  be  explained  in  some 
instances  by  the  subject  having  really  had  the  disease,  or  indeed  small- 
pox, either  before  or  after  birth,  in  so  mild  a  form  as  not  to  have  left  the 
characteristic  marks.  Certain  it  is  that  the  lesion  does  not  always  leave 
a  permanent  scar,  especially  in  the  cow. 

GENERAL  COURSE  OF  THE  DISEASE. — This  is  best  studied  in  cases 
that  have  followed  intentional  inoculation,  for  here  we  know  the  chrono- 


GENERAL  COURSE  OF  THE  DISEASE.  459 

logical  sequence  of  events.  Depending  somewhat  upon  the  method  of 
inoculation,  and  perhaps  also  to  some  extent  upon  the  state  of  the  skin  at 
the  site  of  the  inoculation,  or  even  upon  a  systemic  condition  (since  some 
vacciuators  hail  it  as  a  harbinger  of  success),  at  the  time  of  the  operation 
a  ring-like  erythema  may  be  seen  surrounding  the  inoculation.  This  is 
exceedingly  evanescent,  being  doubtless  due  to  vaso-motor  action,  and  is 
not  often  witnessed. 

Ordinarily,  no  effect  whatever  'is  observed  until  after  the  lapse  of  two 
or  three  days,  when  a  red  papule  is  formed.  This  papule  increases  in 
superficial  area,  but  not  in  height,  and  gradually  loses  its  redness.  It 
assumes  a  circular  form,  or,  in  the  case  of  a  compound  pock  (for  that  is 
the  proper  name  for  the  lesion),  a  configuration  representing  segments  of 
several  circles,  and  as  it  increases  in  area  it  becomes  more  and  more 
raised  at  the  border  (the  bourrelet  of  French  writers),  while  the  central 
portion,  which  also  increases  in  size  pari  passu  with  the  peripheral 
annular  vesicle,  does  not  become  more  elevated,  but  remains  depressed, 
giving  the  pock  as  a  whole  the  peculiar  shape  termed  umbilicatiou.  Up 
to  the  eighth  or  tenth  day,  inclusive,  the  marginal  elevation  contains  a 
limpid  fluid  termed  lymph,  and  consequently  presents  a  pearl-like  lustre. 
At  this  period  a  rather  sudden  increase  takes  place  in  the  corpuscular 
elements  contained  in  the  lymph,  causing  that  liquid  to  become  thick  and 
opaque,  so  that  the  elevated  margin  of  the  pock,  which  before  had  shown 
the  pearl-like  lustre  alluded  to,  now  comes  to  look  as  if  made  of  tallow. 

At  the  same  time  what  is  known  as  the  areola  forms  around  the  pook, 
and  constitutional  symptoms  show  themselves.  The  areola  is  a  circum- 
scribed redness  of  the  skin,  perfectly  circular  in  form  and  of  five  or  six 
times  the  diameter  of  the  pock  itself.  It  is  sharply  defined  and  of  a 
vivid  red  hue.  Usually  it  is  a  mere  hypersemia  of  the  skin,  but  in  some 
instances,  especially  where  the  process  of  pock-formation  is  decidedly 
pronounced,  a  few  papillary  elevations  are  to  be  seen  in  the  immediate 
neighborhood  of  the  pock,  and  at  that  situation  there  may  also  be  some 
lividity.  After  a  few  hours'  persistence  in  the  form  of  a  disc  the  areola 
begins  to  disappear,  the  redness  fading  first  at  the  central  portion,  so  that 
in  its  declining  stage  it  assumes  the  shape  of  a  ring  which  constantly 
grows  narrower  and  narrower  at  the  expense  of  its  inner  portion,  and 
finally  disappears  altogether.  In  the  cow  the  areola  is  only  a  faint  line 
immediately  around  the  pock. 

Constitutional  symptoms  are  invariably  present  in  cases  that  follow 
the  regular  couse.  The  temperature  rises  one  or  two  degrees  Fahrenheit, 
the  appetite  becomes  impaired,  and  sleep  is  somewhat  disturbed.  In 
many  cases,  mostly  those  of  secondary  inoculation,  the  symptoms  are 
more  severe  ;  the  fever  runs  higher,  and  may  be  accompanied  with  tran- 
sient delirium  ;  nausea  is  experienced,  perhaps  with  actual  vomiting ; 
and  severe  pain  is  felt  in  the  head  and  along  the  spine,  the  latter  being 
most  marked  in  the  cervical  region.  These  symptoms  usually  last  but  a 
few  hours,  and  they  are  apt  to  be  accompanied  by  a  modification  of  the 
areola  whereby  it  loses  its  disc-like  outline  and  becomes  diffused  irregu- 
larly, especially,  if,  as  is  usual,  the  inoculation  has  been  done  on  the  arm, 
in  a  downward  direction  toward  the  elbow. 

Along  with  these  phenomena  intense  itching  is  often  felt  at  the  situa- 
tion of  the  pock,  being  an  aggravation  of  the  pruritus  that  in  a  mild 


460  VACCINIA. 

form  accompanies  the  greater  part  of  the  whole  course  of  the  lesion. 
Supposing  the  arm  to  have  been  inoculated,  the  lymphatic  glands  of  the 
axilla  now  become  swollen  and  tender,  but  their  suppuration  is  unusual, 
and  is  to  be  regarded  as  a  complication. 

To  go  back  to  the  pock :  some  time  before  the  contents  of  the  margi- 
nal elevation  become  opaque  the  central  portion  is  converted  into  a  crust 
of  a  brownish  color,  and  finally,  from  the  tenth  to  the  fifteenth  day,  the 
bourrelet  itself,  having  ceased  to  increase  in  size,  takes  part  in  the  pro- 
cess of  incrustation,  the  completed  crust  representing  the  form  of  the 
pock,  having  a  circular  ridge  at  the  border,  at  which  part  its  color  is  not 
so  deep  as  at  the  centre.  The  crust  usually  falls  oif  between  the  fifteenth 
and  the  thirty-fifth  day.  It  is  hard,  translucent,  and  of  a  prune-juice 
color ;  thick  at  the  centre  and  thin  at  the  periphery ;  smooth  on  its 
attached  surface  and  somewhat  wrinkled  on  its  outer  aspect ;  surmounted 
at  the  centre  by  the  epidermal  debris  produced  by  the  operation  of  inoc- 
ulation, mingled  perhaps  with  more  or  less  dried  blood. 

After  the  crust  falls  off  a  reddened  surface  is  left  of  a  cicatricial  nature, 
usually  somewhat  depressed  below  the  level  of  the  surrounding  skin,  and 
frequently  showing  lesser  pits,  which  latter  appearance  is  termed  foveola- 
tion.  Instead  of  these  pits,  radiated  striae  are  frequently  left.  Gradu- 
ally the  scar  loses  its  red  color,  and,  like  other  scars,  finally  becomes  paler 
than  the  surrounding  skin.  It  is  usually  permanent. 

IRREGULARITIES  ix  THE  COURSE  OF  THE  DISEASE. — Ever  since  cow- 
pox  first  became  the  subject  of  medical  study  deviations  from  its  typical 
course  have  been  noticed,  and  have  been  the  theme  of  a  good  deal  of 
speculation.  The  older  writers,  indeed,  bestowed  no  little  attention  upon 
what  they  considered  to  be  not  irregular  forms  of  vaccinia,  but  distinct 
affections  with  which  it  was  liable  to  be  confounded.  Their  descriptions 
of  these  diseases,  which  they  termed  spurious  cow-pox,  are,  however,  so 
vague  as  to  possess  but  little  more  than  an  historical  interest.  In  regard 
to  affections  met  with  casually  in  the  cow,  we  can  often  determine  their 
nature  only  by  test-inoculations,  and  even  that  criterion  is  not  always 
thoroughly  convincing ;  for,  on  one  account  or  another,  we  may  fail  in 
the  attempt  to  propagate  true  cow-pox,  and  on  the  other  hand,  if  we 
admit  that  there  is  a  radical  difference  between  cow-pox  and  small-pox,  it  is 
manifest,  bearing  in  mind  the  errors  into  which  experienced  investigators 
have  fallen,  that  we  may  propagate  small-pox  through  a  long  series  of 
experiments  without  once  suspecting  it  to  be  anything  but  cow-pox.  We 
may,  nevertheless,  always  determine,  provided  we  succeed  at  all,  whether 
we  are  dealing  with  a  disease  that  protects  against  vacciual  and  variolous 
inoculation. 

In  the  human  subject  we  seldom  meet  with  affections  that  counterfeit 
vaccinia,  although,  if  we  take  only  the  lesion  into  consideration,  there 
are  certain  contagious  forms  of  herpes  that  may  give  rise  to  doubt,  and 
possibly  the  same  may  be  true  of  impetigo  contagiosa. 

Turning,  then,  to  the  irregularities  properly  so  called,  we  have  first  to 
consider  the  absence  of  constitutional  infection.  This  must  not  be  con- 
founded with  the  mere  lack  of  obvious  constitutional  symptoms ;  what 
is  meant  by  the  expression  is,  that  in  certain  instances  the  local  lesion 
may  appear  typical,  and  yet  no  such  impression  be  made  upon  the  sys- 
tem as  to  render  it  proof  against  subsequent  inoculation.  Early  in  the 


IRREGULARITIES  IN  THE  COURSE  OF  THE  DISEASE.'       461 

century  the  possibility  of  this  lack  of  systemic  infection  was  insisted 
upon  by  Mr.  Bryce  of  Edinburgh,  who  invoked  it  as  an  explanation  of 
the  occasional  failure  of  vaccinia  to  protect  against  small-pox.  The  prac- 
tical question  was,  how  to  decide,  in  a  given  instance,  whether  general 
infection  had  or  had  not  taken  place.  In  the  opinion  of  many  observers 
— and  that  notion  has  cropped  out  every  now  and  then  up  to  the  present 
day — absence  of  the  areola  furnished  at  least  presumptive  evidence  that 
the  constitution  had  eluded  infection.  But,  whatever  may  be  held  theo- 
retically, it  must  be  conceded  either  that  the  general  system  very  rarely 
fails  to  feel  the  impress  of  the  disease,  or  else  that  the  criterion  is  falla- 
cious. For  in  an  experience  of  seventeen  years  the  present  writer  has  not 
known  of  a  single  instance  in  which  a  vaccinal  lesion  that  pursued  a  reg- 
ular course  in  other  respects  has  failed  to  be  accompanied  by  the  areola. 
And  certainly  Mr.  Bryce  himself  must  have  attached  little  if  any  import- 
ance to  it,  for  he  took  great  pains  to  establish  a  means  of  determining 
the  presence  or  absence  of  constitutional  infection — the  so-called  Bryce's 
test.  This  consists  in  repeating  the  inoculation  at  a  certain  period  in  the 
evolution  of  the  disease,  the  theory  being  that  systemic  infection  does  not 
take  place  at  once,  but  only  after  the  lapse  of  a  number  of  days  from  the 
time  of  the  inoculation,  Up  to  that  time  a  repetition  of  the  inoculation 
is  possible,  and,  if  systemic  infection  results  from  the  first  one,  both 
lesions  will  mature  at  the  same  time,  the  second  one  following  an  accel- 
erated course,  reaching  its  acme  rapidly,  although  dwarfed  in  size.  If, 
on  the  other  hand,  the  first  inoculation  failed  to  infect  the  constitution, 
the  second  one  will  pursue  its  course  in  the  usual  manner.  Moreover,  at 
a  certain  time,  generally  about  the  fifth  day,  a  repetition  of  the  inocula- 
tion will  fail  altogether  if  the  original  insertion  has  really  infected  the 
system.  The  present  writer  can  testify  that  Mr.  Bryce's  statements  are 
correct ;  he  has  applied  the  test  in  many  cases,  but  in  no  instance  has  he 
been  led  to  the  conclusion  that  constitutional  infection  had  failed  to  take 
place.  He  is  inclined  to  think,  therefore,  that  such  failure  is  exceedingly 
rare. 

Passing  over  the  multiplicity  of  irregularities  in  the  lesion  that  were 
described  by  the  older  observers,  it  seems  that  there  are  a  few  that  are  of 
practical  importance.  In  the  first  place,  there  is  a  variety  of  pock  to 
which  it  is  not  easy  to  give  a  definite  name,  but  which  is  characterized 
by  a  lack  of  decided  elevation  above  the  surrounding  skin  (a  deficiency 
for  which  it  makes  up  in  superficial  area),  by  the  early  formation  of  a 
thin,  flimsy,  straw-colored  crust,  and  by  the  utter  failure  of  the  charac- 
teristic firm  brown  crust  of  the  typical  variety  to  become  developed. 
This  form  of  irregular  pock  has  not  been  seen  by  the  writer  of  late 
years,  but  before  animal  vaccination  came  into  general  use  he  met  with 
it  frequently,  mostly  in  cachectic  children.  Notwithstanding  its  sprawly, 
unsatisfactory  appearance,  it  is  undoubtedly  genuine,  for  the-  typical 
lesion  may  be  produced  by  inoculation  with  its  contends. 

Another  irregularity  of  the  pock  is  what  is  familiarly  termed  the  rasp- 
berry excrescence.  A  red  elevation  forms  at  the  seat  of  inoculation,  and 
at  first  promises  to  follow  the  typical  course,  although  it  may  be  tardy  in 
making  it  appearance;  but  it  never  advances  to  full  development.  It 
becomes  indolent,  and  may  last  for  several  weeks,  or  even  months,  in  the 
form  of  a  hard,  flat  nodule  of  a  bright-red  color,  not  unlike  a  small 


462  VACCINIA. 

njevus.  In  many  instances  it  has  a  succulent  look,  but  no  lymph  can  be 
obtained  on  puncturing  it.  No  areola  appears  at  any  time,  and  finally 
the  lesion  slowly  disappears,  leaving  no  trace  of  its  existence.  It  is 
probably  an  abortive  form  of  pock,  in  which  only  the  papillary  layer  of 
the  skin  takes  part,  without  any  exudation  into  the  epidermis.  It  is 
seldom,  if  ever,  protective  against  small-pox,  for  it  constitutes  no  bar  to 
a  subsequent  vaccination.  This  irregular  pock  has  been  observed  from 
time  to  time  ever  since  the  early  days  of  vaccination,  but  for  the  past  six 
years  it  has  been  seen  more  frequently  in  New  York  than  for  many  years 
before.  Now,  however,  it  seems  to  be  growing  less  common.  The  writer 
is  not  aware  of  any  satisfactory  explanation  of  its  occurrence.  It  is  seen 
in  all  sorts  of  subjects,  and  seems  to  follow  the  use  of  one  variety  of  virus 
as  much  as  the  employment  of  any  other. 

AVhat  has  been  termed  generalized  vaccinia  is  another  form  of  irregu- 
larity. The  expression  is  a  vague  one,  covering  as  it  does  not  only  the 
very  rare  cases  of  true  eruptive  vaccinia,  in  which  a  general  eruption  of 
pocks  takes  place  as  a  consequence  of  constitutional  infection,  playing  the 
part  of  an  exanthem,  but  in  addition  those  instances,  not  very  uncommon, 
in  which  pocks  are  formed  here  and  there  on  the  body,  probably  as  the 
result  of  the  accidental  transfer  of  the  virus  from  the  pock  by  scratching. 
Under  such  favorable  conditions — the  immediate  transfer  of  lymph 
from  a  pock  in  which  the  specific  evolution  is  going  on  vigorously — the 
slightest  penetration  of  the  epidermis  with  the  nails  is  enough  to  secure 
self-inoculation.  In  view  of  this  facility  with  which  it  may  be  effected, 
we  should  be  very  careful  not  to  jump  hastily  to  the  conclusion  that  in 
any  given  case  of  generalized  vaccinia  the  supplementary  pocks  are  truly 
eruptive ;  as  a  matter  of  fact,  the  present  writer  has  never  seen  an  instance 
in  which  he  was  convinced  that  such  was  the  case.  Where  the  pocks  are 
very  numerous,  especially  in  subjects  with  an  irritable  skin,  much  distress 
may  be  caused  by  the  itching  and  by  the  consequences  of  scratching,  and 
marked  febrile  reaction  may  accompany  the  processs ;  so  that,  in  view  of 
the  great  similarity  of  the  lesions  to  those  of  the  variolous  eruption, 
much  doubt  is  sometimes  entertained  as  to  whether  the  disease  is  not 
really  small-pox.  This  question  cannot  always  be  definitely  settled  at 
first,  but  the  failure  of  the  secondary  fever  of  small-pox,  together  with 
the  fact  that  the  disease  does  not  spread  by  infection,  will  generally  suffice 
to  decide  it. 

Concerning  those  cases  of  generalized  vaccinia  that  are  manifestly  not 
eruptive,  it  sometimes  happens  that  the  cutaneous  receptivity  is  not 
exhausted  for  several  weeks,  or  even  months.  Such  cases  set  Bryce's 
test  at  defiance,  in  consequence,  probably,  of  an  idiosyncrasy.  In  some 
of  these  instances  the  pocks  appear  in  clusters  of  successive  formation, 
looking  not  unlike  patches  of  zoster.  Small  supplementary  pocks  in 
the  immediate  neighborhood  of  the  original  lesion  are  not  at  all  uncom- 
mon. 

PATHOLOGICAL,  AXATOMY. — Avoiding  the  minute  histological  details 
for  which  the  prescribed  length  of  this  article  gives  no  scope,  but  little  is 
to  be  added  to  what  has  already  been  said  in  the  section  on  the  clinical 
features  of  the  disease.  The  lesions  of  vaccinia  are  wholly  cutaneous. 
Confining  ourselves  to  cases  that  follow  a  regular  course,  there  is, 
indeed,  but  one,  the  pock — a  term  that  seems  preferable  to  vesicle  and 


PATHOLOGICAL  ANATOMY.  463 

pustule,  since  the  latter  apply  only  during  certain  phases  in  the  develop- 
ment of  the  lesion. 

A  pock  may  be  regarded  as  essentially  a  lesion  of  the  epidermis,  for  it 
is  in  that  structure  that  its  most  striking  features  are  developed,  and  in 
some  cases,  although  doubtless  the  papillary  layer  of  the  derma  is  con- 
gested, there  is  no  permanent  alteration  of  tissue  below  the  Malpighian 
layer  of  the  epidermis.  These  are  the  catarrhal  pocks  of  Rindfleisch, 
and  it  is  in  such  cases,  if  in  any,  that  no  scar  (even  of  temporary  dura- 
tion) results.  The  term  catarrhal  pock,  however,  is  not  vitiated  by  an 
extension  of  the  morbid  process  deep  enough  to  produce  a  permanent 
cicatrix,  and  it  is  probable  that  in  most  cases  the  catarrhal  type  predomi- 
nates. By  the  term  diphtheritic  pock  the  same  author  refers  to  cases  in 
which  the  congestion  of  the  papillary  layer  is  so  intense  as  to  block  the 
supply  of  blood  to  the  apices  of  the  papillae,  as  a  result  of  which  they 
become  exsanguinated  and  necrosed,  forming  a  white  pultaceous  layer 
on  the  floor  of  the  pock,  which  is  undoubtedly  what  Ceely  referred  to 
when  he  spoke  of  a  false  membrane.  In  some  cases  even  the  subcu- 
taneous tissue  undergoes  necrosis,  a  sort  of  core  being  included  in  the 
substance  of  the  crust  that  ultimately  forms. 

Whichever  of  these  forms  of  pock  we  take  into  consideration,  always 
excluding  irregularities  and  complications,  we  find  certain  definite  changes 
in  the  epidermis.  The  dome  of  the  pock  is  formed  by  the  unbroken 
transparent  horny  layer  of  the  epidermis,  unaffected  by  the  morbid  pro- 
cess. The  cavity  of  the  pock  is  formed  by  the  squamous  cells  of  the 
epidermis  being  forced  out  of  their  normal  relations  by  an  exudation  of 
lymph  between  them,  some  of  them  being  tilted  up  edgewise  while  still 
retaining  their  connection  with  the  surrounding  cells,  thus  accounting  for 
the  multilocular  structure  of  the  pock ;  for  it  is  a  fact  that  the  circular 
bourrelet  consists  not  of  one  ring-like  cavity,  but  of  many  separate 
chambers.  The  result  of  this  structure  is,  that  the  liquid  contained 
within  the  pock — the  lymph — escapes  only  partly  through  a  puncture 
made  in  the  wall  of  the  vesicle.  In  order  to  evacuate  the  pock  thor- 
oughly it  is  necessary  to  make  a  great  number  of  punctures  or  a  circular 
incision  following  the  ring-like  ridge  of  the  bourrelet. 

The  lymph  contained  within  the  cells  of  the  pock  is  a  liquid  which  in 
its  gross  physical  properties  differs  but  little  from  the  lymph  which 
exudes  from  any  traumatic  surface  shortly  after  .the  injury  has  been 
inflicted,  as  in  the  glazing  process  that  takes  place  in  wounds.  Examined 
microscopically,  however,  it  is  found  to  contain  not  only  the  fibrin,  the 
salts,  the  corpuscular  elements,  and  the  debris  that  ordinary  tissue-juice 
presents,  but  also  certain  minute  spherical  bodies — termed  microspheres, 
microzymes,  vaccinads,  etc. — that  give  it  its  characteristic  infective  quality 
and  justify  the  title  of  virus  commonly  applied  to  it.  That  these  minute 
bodies  really  constitute  the  virulent  element  of  the  lymph,  or  at  least  that 
they  are  the  vehicle  of  the  contagium,  is  not  a  mere  matter  of  conjecture, 
but  has  been  demonstrated  abundantly,  notably  by  Chauveau  and  Sander- 
son's diffusion  experiments.  Inoculation  with  the  supernatant  liquid, 
containing  none  of  these  bodies,  always  fails  to  convey  the  disease,  but  it 
is  not  absolutely  essential  that  they  should  be  present  in  large  proportion 
in  the  lymph  to  render  the  latter  virulent,  for  Chauveau  found  that  lymph 
diluted  with  thirty  times  its  bulk  of  water  was  not  without  infective 


464  VACCINIA. 

power.  It  scarcely  need  be  said,  however,  that  the  greater  the  propor- 
tion in  which  they  are  present,  the  greater  is  the  probability  that  the 
lymph  will  prove  infective  on  inoculation.  These  bodies  have  been  sup- 
posed to  be  of  a  vegetable  nature,  and  Hallier,  Kohn,  and  others  have 
bestowed  no  little  study  upon  their  botanical  characteristics.  Under 
favorable  circumstances  they  retain  their  virulent  properties  for  a  long 
time,  especially  if  kept  perfectly  dry  and  not  subjected  to  a  high  tempera- 
ture. The  present  writer  has  met  with  success  in  the  use  of  vacciual 
virus  seven  years  old. 

The  lymph  differs  somewhat  in  its  gross  appearances  according  as  it  is 
produced  in  man  or  in  the  bovine  animal.  In  the  former  it  is  clear  and 
limpid,  and  exudes  freely  in  great  drops  when  the  pock  is  punctured  in 
its  peripheral  portion ;  in  the  latter  it  is  more  straw-colored  and  more 
viscid,  exuding  sluggishly,  or  even  refusing  to  flow  without  the  aid  of 
pressure.  Moreover,  the  vaccinads  seem  endowed  with  different  proper- 
ties in  the  two  cases :  in  man  they  have  a  tendency  to  remain  equably 
diffused  through  the  liquid,  while  in  the  cow  they  tend  to  separate  from 
it  and  to  be  deposited  upon  any  solid  surface  at  hand. 

The  phenomenon  termed  umbilication,  common  to  the  vaccinal  pock 
and  to  that  of  variola,  has  given  rise  to  some  differences  of  opinion  as  to 
the  mechanism  of  its  production.  The  term  implies  a  depression  at  the 
centre  of  the  pock.  This  appearance  is  not  invariable,  but  it  is  constant 
enough  to  have  met  with  general  acceptance  as  a  characteristic  feature, 
notwithstanding  the  undoubted  fact  that  it  is  found  in  lesions  that  have 
nothing  whatever  to  do  with  any  of  the  varioliform  diseases.  Not  to 
waste  space  in  discussing  the  various  theories  that  have  found  supporters, 
it  may  be  said  that  they  have  all  been  proved  to  be  defective,  save  only 
the  simple  explanation  that  as  the  process  of  evolution  advances  the  centre 
of  the  pock  undergoes  desiccation,  whereby  that  portion  of  the  tissue 
involved  is  so  glued  and  drawn  together  as  to  become  incapable  of  the 
swelling  that  is  still  going  on  in  the  growing  peripheral  portion  of  the 
lesion. 

The  crust  into  which  the  pock  ultimately  becomes  converted  is  not,  as 
is  commonly  supposed,  mere  dried  lymph  and  nothing  else ;  it  is  dried 
tissue  enclosing  concrete  lymph.  It  generally  includes  also  various  sorts 
of  debris — broken-down  epithelium,  blood-corpuscles,  pus-corpuscles,  and 
even,  in  rare  cases,  a  core  of  sphacelated  tissue  like  that  of  a  furuncle. 

As  has  already  been  said,  the  cicatrix  is  to  a  certain  extent  peculiar  in 
that  it  is  usually  depressed  and  foveolated.  Too  much  stress  has  been 
laid  upon  these  features,  however,  and  the  truth  is  that  some  traumatic 
scars  cannot  be  distinguished  readily  from  that  of  vaccinia,  while,  on  the 
other  hand,  many  a  genuine  pock  leaves  no  permament  trace  behind  it. 
Indeed,  in  the  cow  it  is  the  exception  for  a  noteworthy  scar  to  form. 
^  SEQUELJE  AND  COMPLICATIONS. — The  most  important  sequela  of  vac- 
cinia is  the  fact  that  it  protects  the  subject  against  small-pox,  and  on  that 
circumstance  hinges  the  chief  practical  interest  of  the  disease.  This  leads 
us  at  once  to  the  subject  of  vaccination,  and  therefore  under  that  head  we 
shall  pursue  our  consideration  of  this  curious  affection. 


SYNONYMS.— HISTORY.  465 

Vaccination. 

SYNONYMS. — "The  new  inoculation;"  Fr.  Vaccination ;  Ger.  Kuh- 
pockenimpfung,  Schutzpockenimpfung ;  It.  Vaccinazione ;  Sp.  Vacu- 
nacion. 

HISTORY. — Before  giving  the  history  of  vaccination  itself  (meaning 
by  that  term  the  intentional  inoculation  of  vaccinia  for  the  purpose  of 
protecting  the  subject  against  small-pox),  it  may  be  well  to  devote  a  few 
words  to  a  practice  that  preceded  it — that  of  the  intentional  inoculation 
of  small-pox  (or  simply  inoculation,  latterly  called  variolation).  In  very 
early  times  various  Oriental  peoples  became  aware  of  the  fact  that  small- 
pox might  be  very  decidedly  mitigated  by  inoculation.  This  was  prac- 
tised in  various  ways,  all  of  which  may  be  reduced  to  the  process  of 
inserting  small-pox  virus  into  a  solution  of  continuity.  Lady  Montagu, 
the  wife  of  an  English  ambassador  to  Turkey,  brought  the  practice  back 
to  England  with  her,  where  it  soon  made  its  way  into  popular  favor,  and 
whence  it  spread  rapidly  over  Europe  and  America.  Thus  contracted, 
small-pox  was  shorn  of  a  great  part  of  its  terrors ;  the  eruption  was 
usually  trifling  in  amount,  and  in  every  way  the  disease  was  mild  as  a 
rule.  Still,  the  mortality  was  something  worth  considering,  and,  worse 
than  that,  the  inoculated  disease  was  communicable  by  effluvium,  so  that 
an  inoculated  person  had  to  be  secluded  carefully  for  fear  of  spreading 
the  disease  in  the  ordinary  way.  In  all  cases,  too,  careful  medical  treat- 
ment was  thought  necessary.  On  the  whole,  then,  while  inoculation  was 
undoubtedly  a  boon,  it  was  fraught  with  many  grave  perils.  So  great, 
indeed,  were  these  perils,  and  so  thoroughly  were  they  appreciated,  that 
the  practice  was  interdicted  by  law  in  most  civilized  countries  so  soon  as 
vaccination  had  become  established  in  popular  favor. 

In  several  European  countries  the  common  people — at  least  those  of 
them  who  had  much  to  do  with  dairies — gradually  became  aware  of  the 
existence  of  the  disease  termed  cow-pox,  and  of  the  fact  that  those  indi- 
viduals who  had  accidentally  contracted  it  were  rendered  proof  against 
the  infection  of  small-pox.  There  is  even  fair  testimony  to  show  that 
some  of  these  people,  particularly  the  English  farmer,  Benjamin  Jesty, 
relying  on  their  observation  to  this  eifect,  employed  intentional  cow-pox 
inoculation  as  a  protective  measure.  These  facts,  however,  do  not  detract 
in  the  least  from  the  credit  that  all  Christendom  has  awarded  to  a  man 
who  subjected  the  popular  impression  in  question  to  the  test  of  scientific 
investigation,  proved  its  truth,  and  demonstrated  its  value  to  the  world. 
That  man  was  Edward  Jenner,  an  English  country  physician.  It  \vas 
in  the  last  quarter  of  the  eighteenth  century  that  he  entered  upon  his 
course  of  inquiry,  and  on  the  eve  of  the  present  century  he  published  his 
demonstration  to  the  world.  It  was  not  a  discovery;  it  was  not  an 
invention  :  it  was  more  than  either,  "  a  matchless  piece  of  induction,"  to 
quote  the  words  of  Mr.  John  Simon.  Filled  as  he  must  have  been  with 
the  consciousness  of  his  great  achievement,  Jenner  set  this  good  example 
to  all  investigators :  that  he  did  not  make  haste  to  convert  the  world ;  he 
first  convinced  himself.  It  may  almost  be  said,  indeed,  that,  like  Minerva 
from  the  head  of  Jove,  the  rational  and  perfected  practice  of  vaccination 
sprang  complete  from  Jenner's  hands.  Doubt  and  ridicule  he  had  to 
encounter  at  first,  and  afterward  envy  and  detraction ;  but  the  force  of 

VOL.  I.— 30 


466  VACCINIA. 

his  facts  and  the  symmetry  of  his  deductions  were  such  that  the  new 
inoculation  soon  spread  through  the  broad  world,  and  has  ever  since 
maintained  its  sway,  save  with  a  few  fanatical  scoffers. 

That  vaccination  really  does  protect  against  small-pox  observation  has 
taught  the  whole  civilized  world,  if  we  leave  out  of  account  the  few  con- 
scientious and  intelligent  doubters  (made  such,  doubtless,  quite  as  much 
by  the  extravagant  statements  often  put  forth  by  those  who  from  time  to 
time  think  it  incumbent  on  them  to  defend  vaccination,  as  by  their  own 
misinterpretation  of  facts)  who  are  to  be  found  associated  with  the  noisy 
little  body  of  actual  opponents  of  the  practice.  One  of  the  most  inju- 
rious statements  ever  made  in  the  advocacy  of  vaccination  is,  that  it 
always  protects  if  properly  done.  When  one  of  these  illogical  defenders 
of  that  proposition  is  confronted  with  an  instance  that  disproves  his 
assertion,  he  falls  back  on  the  allegation  that  in  that  instance  the  vaccina- 
tion was  not  properly  done.  The  manifest  absurdity  of  such  an  argu- 
ment strikes  the  doubter  most  forcibly,  and  inclines  him  to  say  to  him- 
self, Falsus  in  uno,  falsus  in  omne.  Unbelief  founded  on  this  ground 
would  never  have  arisen  if  the  plain  truth  had  always  been  adhered  to  : 
that  the  protection  afforded  by  vaccination  is  not  invariable,  and  that 
very  often  it  is  not  permanent.  In  the  infancy  of  the  practice  these 
facts  were  not  known,  but  it  is  now  many  years  since  they  became  obvious 
to  every  fair-minded  observer.  The  misapprehension  of  facts  lies  chiefly 
in  the  false  deduction  from  the  circumstance  that  the  great  majority  of 
cases  of  small-pox  occur  in  persons  who  have  been  vaccinated.  But  the 
explanation  of  this  is  very  simple.  Suppose  that,  of  one  hundred  per- 
sons vaccinated,  twenty  fail  to  be  protected  permanently ;  that  all  persons 
not  vaccinated  are  unprotected  ;  and  that  throughout  the  civilized  world 
the  proportion  of  vaccinated  to  unvaccinated  persons  is  as  ninety  to  ten. 
Making  no  pretence  of  arithmetical  accuracy,  it  may  certainly  be  said 
that  all  these  suppositions  are  well  within  the  truth.  It  follows  from 
them  that  in  a  community  of  ten  thousand  persons  there  will  be  nine 
thousand  who  have  been  vaccinated,  and  one  thousand  who  have  not. 
Of  the  former,  eighteen  hundred  will  have  failed  to  secure  lasting  pro- 
tection. Therefore  in  case  of  an  epidemic  there  will  probably  be  a  pro- 
portion of  eighteen  cases  of  small-pox  in  the  vaccinated  to  ten  in  the 
unvaccinated ;  and  yet  this  should  not  obscure  the  fact  that  of  the  nine 
thousand  vaccinated  more  than  seven  thousand  were  absolutely  protected, 
whereas  of  the  one  thousand  not  vaccinated  not  one  could  escape  the  dis- 
ease if  exposed  to  it.  When  we  add  the  further  observation  that  of  the 
eighteen  hundred  cases  of  small-pox  among  the  vaccinated  not  more  than 
thirty  or  forty  would  probably  prove  fatal,  while  of  the  one  thousand 
cases  in  the  unvaccinated  about  two  hundred  would  end  in  death,  we 
have  a  striking  demonstration  of  the  efficiency  of  vaccination.  As  a 
matter  of  fact,  statistics  show  that  the  figures  here  given  err  rather  in 
allowing  too  little  than  in  asserting  too  much  in  favor  of  vacciual 
protection. 

The  question  naturally  arises,  Why  it  is  that  vaccination  protects  some 

persons  and  does  not  protect  others  ?— reference  being  had,  of  course,  to 

permanent  protection,  for  it  is  exceedingly  rare  for  temporary  immunity 

to  be  attained  if  we  exclude  those  instances  in  which  the  variolous 

3tion  has  taken  place  before  the  operation  is  resorted  to.     This  ques- 


HISTORY.  467 

tion  cannot  be  answered  with  any  certainty,  but  various  theories  have 
been  brought  forward,  some  of  which  call  for  notice. 

In  the  first  place,  it  has  been  thought  that  the  revolution  of  the  system 
termed  puberty  was  fraught  with  such  a  radical  change  as  to  do  away 
with  the  mild  modification  due  to  vaccination.  While  this  theory  has  an 
air  of  plausibility,  it  seems  to  lack  proof  and  not  to  be  upheld  by  anal- 
ogy, for  we  do  not  find  that  children  who  have  had  scarlet  fever,  measles, 
and  the  like  often  undergo  those  diseases  a  second  time  on  arriving  at  the 
age  of  puberty. 

The  only  remaining  theory  that  our  limits  will  allow  a  consideration 
of  is  that  put  forward  by  Marson  of  London,  that  the  degree  and  dura- 
tion of  vaccinal  protection  are  proportionate  to  the  perfection  of  the  vac- 
cinal  lesion  and  to  the  number  of  insertions  made.  In  a  large  experience 
with  small-pox  Marson  found  that  the  disease  was  more  fatal  among 
those  whose  vaccinal  scars  were  imperfect  or  few  in  number  than  among 
those  who  bore  evidence  that  several  pocks  had  been  produced  and  had 
run  a  typical  course.  As  to  the  influence  of  a  perfect  evolution  of  the 
lesion,  but  little  doubt  can  be  entertained,  for  we  have  already  seen  that 
in  some  instances  its  course  is  so  different  from  what  it  should  be  that  no 
protection  whatever  seems  to  result.  "When  we  come  to  consider  the 
number  of  the  pocks  as  affecting  the  degree  or  the  duration  of  protection, 
however,  an  obvious  source  of  fallacy  arises  in  the  fact  that  we  cannot 
always  be  sure  that  some  of  the  scars  on  a  person  having  a  number  of 
them  were  not  the  products  of  a  repetition  of  the  operation  several  years 
after  the  first — that  is  to  say,  a  revaccination,  the  efficiency  of  which  in 
restoring  lost  immunity  is  now  well  established.  Nevertheless,  as  long  as 
the  doubt  remains  the  best  course  to  pursue  seems  to  be  to  act  as  if 
Marson' s  theory  were  in  all  respects  correct,  and  vaccinate  by  multiple 
insertions. 

We  have,  then,  no  positive  means  of  ascertaining  who  those  persons 
are  that  are  likely  to  fail  of  lasting  protection,  or  how  long  a  time  will 
elapse  before  the  cessation  of  their  immunity  will  take  place.  The  only 
safety  lies  in  revaccination.  But  after  how  many  years  should  revacciua- 
tion  be  resorted  to  ?  It  has  been  thought  that  this  question  might  be 
settled  by  noting  at  what  age,  or  at  what  period  after  primary  vaccina- 
tion, large  numbers  of  people  became  susceptible  of  revaccination.  This 
test,  however,  is  not  altogether  trustworthy,  for  a  renewed  susceptibility 
to  vaccinia  by  inoculation  does  not  necessarily  imply  that  the  liability  to 
take  small-pox  by  effluvium  has  been  regained.  If  it  did,  modified 
small-pox  (varioloid)  would  be  far  more  common  than  it  is,  for  it  is  cer- 
tain that  revaccination  can  be  made  to  succeed  in  a  very  large  proportion 
of  children  long  before  they  have  reached  the  age  of  puberty.  The 
fact  is,  contrary  to  the  notions  of  the  last  generation,  that  success  in 
revaccination  is  the  rule,  not  the  exception.  Formerly  it  was  not  ex- 
pected to  succeed,  and  therefore  no  special  pains  were  taken  to  ensure 
success. 

Definite  rules  cannot  be  laid  down  as  to  the  time  that  should  be  suf- 
fered to  elapse  before  vaccination  is  repeated,  but  in  the  great  majority  of 
instances  safety  may  be  attained  by  revaccination  every  five  or  six  yearn, 
and  always  in  the  presence  of  an  epidemic,  regardless  of  the  lapse  of 
time ;  also  whenever  one's  mode  of  life  is  to  undergo  a  noteworthy  change, 


468  VACCINIA. 

as  in  emigrating  to  a  foreign  country,  on  entering  the  military  service, 

and  the  like. 

To  sum  up,  then,  vaccination  almost  invariably  protects  against  small- 
pox for  the  time  being ;  generally  for  a  long  term  of  years ;  sometimes 
for  a  lifetime.  Often  the  protection  is  absolute ;  as  a  rule,  it  is  very 
nearly  so ;  in  rare  instances  it  is  trifling.  In  general^  terms,  it_  may  be 
said  that  it  is  scarcely  less  protective  than  variolous  infection  itself  for 
death  from  a  second  attack  of  small-pox  is  by  no  means  rare.  Here  the 
question  comes  up :  Is  vaccination  less  protective,  either  in  degree  or  in 
duration  of  effect,  than  it  was  at  the  time  of  its  adoption?  Given  a 
typical  vaccinia,  we  may  unhesitatingly  answer,  No ;  but  do  we  now  so 
invariably  produce  the  disease  in  all  its  essential  features  as  was  done  in 
Jenner's  time  ?  Yes,  provided  we  use  proper  virus  and  employ  as  much 
care  as  was  taken  by  the  older  physicians,  who,  trained  to  the  practice  of 
variolation  (the  inoculation  par  excellence  of  bygone  days),  did  their 
work  with  a  gusto  now  seldom  witnessed.  But  there  was  a  time,  now 
happily  at  an  end,  when  it  was  not  easy  to  obtain  thoroughly  good  virus, 
and  when,  therefore,  the  result  was  apt  to  vary  materially  from  the 
standard.  This  may  be  conceded  without  entering  upon  the  vexed  ques- 
tion of  the  general  deterioration  of  the  Jennerian  stock  of  vaccine. 

Besides  immunity  from  small-pox,  there  are  one  or  two  sequelae  of 
vaccinia  that  deserve  mention  before  we  proceed  to  consider  what  it  is 
better  to  class  as  complications.  In  the  first  .place,  vaccination  has  been 
supposed  to  confer  temporary  protection  against  whooping  cough.  The 
writer  is  not  aware,  however,  of  any  precise  data  going  to  prove  either 
the  truth  or  the  falsity  of  this  supposition. 

Secondly,  by  virtue  probably  of  the  inflammation  that  attends  the 
evolution  of  the  vaccinal  pock,  vaccination  practised  in  the  immediate 
neighborhood  of  'a  small  navus  often  cures  that  blemish,  and  it  has  been 
done  for  that  purpose  in  many  cases.  It  has  no  advantage  over  many 
other  measures,  however,  and  there  is  the  disadvantage  that  the  nsevus 
may  so  mask  the  pocic  as  to  give  rise  to  some  doubt  as  to  the  satisfactory 
character  of  the  latter.  The  practice,  therefore,  is  not  to  be  urged. 

COMPLICATIONS. — These  are  local  and  systemic.  Those  of  them  that 
are  at  all  serious  are  rare,  and  can  generally  be  traced  to  fortuitous  cir- 
cumstances. 

^  Inflammatory  complications  are  usually  due  to  undue  traumatism  at  the 
time  of  the  inoculation,  to  injury  of  the  pock,  or  to  the  previous  existence  of 
a  cutaneous  disease  or  of  some  dyscrasia.  Dermatitis  is  the  most  common. 
It  is  usually  a  mere  erythema,  but  in  some  instances  lymphangeitis, 
lymphadenitis,  phlegmonous  inflammation,  with  diffuse  suppuration,  may 
result.  From  injury  of  the  pock  ulceration  and  gangrene  may  take 
place,  and  septic  absorption  may  follow  in  their  train.  These  complications 
are  to  be  treated  as  if  they  had  occurred  from  any  other  cause.  Gene- 
rally, the  mere  vaccination  is  not  responsible  for  them,  but  in  some 
instances  putrescent  vaccine  may  be  adduced  as  their  source.  In  such 
cases  the  complications,  if  they  can  still  be  called  so,  are  apt  to  make 
their  appearance  long  before  the  pock  matures,  even  within  forty-eight 
hours  of  the  vaccination.  Inflammatory  complications  supervening  on  the 
full  development  of  the  pock  may  invariably  be  set  down  as  due  to  some 
cause  not  connected  with  the  quality  of  the  virus  employed. 


COMPLICATIONS.  469 

An  undue  amount  of  dermatitis  is  best  treated  with  some  mildly- 
astringent  and  anodyne  application.  The  following  liniment  is  excellent 
for  the  purpose  :  Jfc.  Unguenti  Stramonii  |j  •  Liquoris  Plumbi  Subacetatis 
fgss ;  Olei  Lini  f  %iv. — M.  fiat  linimentum.  As  a  rule,  it  is  best  to  avoid 
poultices  applied  over  the  pock  itself,  for  they  soften  the  tender  struc- 
tures that  make  up  its  dome  and  render  it  prone  to  rupture,  with  all  the 
consequences  that*  may  follow  its  conversion  into  an  open  sore.  When 
the  latter  accident  has  occurred,  dusting  powders  will  ordinarily  suffice  to 
absorb  the  discharge,  and  thus  prevent  putrefaction — either  the  ordinary 
toilet  powder  or  salicylized  or  carbolized  powders,  the  basis  of  which 
may  be  starch  with  a  small  proportion  of  the  oxide  of  zinc.  Besides  the 
antiseptics  mentioned,  iodoform,  boric  acid,  etc.  may  be  used  to  advan- 
tage. Liquid  applications  are  not  usually  so  appropriate,  but  the  writer 
has  known  the  proprietary  preparation  termed  Listerine  to  answer 
admirably. 

Circumscribed  collections  of  pus  are  to  be  treated  as  under  other  cir- 
cumstances, and  burrowing  is  to  be  guarded  against.  It  is  only  in  the 
worst  cases  that  constitutional  treatment  of  any  sort  is  demanded,  and  in 
these  it  should  be  of  a  supporting  nature. 

Passing  from  the  simple  inflammatory  complications  to  those  of  a 
specific  character,  we  will  first  mention  erysipelas.  Genuine  erysipelas 
following  vaccination  is  quite  rare,  but  when  it  does  occur  it  is  prone  to 
prove  serious.  The  writer  believes  that  it  always  depends  on  secondary 
infection — i.  e.  that  the  vaccinal  wound  becomes  the  nidus  of  an  erysipe- 
latous  contagium  already  existing  in  the  patient's  surroundings,  just  as 
any  other  traumatic  surface  might,  and  that  the  vaccinal  virus  has  nothing 
whatever  to  do  with  it.  Admitting  that  improper  virus  is  apt  to  give 
rise  to  dangerous  inflammatory  complications,  the  latter  are  not  really  ery- 
sipelatous,  whatever  guise  they  may  put  on.  Erysipelas  following  vac- 
cination calls  for  no  other  treatment  than  what  is  proper  for  traumatic 
erysipelas  under  ordinary  circumstances. 

We  now  come  to  the  subject  of  vaccinal  syphilis.  The  question  of  the 
possibility  of  conveying  constitutional  taints  along  with  vaccinia  was 
raised  long  ago,  but,  partly  relying  on  certain  theoretical  tenets,  and  partly 
because  of  the  rarity  of  well-ascertained  facts  to  shake  the  blind  confi- 
dence felt  in  the  utter  harmlessness  of  vaccination,  the  profession  fought 
the  suggestion  without  properly  investigating  it.  In  regard  to  syphilis, 
the  broad  assertion  was  maintained  that  two  infectious  diseases  could  not 
affect  an  individual  at  one  and  the  same  time :  either  syphilis  would  be 
communicated  alone  or  vaccinia  alone ;  moreover,  it  was  affirmed  that  the 
juices  of  a  syphilitic  person  were  not  capable  of  giving  rise  to  the  disease 
by  inoculation  unless  they  happened  to  proceed  from  a  syphilitic  lesion. 
There  was  never  sufficient  basis  for  the  former  of  these  two  doctrines, 
and  the  latter  received  a  rude  shock  when  it  was  shown  by  Pallizzari  and 
the  anonymous  physician  of  the  Palatinate  that  the  blood  of  a  syphilitic 
subject  was  capable  of  conveying  the  taint.  Meantime,  certain  horrible 
outbreaks  of  syphilis  were  reported,  chiefly  in  Italy,  that  could  not 
reasonably  be  imputed  to  the  ordinary  occasions  of  syphilitic  infection. 
Even  these  occurrences,  however,  failed  to  shake  the  general  incredulity, 
especially  in  Great  Britain,  where  until  quite  recently  men's  orthodoxy 
in  medical  matters  wras  gauged  by  their  obstinacy  in  refusing  to  investi- 


470  VACCINIA. 

gate,  far  less  believe,  the  slightest  proposition  unfavorable  to  vaccination, 
and  where,  also,  observations  from  beyond  the  limits  of  the  empire  were 
looked  upon  as  in  all  probability  fallacious. 

To  a  Frenchman,  M.  Viennois,  we  are  indebted  for  the  first  systematic 
and  fair-minded  study  of  the  subject  of  vaccinal  syphilis.  This  writer 
demonstrated  that  the  Rivalta  cases  and  those  of  other  like  outbreaks 
were  certainly  due  to  vaccination,  but  he  concluded  thatf  they  owed  their 
occurrence  not  necessarily  to  the  use  of  lymph  from  syphilitic  subjects, 
but  to  the  fact  that  that  lymph  contained  blood.  By  this  time  it  had 
come  to  be  recognized  that  syphilis  was  inoculable  by  the  blood.  But 
even  Vennois's  masterly  essay,  and  the  facilis  descensus  it  oifered  to  those 
English  authors  who  found  themselves  confronted  with  proof  positive  of 
then-  error,  failed  to  make  any  noteworthy  impression  beyond  the  con- 
cession that  syphilis  might  possibly  be  communicable  in  vaccination,  but 
that,  if  it  were,  the  catastrophe  might  easily  be  escaped  by  avoiding  the 
use  of  lymph  contaminated  with  blood,  and  that,  therefore,  the  danger 
was  practically  no  danger  at  all,  for  no  one  in  England  would  think  of 
using  bloody  lymph !  In  all  this  the  English  were  slavishly  followed 
by  our  own  countrymen.  It  is  proper  to  add,  however,  that  Ballard 
of  London  did  his  best  to  present  the  matter  in  a  proper  light  .to  the 
British  profession,  and  that  it  is  largely  due  to  his  labors  and  to  those 
of  Jonathan  Hutchiuson  (the  latter  of  whom  supplemented  Rlcord's 
discovery  that  vaccine  lymph  is  never  free  from  blood  with  abundant 
clinical  evidence  of  the  existence  of  vaccinal  syphilis  unavoidable  by  the 
mere  observance  of  Vieunois's  safeguard)  that  we  are  now  freed  from  the 
clog  of  error  in  this  matter.  Nor  was  it  the  English  alone  that  so  long 
baffled  the  recognition  of  the  truth ;  in  the  French  Acad6mie  de  Medicine, 
Jules  Guerin  and  his  adherents  fought  desperately  against  it. 

At  the  present  day  we  know  that  syphilis  is  liable  to  be  communicated 
in  vaccination,  and  that,  too,  without  regard  to  visible  blood  in  the  lymph 
employed.  There  are  two  ways  of  avoiding  it.  One  is,  to  use  non- 
humanized  lymph,  since  the  lower  animals  are  insusceptible  to  syphilis.1 
This  is  simple.  The  other  is,  to  select  a  human  vaccinifer  that  is  free 
from  syphilis.  This  is  difficult.  Too  great  reliance,  however,  should 
not  be  placed  upon  the  vaccinifer ;  it  is  possible  to  convey  syphilis  even 
in  the  use  of  bovine  virus.  Suppose  two  persons,  A  and  B,  are  to  be 
vaccinated  at  one  sitting,  A  being  syphilitic.  If  A  is  vaccinated  first, 
and  the  same  lancet,  imperfectly  cleansed,  is  used  on  B,  it  is  plain  that  B 
will  be  inoculated  not  only  with  vaccine  lymph,  but  also  with  A's  blood. 
It  is  of  the  first  importance,  therefore,  that  this  form  of  vaccinal  inocu- 
lation of  syphilis  should  be  carefully  guarded  against ;  and  that  can  be 
accomplished  most  certainly  by  using  a  fresh  instrument  for  each  patient. 

From  a  medico-legal  point  of  view  it  is  important  to  note  that  con- 
stitutional syphilis  may  follow  vaccination,  and  yet  have  nothing  to  do 
with  it.  Suppose  an  infant  to  be  born  syphilitic,  but  with  no  visible 
manifestations  of  the  taint.  Let  that  child  be  vaccinated,  and  let  the 
syphilitic  dyscrasia  afterward  break  forth.  The  ordinary  inference  would 
be  that  the  syphilis  was  due  to  the  vaccination  ;  and  in  most  instances  this 
view  would  certainly  be  urged  by  the  syphilitic  parent,  since  it  would 

1  Practically,  this  is  certain,  although  there  is  some  reason  to  believe  that  the  disease 
may  be  conveyed  to  monkeys. 


COMPLICATIONS.  471 

free  him  from  suspicion.  It  is  always  easy  to  disprove  such  an  allega- 
tion, however,  for  syphilis  communicated  in  vaccination  always  shows 
itself  first  in  the  form  of  a  chancre  at  the  site  of  the  vaccination. 
Therefore  in  any  given  case,  unless  this  mode  of  onset  can  be  proved, 
the  syphilis  is  manifestly  not  of  vaccinal  origin.  Some  observers,  it  is 
true,  are  of  the  opinion  that  vaccination  may  evoke  a  pre-existing  syph- 
ilis, to  use  Lanoix's  term — i.  e.  that  it  may  hasten  the  appearance  of 
of  the  characteristic  manifestations,  and  even  determine  their  localization 
at  the  site  of  the  vaccinal  inoculation.  But,  even  allowing  the  truth  of 
that  proposition,  in  such  a  case  the  lesion  would  be  constitutional,  not 
chancrous. 

It  is  well,  nevertheless,  to  take  precautions  against  being  placed  on  the 
defensive  in  this  way ;  and  it  may  commonly  be  avoided  by  declining  to 
vaccinate  infants  under  three  or  four  months  old,  since  inherited  syphilis 
generally  manifests  itself  by  that  time.  This  prudence  on  our  own 
behalf  should  not  be  carried  so  far,  however,  as  to  lead  us  to  deny  the 
benefit  of  vaccination  to  very  young  infants  whenever  the  prevalence  of 
small-pox  is  such  that  they  are  in  obvious  danger  of  exposure. 

As  regards  its  management,  vaccinal  syphilis  does  not  differ  from  the 
ordinary  form  of  the  aifection,  and  hence  demands  no  other  treatment 
than  what  is  proper  for  the  disease  contracted  in  the  usual  way.  It 
simply  originates  in  an  extragenital  chancre. 

Concerning  the  conveyance  of  other  constitutional  taints  in  vaccination 
our  knowledge  is  very  limited.  The  present  tendency  of  pathological 
investigation  is,  however,  to  accord  inoculability  to  many  diseases  that 
formerly  were  not  imagined  to  possess  that  quality,  so  that  in  regard  to 
other  affections  than  syphilis  it  is  prudent  to  use  the  utmost  care  in  the 
choice  of  lymph.  There  is  one  supposed  safeguard  that  does  not  seem  to 
have  the  slightest  title  to  be  so  regarded — namely,  the  notion  that  a  typ- 
ical pock  cannot  be  developed  on  a  person  affected  with  a  specific  cachexia. 
There  is  no  truth  in  the  doctrine.  Over  and  over  again  the  writer  has 
seen  perfect  vaccine  pocks  on  persons  whom  he  knew  to  be  syphilitic. 

Cutaneous  affections  of  a  non-specific  character  are  sometimes  observed 
to  result  from  vaccination ;  that  is  to  say,  they  follow  close  upon  its  per- 
formance, without  any  other  known  exciting  cause.  It  may  fairly  be 
supposed  that  in  many  instances  they  would  have  shown  themselves  even 
if  the  vaccination  had  not  been  performed,  for  it  is  often  the  case  that  we 
are  unable  to  speak  positively  in  regard  to  the  exciting  cause  of  an  erup- 
tion. Several  years  ago  a  striking  case  in  point  was  related  to  the  writer 
by  a  well-known  physician  of  this  city,  S.  S.  Purple,  in  whose  prac- 
tice it  occurred.  Purple  had  engaged  to  vaccinate  a  child  on  a  cer- 
tain day,  but  for  some  reason  the  vaccination  was  not  done.  In  about  a 
week  from  the  appointed  day,  however,  erysipelas  made  its  appearance, 
beginning  on  the  left  arm  at  the  usual  site  of  vaccination,  and  pursued 
its  course  to  a  fatal  termination.  To  be  sure,  we  are  now  speaking  of 
non-specific  affections,  but  erysipelas  illustrates  the  proposition  perfectly, 
notwithstanding  its  specific  character. 

Children  with  a  tendency  to  eczema  are  prone  to  suffer  an  outbreak  of 
that  disease  as  the  result  of  vaccination.  In  Jenner's  time,  indeed,  it  was 
considered  not  only  that  there  was  great  risk  of  causing  an  aggravation 
of  any  slight  eczematous  eruption  by  vaccination,,  but  that  the  mere 


472  VACCINIA. 

existence  of  the  eczema,  even  in  the  most  trivial  form,  was  likely  to 
interfere  with  the  success  of  the  vaccinal  inoculation.  This  has  been  the 
general  feeling  of  the  profession.  Quite  recently,  however,  many  obser- 
vations have  been  recorded  tending  to  show  that  the  old  dread  of  vacci- 
nating an  eczematous  child  was  not  altogether  warranted.  The  question 
needs  farther  study,  and,  while  it  is  probably  best  to  postpone  the  opera- 
tion under  ordinary  circumstances,  nothing  should  induce  us  to  withold 
its  protective  influence  where  there  is  any  manifest  danger  of  actual 
exposure  to  small-pox. 

Although  eczema  is  the  most  common  of  the  cutaneous  affections^  called 
forth  or  aggravated  by  vaccination,  there  are  various  forms  of  skin  dis- 
ease, some  of  them  difficult  to  classify,  that  occasionally  result.  _  They 
are  usually  vesicular,  pustular,  or  furuncular — that  is  to  say,  irritative. 
In  the  majority  of  instances  it  will  be  found  either  that  the  pock  itself 
has  followed  an  irregular  course,  being  whitish,  diffuse,  and  ending  in  an 
exaggerated  although  superficial  incrustation,  or  that  it  has  been  subjected 
to  injury.  Still,  in  some  cases  neither  of  these  conditions  is  the  precur- 
sor of  the  skin  affection.  In  many  instances  the  latter  can  only  be  called 
nondescript.  There  seems  to  be  some  occult  connection  between  vaccina- 
tion and  the  curious  skin  disease  described  by  the  late  Tilbury  Fox  of 
London  under  the  name  of  impetigo  contagiosa ;  and,  indeed,  Piffard  of 
this  city  has  found  certain  microphytes  to  be  common  to  the  crusting 
period  of  vaccinia  and  that  of  contagious  impetigo.  What  the  relation 
of  the  two  affections  is  to  each  other,  however,  it  is  difficult  to  say. 

Apart  from  impetigo  coutagiosa,  the  cutaneous  complications  that 
follow  in  the  wake  of  vaccination  possess  no  distinctive  features,  and 
their  management  differs  in  no  wise  from  that  of  the  same  manifestations 
due  to  other  causes. 

THE  TECHNICS  OF  VACCINATION. — This  aspect  of  our  theme  involves 
a  number  of  separate  considerations.  It  will  be  convenient  to  give  our 
attention  first  to  the  matter  of  the  choice  of  virus.  The  question  arises 
at  once  as  to  the  selection  between  animal  vaccine  and  the  humanized 
variety.  In  a  broad  sense  the  term  animal  vaccine  includes — 1.  Virus 
derived  directly  from  a  case  of  so-called  spontaneous  cow-pox.  2. 
Variola  vaccine — i.  e.  the  virus  of  an  affection  of  the  cow  resulting 
from  variolation.  3.  The  virus  of  horse-pox  (not  strictly  vacciual).  4. 
Retro-vaccine — i.  e.  the  virus  of  an  affection  produced  in  the  cow  by  the 
inoculation  of  vaccinia  from  the  human  subject.  5.  The  virus  of  a 
disease  (true  vaccinia)  propagated  through  a  series  of  bovine  animals 
from  the  so-called  spontaneous  cow-pox,  being  the  virus  now  commonly 
understood  by  the  term,  and  the  variety  here  referred  to  when  it  is  not 
stated  to  the  contrary. 

By  humanized  vaccine  we  understand  that  which  is  obtained  from  the 
human  subject,  no  matter  how  short  or  how  long  its  descent  from  the 
cow.  As  regards  animal  vaccine,  we  may  practically  exclude  from  con- 
sideration all  but  the  last  variety  mentioned,  that  being  the  one  to  which, 
in  the  great  majority  of  instances,  the  term  is  now  restricted.  This  nar- 
rows the  question  down  to  the  choice  between  virus  that  has  been  prop- 
agated through  a  number  of  bovine  animals  (practically,  calves)  from  the 
spontaneous  disease  in  the  cow,  and  that  which,  whatever  its  original 
fource,  lias  already  passed  through  the  human  system. 


THE  TECHNICS  OF  VACCINATION.  473 

The  variety  first  mentioned,  sometimes  called  primary  vaccine,  is  gene- 
rally spoken  of  by  authors  as  not  very  trustworthy  as  regards  its  infec- 
tive power  (that  is,  not  to  be  counted  on  to  take),  and  as  prone  to  give 
rise  to  undue  inflammatory  complications  when  its  use  does  prove  success- 
ful. These  unpleasant  qualities  might  be  explained  by  the  supposition 
that  primary  vaccine  is  not  apt  to  be  at  its  best  when  it  is  now  and  then 
obtained.  Practically,  however,  it  may  be  dismissed  without  further 
consideration,  for  it  is  seldom  to  be  had. 

The  second  form — variola-vaccine — is  manifestly  improper  to  be  used 
whenever  genuine  vaccine  is  to  be  obtained,  unless,  indeed,  we  shut  our 
eyes  to  the  accumulating  evidence  that  variola-vaccine,  so  called,  is  not 
vaccine  at  all.  Furthermore,  it  is  a  question  whether  its  use,  as  well  as 
all  attempts  to  produce  it,  should  not  be  forbidden  by  law. 

The  third  variety,  if  such  it  may  be  called,  it  does  not  seem  legitimate 
to  use  in  the  present  state  of  our  knowledge,  since  it  is  not  yet  proved 
satisfactorily  that  horse-pox  possesses  the  full  protective  power  of  cow- 
pox,  or  is  free  from  objections  that  do  not  arise  in  connection  with  the 
latter. 

As  to  retro-vaccine,  while  the  writer  is  unable  to  see  any  positive  rea- 
son against  its  use,  neither  can  he  see  any  reason  why  it  should  be  supe- 
rior to  humanized  vaccine,  as  such,  save  that  during  the  period  of  its 
bovine  propagation  it  is  not  liable  to  become  contaminated  with  the  poison 
of  syphilis.  The  idea  that  an  enfeebled  stock  of  humanized  vaccine  can 
have  new  life  infused  into  it  by  passing  through  the  system  of  the  cow  is 
not  reasonable  prima  facie,  and  there  are  no  particular  facts  to  support  it. 
By  ensuring  freedom  from  the  da*nger  of  communicating  syphilis  retro- 
vaccination  doubtless  served  a  good  purpose  at  one  time,  but  now,  since 
the  remarkable  and  enduring  excellence  of  the  Beaugency  stock  is  so 
well  established,  there  seems  to  be  no  excuse  for  a  further  resort  to  the 
practice. 

The  last  of  our  five  forms  of  animal  vaccine,  that  produced  by  the 
continued  propagation  of  spontaneous  cow-pox  through  calves,  is  what  is 
now  known  as  animal  vaccine  par  excellence.  Its  advantages  over  the 
other  forms  are  so  obvious  that  it  alone  should  figure  in  any  comparison 
between  animal  and  humanized  vaccine.  That  being  understood,  what 
are  the  relative  merits  of  animal  and  humanized  vaccine  ?  It  should  be 
stated,  in  the  first  place,  that  bovine  virus  should  be  compared  with  virus 
that  has  long  been  humanized,  for  lymph  of  but  a  few  removes  from  the 
bovine  animal  does  not  show  any  noteworthy  differences  from  animal 
vaccine  itself. 

In  behalf  of  humanized  virus  it  is  maintained — 1,  that  it  is  a  more 
trustworthy  preventive  of  small-pox ;  2,  that  it  is  superior  in  its  infective 
property,  so  that  it  is  surer  to  take ;  3,  that  it  is  more  prompt  in  its  action, 
thereby  affording  more  speedy  protection  to  persons  who  have  actually 
been  exposed  to  small-pox ;  4,  that  its  virulent  property  is  easier  of  pres- 
ervation, wherefore  it  is  more  to  be  depended  on  when  it  is  necessary  to 
keep  it  on  hand  for  a  long  time  or  to  transmit  it  to  great  distances ;  5, 
that  its  use  requires  less  skill,  or,  rather,  less  special  knowledge  of  the 
peculiarities  of  the  animal  virus ;  6,  that  it  is  less  violent  in  its  effects  ;  7, 
that  it  is  less  apt  to  give  rise  to  irregular,  and  therefore  more  or  less  abor- 
tive and  non-protective,  forms  of  pock. 


474  VACCINIA. 

The  first  of  these  propositions,  which  asserts  that  humanized  vaccine 
confers  greater  protection  against  small-pox  than  the  animal  virus,  was 
warmly  'maintained  by  those  who  opposed  animal  vaccination  on  its  first 
introduction  into  this  country ;  but  now  the  record  of  the  past  thirteen 
years,  during  which  period  bovine  virus  has  more  and  more  borne  the 
brunt  of  the°  fight  against  small-pox,  has  disproved  it  in  the  judgment 
of  all  competent  and  fair-minded  observers.  So  far,  indeed,  as  the  facts 
have  been  analyzed,  they  go  to  show  that  the  reverse  is  the  case — that 
bovine  virus  confers  a  more  complete  and  a  more  lasting  protection. 
Direct  observation  on  this  point  is  strengthened  by  the  collateral  fact  that 
revaccination  became  at  once  astonishingly  successful  when  the  use  of 
animal  vaccine  first  gained  currency,  whereas  now  it  is  again  declining  in 
success ;  the  explanation  of  which  latter  circumstance  is,  that  it  is  now 
found  difficult  to  revaccinate  those  whose  primary  vaccination  was  done 
with  bovine  virus — a  striking  indication  of  the  permanence  of  the  pro- 
tection accomplished  with  the  latter. 

The  second  assertion — that  humanized  virus  succeeds  more  readily  than 
the  bovine  variety — is  still  maintained  by  many,  but,  it  may  confidently 
be  said,  by  few  if  any  whose  experience  with  good  animal  vaccine  has 
been  large.  The  truth  is,  that  every  large  public  vaccination  service  in 
the  country  is  now  carried  on  almost  solely  with  bovine  virus,  and  that 
results  are  thus  achieved  that  were  not  dreamed  of  in  former  times. 
Individual  experience  cannot  weigh  against  this  fact,  but  may  be 
explained,  rather,  by  what  modicum  of  truth  there  may  be  in  the  fifth 
proposition,  or  by  the  assumption  (surely  a  legitimate  one,  in  view  of  the 
number  of  irresponsible  and  ignorant  purveyors  of  animal  vaccine  that 
have  thrust  themselves  before  the  profession  since  the  advantages  of  the 
practice  were  established  by  the  labors  of  others)  that  those  whose  obser- 
vation leads  them  to  a  conclusion  at  variance  with  that  reached  by  the 
great  majority  of  trained  observers  have  really  been  unfortunate  in  the 
quality  of  the  virus  with  which  they  have  been  supplied.  Whatever 
the  explanation  may  be,  however,  there  is  nothing  more  certain  than  that 
the  use  of  animal  vaccine,  properly  carried  out,  is  daily  furnishing  results 
that  have  never  been  excelled,  if  they  have  been  equalled,  in  the  employ- 
ment of  humanized  virus  on  a  like  scale. 

The  third  suggestion — that  the  humanized  virus  acts  the  more  promptly 
of  the  two,  and  is  therefore  to  be  preferred  for  immediate  protection — is 
plausible,  since  the  areola  (the  alleged  sign  of  systemic  infection)  forms 
somewhat  later  around  a  pock  produced  by  animal  virus  than  around  one 
that  is  the  result  of  vaccination  with  the  humanized  variety.  The  differ- 
ence is  one  of  a  few  hours  only  at  the  most,  and  it  is  not  by  any  means 
a  general  occurrence ;  still,  we  may  concede  that  in  this  respect  the  use 
of  humanized  virus  is  to  be  preferred  under  certain  circumstances. 
^  As  to  the  fourth  statement — that  humanized  virus  is  more  tenacious  of  its 
infective  property — strictly  speaking,  there  is  not  a  particle  of  truth  in 
it.  In  the  case  of  liquid  lymph  preserved  in  capillary  tubes  it  has  the 
the  semblance  of  truth,  but,  for  reasons  that  will  be  more  fully  set  forth 
hereafter,  that  is  because  it  is  difficult  to  get  the  virulent  portion  of 
bovine  lymph  out  of  the  tube.  In  the  form  of  dried  lymph  (the  only 
form  that  ought  to  be  used)  animal  vaccine  may  be  sent  to  all  parts  of 
world,  and  may  be  kept  any  reasonable  length  of  time  and  without 


THE  TECHNICS  OF  VACCINATION.  475 

special  care,  without  undergoing  sensible  deterioration,  if  tested  by  one 
who  is  familiar  with  its  peculiarities  and  aware  of  the  care  that  should 
be  taken  in  using  it.  Under  ordinary  circumstances  there  is  no  difficulty 
about  preserving  animal  vaccine  with  its  energy  practically  unimpaired. 

The  statement  that  the  use  of  humanized  virus  demands  less  special 
knowledge  than  that  of  bovine  virus  is  conceded  at  once.  That  special 
knowledge  is  easily  mastered,  however,  and  no  man  fitted  to  practise 
medicine  will  look  upon  its  acquirement  as  a  bugbear  or  a  hardship. 

The  impression,  almost  universal  thirteen  years  ago,  that  humanized 
vaccine  is  less  severe  in  its  local  and  constitutional  effects  than  the  animal 
virus  has  been  eradicated  from  the  minds  of  all  but  those  who  still  follow 
the  teachings  of  the  older  writers  rather  than  yield  to  what  daily  experi- 
ence has  been  teaching  during  these  thirteen  years,  or  those  who  reason 
from  exceptional  cases  rather  than  from  a  general  drift.  The  truth  seems 
to  be  this  :  with  revaccinated  adults  animal  vaccine  acts  somewhat  more 
severely  than  the  humanized  virus ;  in  infants,  on  the  other  hand,  its  action 
is  not  so  violent  as  that  of  the  humanized  variety. 

Concerning  the  seventh  and  last  claim  put  forward  in  behalf  of  human- 
ized vaccine — that  it  is  less  apt  to  give  rise  to  irregular  or  spurious  pocks — 
we  may  say  that  no  form  of  irregularity  has  been  observed  by  those  who 
have  lately  used  the  bovine  virus  that  was  not  well  known  to  the  older 
writers,  who  founded  their  observations  wholly,  or  almost  wholly,  on  the 
use  of  the  humanized  virus ;  nor  is  there  any  proof  that  such  irregular- 
ities are  more  common  now  than  formerly.  The  truth  seems  to  be,  that 
these  irregular  forms  of  pock  seem  to  prevail  at  certain  times,  and  not 
at  other  times,  regardless  of  the  particular  stock  of  virus  used,  other 
things  being  equal.  Why  this  should  be  so  we  do  not  know,  but  the  fact 
is  beyond  dispute. 

To  sum  up,  then,  we  can  only  say  that  in  barely  one  particular — that 
of  promptness  of  action — can  humanized  virus  justly  be  credited  with 
any  superiority,  while  in  every  other  essential  respect  it  is  inferior,  so  far 
as  any  difference  is  to  be  observed. 

What,  on  the  other  hand,  are  the  points  of  superior  excellence  attaching 
to  bovine  virus  ?  Setting  aside  certain  extravagant  assertions  that  have  some- 
times been  made  in  its  behalf,  such  as  that  it  far  exceeds  the  humanized  virus 
in  its  protective  virtue  (which  may  be  true,  but  is  not  yet  proved),  they 
may  be  put  in  general  terms  in  the  form  of  a  denial  of  all  the  particular 
claims  that  we  have  enumerated  as  having  been  put  forth  for  its  rival. 
Such  a  denial,  it  has  been  seen,  seems  to  the  writer  to  be  justified,  save 
in  the  one  particular  that  perhaps  we  should  accord  to  humanized  virus 
the  merit  of  speedier  action,  and  consequently  greater  certainty  of  pro- 
tection, in  cases  of  actual  exposure  to  small-pox. 

Besides  these  negative  points  in  its  favor,  the  foremost  advantage  of 
animal  vaccine  is  the  guarantee  it  gives  that,  properly  used,  no  syphilitic 
contamination  will  result.  On  this  point  no  argument  is  needed,  for  the 
cow  is  insusceptible  to  syphilis. 

A  second  consideration  in  its  favor  is,  that  it  can  always  be  had  in  large 
quantities  at  short  notice.  The  young  practitioner  of  the  present  day  can 
scarcely  appreciate  the  importance  of  this  fact,  but  whoever  remembers 
the  comparative  helplessness  in  which,  in  past  years,  he  has  found  him- 
self in  the  face  of  a  sudden  outbreak  of  small-pox,  not  knowing  which 


476  VACCINIA. 

way  to  turn  for  an  adequate  supply  of  vaccine,  will  at  once  concede  its 

force. 

On  the  whole,  then,  it  must  be  said  that  bovine  virus  is  entitled  to  the 
preference  as  a  rule,  but  that  possibly  it  is  well  to  resort  to  humanized 
Ivmph  of  early  removes  under  the  special  circumstances  above  referred  to. 
On  no  account  should  long-humanized  vaccine  be  used  so  long  as  our 
present  stocks  of  animal  virus  maintain  the  excellence  they  have  thus  far 
preserved,  nor  should  humanized  virus  of  any  sort  be  preferred  in  the 
general  run  of  cases. 

Passing  now  to  a  consideration  of  the  various  forms  of  vaccine,  disre- 
garding its  source,  there  are  practically  these  three :  the  crust,  liquid 
lymph  preserved  in  capillary  tubes,  and  dried  lymph. 

Until  recently  the  crust,  or  scab,  was  much  used  in  this  country.  Its 
capability  of  being  preserved  unimpaired  for  a  long  time  was  a  valid 
excuse  for  this,  especially  in  regions  remote  from  the  great  channels  of 
communication,  and  it  was  in  such  districts  that  the  use  of  the  crust  was 
chiefly  practised.  That  excuse  scarcely  exists  now,  for  there  are  few  phy- 
sicians who  cannot  obtain  a  better  form  of  vaccine  within  a  very  short 
time.  The -objections  to  the  crust  are  two:  1.  Most  crusts  are  inert. 
Especially  is  this  true  of  bovine  crusts,  which  are  wellnigh  worthless.  It 
must  be  confessed,  however,  that  when  once  a  crust  has  proved  itself 
active  it  may  be  trusted  to  retain  its  infective  property  for  a  very  long 
time.  The  writer  has  made  successful  use  of  crusts  seven  years  old  that 
had  made  the  voyage  to  Japan  and  back ;  and  they  were  bovine  crusts 
too.  Still,  the  rule  is,  that  crusts  are  untrustworthy.  2.  Their  use  is 
apt  to  be  followed  by  undue  inflammation,  probably  of  septic  origin,  for 
they  almost  invariably  contain  putrescent  or  readily  putrescible  elements. 
It  has  even  happened  to  the  writer  to  cut  open  a  crust  that  to  all  appear- 
ance was  typical  and  innocent,  and  to  find  in  its  interior  a  cavity  occupied 
by  a  pulpy,  stinking  slough.  Manifestly,  such  material  is  unfit  to  be 
introduced  into  the  system  of  any  human  being. 

In  regard  to  liquid  lymph  in  tubes,  it  is  not  much  used  in  this  country, 
and  its  employment  elsewhere  is  on  the  decline.  At  first  thought,  it 
would  seem  to  be  the  best  form  of  all,  but  experience  does  not  bear  out 
this  view.  In  this  form  humanized  lymph  is  vastly  superior  to  animal 
lymph,  but  with  every  possible  care  in  charging  and  sealing  the  tubes  it 
is  not  uncommon  to  find  their  contents  putrid.  There  are  low  vegetable 
organisms  that  are  supposed  to  prey  on  the  vaccinad.  If  there  is  any 
truth  in  this  supposition,  those  organisms  are  certainly  favored  in  their 
destructive  luxuriance  by  keeping  the  lymph  liquid,  thus  furnishing  them 
with  the  best  possible  culture-fluid.  Be  this  as  it  may,  the  fact  is  well 
ascertained  that  tube-lymph  does  not  keep  well.  It  has  been  mentioned 
already  that  bovine  lymph  stored  in  tubes  is  decidedly  inferior  to  the 
same  form  of  humanized  lymph.  This  was  long  ago  recognized  by  propa- 
gators of  animal  vaccine,  but  the  cause  remained  a  mystery  until  Warlo- 
mont  of  Brussels  suggested  that  it  was  due  to  one  of  the  'physical  pecu- 
liarities of  animal  lymph— that,  namely,  as  already  hinted  at,  by  virtue 
f  which  its  formed  elements  tend  to  attach  themselves  to  any  surface 
presented  to  them,  leaving  the  supernatant  liquid  a  mere  inert  compound 
of  water,  albumen,  and  salts ;  so  that  in  the  case  of  tube-lymph  the  viru- 
lent elements  remain  attached  to  the  glass,  and  only  the  inert  constituents 


THE  TECHNICS  OF  VACCINATION.  477 

are  really  used.  This  theory  is  exceedingly  ingenious  and  plausible,  but 
the  writer  is  not  aware  that  it  has  been  proved.  He  does  know,  how- 
ever, that  in  some  South  American  countries,  where  calf  lymph  in  tubes 
is  used  with  success,  the  custom  is  to  grind  the  tubes  to  powder,  and  inoc- 
ulate with  the  resulting  magma,  glass  and  all.  This  practice  is  certainly 
not.  to  be  commended. 

Dried  lymph  is  the  most  efficient  of  all  forms  of  vaccine,  and,  kept  as 
it  ought  to  be,  it  retains  its  infective  power  long  enough  to  answer  all 
ordinary  requirements.  The  writer  has  used  it  three  years  old  with  suc- 
cess. It  may  commonly  be  counted  on  for  six  weeks.  One  fact  should 
be  borne  in  mind,  however :  the  longer  dried  lymph  has  been  kept  the 
more  care  is  necessary  in  its  use,  for  by  long  keeping  it  becomes  very 
hard,  so  that  it  is  a  work  of  patience  to  dissolve  it  off  from  the  surface 
on  which  it  was  deposited.  Failure  to  accomplish  its  solution  is  the  most 
common  cause  of  a  lack  of  success  in  its  employment. 

The  various  forms  of  stored  vaccine  are  esteemed  by  the  writer  in  the 
following  order  :  1,  dried  bovine  lymph  ;  2,  dried  humanized  lymph ;  3, 
humanized  tube-lymph ;  4,  humanized  crusts ;  5,  bovine  tube-lymph ;  6, 
bovine  crusts. 

The  age  and  other  circumstances  under  which  it  is  best  to  vaccinate 
children  .constitute  a  point  for  practical  consideration.  It  may  first 
be  mentioned  that  pre-natal  vaccination  has  been  advocated  by  some 
authors ;  that  is  to  say,  the  vaccinal  infection  of  the  fetus  in  utero  by 
vaccinating  the  mother  during  gestation.  There  seems  to  be  respect- 
able testimony  going  to  show  that  the  end  may  thus  be  accomplished, 
but  a  weighty  objection  arises  in  the  fact  that  this  mediate  vaccina- 
tion of  the  foetus  produces  no  physical  sign  of  its  success,  so  that  doubt 
must  always  be  felt  as  to  whether  or  not  the  procedure  has  been  effica- 
cious. Moreover,  it  is  seldom  indeed  that  a  child  needs  protection  before 
its  birth,  provided  we  protect  the  mother,  for  it  is  well  known  that 
vaccinia  will  overtake  and  destroy  the  variolous  infection,  even  when 
the  latter  has  had  two  or  three  days'  start.  The  practice  has  been  chiefly 
urged  by  Bellinger.  It  is  not  likely  to  come  into  general  use. 

There  is  no  special  objection  to  vaccinating  an  infant  at  any  time  after 
birth,  but  usually  it  is  well  to  defer  the  operation  until  the  child  is  about 
three  months  old,  unless  there  is  actual  danger  of  exposure  to  small-pox. 
Yet  it  is  not  well  to  postpone  vaccination  until  the  period  of  dentition, 
for  the  combined  irritation  of  the  two  disturbing  elements  may  prove 
decidedly  uncomfortable  if  not  serious. 

Something  is  to  be  said  as  to  the  time  of  the  year  to  be  chosen.  In 
New  York  the  bad  custom  prevails,  especially  among  the  poorer  classes, 
of  having  children  vaccinated  only  in  April,  May,  or  June — just  the 
part  of  the  year  in  which  erysipelas  is  most  rife.  The  hot  months 
should  not  generally  be  chosen,  for  any  source  of  irritation  is  apt  to  be 
felt  more  severely  by  infants  during  the  summer  heat.  However,  no 
circumstances  should  be  looked  upon  as  a  positive  bar  to  vaccination  in 
case  of  actual  danger  of  exposure  to  small-pox,  and  in  large  towns  chil- 
dren should  never  be  taken  into  public  conveyances  or  carried  into  any 
promiscuous  assemblage  until  they  have  been  protected  by  vaccination. 

The  next  question  is  as  to  the  part  of  the  body  that  should  be  selected 
for  the  inoculation.  The  region  of  the  insertion  of  the  left  deltoid  muscle 


478  VACCINIA. 

is  usually  chosen — the  left  rather  than  the  right,  because  most  nurses 
habitually  carry  an  infant  on  their  own  left  arm,  so  that  the  child's  left 
arm  is  uppermost,  and  hence  less  exposed  to  injury.  The  region  of  the 
deltoid  insertion  is  comparatively  free  from  the  irritation  of  muscular 
contraction,  and  it  is  easily  accessible.  If  two  insertions  are  made,  it  is 
well  to  make  one  of  them  over  the  deltoid  insertion  and  the  other  at  a 
point  about  an  inch  distant  on  the  line  of  the  posterior  border  of  the 
same  muscle,  for  there  the  lymphatic  connection  with  the  axillary  glands 
is  less  free,  so  that  adenitis  is  not  so  much  to  be  feared.  To  avoid  a  scar 
in  a  locality  that  may  be  exposed  to  view  on  certain  occasions  some 
mothers  prefer  that  their  daughters  should  be  vaccinated  on  the  lower 
limb.  To  this  there  is  no  special  objection,  further  than  that  the  lower 
limb  is  rather  more  exposed  to  rough  handling  than  the  arm.  If  the 
leg  is  chosen,  the  point  of  junction  of  the  two  heads  of  the  gastrocne- 
mius  is  an  eligible  situation. 

The  actual  operation  is  performed  in  various  ways.  The  old  inocu- 
lators  generally  made  an  incision  through  the  whole  thickness  of  the 
skin,  so  that  a  pellet  of  subcutaneous  fat  rolled  up  into  the  little  wound. 
This  is  wholly  unnecessary;  furthermore,  it  is  objectionable,  for  it 
decidedly  increases  the  risk  of  inflammatory  complications.  Still  more 
to  be  avoided  are  the  methods  by  inserting  a  seton  imbued  with  the  virus 
and  by  hypodermic  injection  or  other  like  procedures.  The  best  way  is, 
simply  to  remove  the  horny  layer  of « the  cuticle,  so  as  to  expose  the  suc- 
culent portion  of  the  epidermis.  This  surface  is  somewhat  red,  and  from 
it  a  slight  exudation  of  lymph  will  be  observed,  but  there  need  not  be  the 
least  flow  of  blood.  By  this  procedure  it  is  not  uncommon  to  vaccinate  a 
sleeping  child  without  waking  it.  It  is  not  only  admissible,  but  prefer- 
able, not  to  wound  the  derma  at  all.  Such  an  abrasion  is  easily  made 
with  an  ordinary  lancet,  which,  contrary  to  the  advice  sometimes  given, 
should  be  very  sharp ;  out  no  cutting  or  scratching  should  be  done  with 
it,  only  scraping  with  the  convex  part  of  its  edge,  precisely  as  in  using 
an  ink-eraser.  Scratching  instruments  (such  as  the  rake-like  vaccinator 
often  used  or  a  row  of  needles  set  in  a  handle)  are  not  easy  to  adapt  to 
varying  degrees  of  plumpness  of  the  arm,  and  are  apt  to  make  too  deep 
scratches,  one  at  either  side,  while  the  skin  between  the  two  is  scarcely 
touched.  Whatever  instrument  is  chosen,  it  should  not  be  used  again 
until  it  has  been  thoroughly  cleansed — made  chemically  clean — which  can 
be  Accomplished  only  by  heating  it  or  by  wiping  it  off  and  then  dipping 
it  into  a  strong  disinfectant  solution. 

Some  individuals  are  refractory  to  vaccination,  but  complete  insus- 
ceptibility is  exceedingly  rare.  Various  expedients  have  been  resorted 
to  in  rebellious  cases,  such  as  vesication  with  ammonia-water,  maceration 
of  the  skin  for  some  hours  with  glycerine,  and  the  like.  The  writer  has 
known  these  devices  to  succeed,  but  he  has  not  seen  the  slightest  advan- 
tage m  the  plan  recommended  by  Ceely,  that  of  using  a  wound  some 
3urs  old  rather  than  one  just  made,  although  he  has  tried  the  experi- 
ment many  times.  It  is  not  necessary  to  make  a  large  abrasion  :  one  as 
large  as  the  little  finger-nail  is  ample. 

The  next  step  is  to  apply  the  virus,  and  it  should  be  so  applied  as  to 
mto  contact  with  every  part  of  the  denuded  surface.  In  what  is 

lown  as  arm-to-arm  vaccination,  or  its  equivalent,  calf-to-arm  vaccina- 


THE  STORAGE  AND  PRESERVATION  OF  VACCINE   VIRUS.     479 

tiou  (by  all  means  the  most  successful  method,  although  not  often  prac- 
ticable in  this  country),  the  liquid  lymph,  fresh  from  the  vaccinifer's  pock, 
is  simply  applied,  when  it  will  at  once  become  diffused  over  the  abraded 
surface  without  any  special  pains  being  taken  to  accomplish  that  end. 

If  dried  lymph  is  used,  particular  care  should  be  taken  to  see  that  it  is 
actually  dissolved  and  transferred  from  the  substance  on  which  it  was 
dried  to  the  abraded  surface.  Failure  to  accomplish  this  is  the  cause  of 
almost  all  the  lack  of  success  that  inexperienced  vaccinators  meet  with. 
The  lymph  should  be  moistened  with  water,  or,  if  it  is  quite  old,  with 
glycerine,  before  the  abrasion  is  made,  so  that  it  may  have  time  to  dis- 
solve. It  should  then  be  rubbed  upon  the  abraded  spot  vigorously,  and 
at  least  for  the  space  of  a  full  minute. 

In  the  use  of  tube-lymph  no  other  precautions  are  necessary  than  in 
arm-to-arm  vaccination,  but,  simple  as  this  method  is,  its  results  are 
unsatisfactory. 

Crusts  should  be  reduced  to  a  powder,  and  then  made  into  a  thin  paste 
with  water  or  glycerine.  A  convenient  way  of  powdering  a  crust  is  to 
rub  it  on  a  file  or  between  two  files.  The  paste  is  to  be  well  rubbed 
upon  the  abrasion.  The  insertion  of  a  solid  piece  of  crust  into  a  valvu- 
lar incision  is  not  to  be  recommended. 

When  the  operation  is  finished  it  is  well  to  keep  the  arm  bare  for 
about  five  minutes,  but  not  necessarily  until  the  spot  has  become  dry. 
It  is  not  well  to  apply  any  sort  of  plaster,  but  means  should  be  taken  to 
prevent  the  underclothing  from  sticking  to  the  abrasion.  For  this  pur- 
pose there  is  no  objection  to  the  shields  that  are  furnished  by  the  surgical 
instrument-makers.  Usually,  however,  nothing  of  the  sort  is  necessary. 

THE  STORAGE  AND  PRESERVATION  OF  VACCINE  VIRUS. — Lymph 
should  usually  be  taken  on  the  eighth  day,  inclusive — never  after  the 
ireola  has  formed.  On  the  other  hand,  the  writer's  experience  does  not 
lead  him  to  coincide  with  those  who  state  that  the  earliest  lymph  that  can 
be  obtained  is  the  most  energetic.  If  it  is  to  be  dry-stored,  the  substance 
to  be  coated  with  it  (slips  of  quill,  ivory,  wood,  whalebone,  glass,  and  the 
like)  should  be  laid  gently  in  the  pool  of  lymph  that  exudes  on  punctur- 
ing the  pock,  and  allowed  to  dry,  preferably  without  the  aid  of  artificial 
warmth.  The  layer  of  lymph  should  be  plainly  visible  after  it  has  dried. 
A  second  coating  is  advisable,  as  it  serves  to  preserve  the  first. 

Capillary  glass  tubes  are  either  cylindrical  or  furnished  with  a  bulbous 
expansion  at  the  middle,  the  latter  form  being  most  commonly  used.  To 
charge  a  tube  make  sure  that  both  ends  are  open,  and  then  submerge  one 
end  in  the  pool  of  lymph.  Capillary  attraction  will  cause  the  tube  to 
fill,  and  the  process  may  be  facilitated  materially  by  inclining  the  tube 
toward  a  horizontal  direction,  so  that  the  capillary  attraction  is  not 
opposed  by  that  of  gravitation.  Care  should  be  taken  to  keep  the 
applied  end  of  the  tube  constantly  submerged,  or  bubbles  of  air  will 
enter  it.  The  sealing  may  be  done  with  a  blowpipe,  by  simply  holding  the 
ends  in  a  flame,  or  by  means  of  sealing-wax  or  some  similar  substance. 
The  satisfactory  charging  of  tubes  demands  some  practice,  but  a  little 
patience  will  enable  any  intelligent  person  to  succeed. 

In  regard  to  crusts,  they  should  never  be  removed  until  the  surface 
beneath  has  become  cicatrized  and  they  have  been  partially  detached  by 
the  natural  process.  A  crust  torn  off  prematurely  should  never  be  used, 


480  VACCINA. 

and  the  same  may  be  said  of  secondary  crusts — i.  e.  those  that  form  by 
the  desiccation  of  the  discharge  from  the  raw  surface  left  when  the  primary 
crust  has  been  removed  forcibly. 

For  the  preservation  of  vaccine  in  these  various  forms  tubes  need  only 
be  kept  in  a  cool  place.  Dried  lymph  and  crusts  should  be  guarded 
against  dampness  even  more  than  against  warmth.  Their  preservation 
may  be  decidedly  favored  by  over-drying,  either  in  an  exhausted  receiver 
or  by  keeping  them  in  a  closed  vessel  in  the  presence  of  sulphuric  acid, 
chloride  of  calcium,  or  some  other  substance  having  a  strong  affinity  for 
water.  It  is  needless  to  say,  however,  that  they  should  not  come  into 
actual  contact  with  any  such  agent.  While  this  artificial  desiccation  tends 
powerfully  to  preserve  dried  lymph,  it  makes  it  more  difficult  to  use. 
"\Vhen  dried  lymph  or  a  crust  is  to  be  sent  by  mail  or  other  conveyance, 
it  should  be  wrapped  in  some  impermeably  envelope,  for  which  purpose 
gutta-percha  tissue  is  very  convenient.  Both  these  forms  of  virus  should 
be  kept  in  a  cool  place.  There  is  no  objection  to  keeping  them  on  ice, 
provided  they  are  well  protected  against  moisture. 

In  conclusion,  the  writer  wishes'  to  say  that  the  limited  space  at  his 
command  has  compelled  the  assumption  of  a  dogmatic  rather  than  an 
inductive  form  in  the  construction  of  this  article.  To  the  reader  who 
may  wish  to  pursue  the  subject  further — and  it  will  well  repay  thorough 
study — he  would  recommend  the  following  bibliography  : 

Ballard :  On  Vaccination :  its  Value  and  Alleged  Dangers,  London, 
1868. 

Bousquet:  Nouveau  traite  de  la  vaccine  et  des  eruptions  varioleuses, 
Paris,  1848. 

Bryce :  Practical  Observations  on  the  Inoculation  of  Cow-pox,  Edin- 
burgh, 1809. 

Ceely :  Observations  on  the  Variolce  Vaccine,  Worcester,  1840. 

Chauveau  et  al. :   Vaccine  et  Variok,  Paris,  1865. 

Depaul :  Nouvettes  recherches  sur  la  veritable  origine  du  virus  raccin, 
Paris,  1863 ;  De  Porigine  reelle  du  virus  vaccin,  Paris,  1864 ;  et  al. :  De 
la  syphilis  vaccinak,  Paris,  1865. 

Hardaway  :  Essentials  of  Vaccination,  Chicago,  1882. 

Hering :   Ueber  Kuhpocken  an  Kuhen,  Stuttgart,  1839. 

Jenner:  An  Inquiry,  etc.,  2d  ed.,  London,  1800. 

Sacco:  T)-attato  di  Vaccinazione,  Milano,  1809. 

Seaton  :  A  Handbook  of  Vaccination,  London,  1868. 

Steinbrenner :  Traite  sur  la  vaccine,  Paris,  1846. 


VARICELLA. 

BY  JAMES  NEVINS  HYDE,  M.  D. 


VARICELLA  is  an  acute  disorder  of  infancy  and  childhood,  in  the 
course  of  which  appears  a  cutaneous  exanthem  of  vesicular  type,  accom- 
panied at  times  by  systemic  symptoms  of  moderate  severity,  termina- 
ting in  the  course  of  from  three  days  to  a  fortnight,  after  the  forma- 
tion of  relatively  few  crusts  upon  the  skin,  with  occasionally  persistent 
cicatrices. 

SYNONYMS. — Eng.,  Chicken-pox;  Ger.,  Windblattern,  Schafpocken ; 
Fr.,  Varicelle ;  Lot.,  Variola  notha,  seu  spuria ;  ItaL,  Morviglione. 

HISTORY. — The  literature  of  the  disease  which  is  now  best  recognized 
under  the  title  of  varicella  has  been,  in  the  history  of  medicine,  wellnigh 
inextricably  confused  with  that  of  variola.  In  the  latter  part  of  jthe 
seventeenth  and  the  early  part  of  the  eighteenth  century  the  distinction 
between  typical  forms  of  the  two  disorders  became  apparent,  and  was 
described  by  Willan  and  Harvey  in  England,  and  other  writers  in  Ger- 
many, France,  Holland,  and  Belgium.  Among  those  who  have  contrib- 
uted to  its  literature  may  be  named  Hebra,  Kaposi,  Trousseau,  Simon, 
Thomas,  Giintz,  Henoch,  Kassowitz,  and  Boeck. 

ETIOLOGY. — Varicella  is  essentially  a  disease  of  early  life,  occurring 
almost  exclusively  in  infants  and  young  children.  It  is  a  contagious 
disorder,  and  at  times,  especially  in  hospitals  and  asylums  for  children, 
occurs  in  apparently  epidemic  forms.  The  question  relating  to  the  inoc- 
ulability  of  the  contents  of  its  vesicular  lesions  is  still  open,  positive  and 
negative  results  being  recorded  by  different  experiments. 

SYMPTOMATOLOGY. — The  period  of  incubation  of  the  disease  cannot 
be  said  to  be  definitely  established.  At  times,  without  question,  an  entire 
fortnight  elapses  between  the  dates  of  exposure  and  the  evolution  of  the 
disease,  but  both  longer  and  shorter  intervals  have  been  recorded. 

1  The  writer  has  purposely  avoided,  in  the  brief  space  here  devoted  to  the  disease  under 
consideration,  entering  into  a  discussion  of  the  question  respecting  the  relation  sustained 
by  varicella  to  variola.  On  one  side  are  the  views  entertained  by  the  Vienna  school  of 
dermatologists,  according  to  which  there  is  but  a  single  virus  in  these  several  forms  of 
disease — the  variolous  poison.  On  the  other  are  the  opinions  and  the  practice,  largely 
based  upon  the  latter,  of  most  English  and  American  physicians,  who  deny  the  existence 
of  any  relation  between  the  pathological  states  recognized  by  them  as  occurring  in  two 
entirely  distinct  affections. 

My  personal  view  may  be  briefly  formulated  as  follows :  Practically  and  clinically,  it  is 
useful  to  regard  these  disorders  as  of  a  distinct  nature.  The  arguments,  however,  in 
favor  of  such  absolute  distinction  are  not  irrefutable.  There  is  probably  in  both  forms 
of  disease  but  a  single  virus,  that  of  variola ;  but  this,  modified  by  evolution  among  gen- 
erations of  vaccinated  children,  has,  in  this  process  of  natural  cultivation  or  attenuation, 
produced  a  malady  of  tender  years  whose  attacks  do  not  protect  from  variola  and  occur 
irrespective  of  vaccination. 

VOL.  I.— 31  481 


482  VARICELLA. 

If  there  be  a  prodromal  stage  of  the  disease,  certainly  in  the  vast 
majority  of  the  little  patients  it  cannot  be  recognized.  During  the  last 
month  the  writer  has  observed  the  evolution  of  the  disease  in  twenty 
children  gathered  together  in  the  Chicago  Home  for  the  Friendless,  no 
one  of  whom  was  recognized  as  ailing  before  the  eruption  appeared. 
Occasionally  the  disease  is  preceded  by  mild  or  even  severe  febrile  symp- 
toms, accidents  sufficiently  common  in  this  class  of  patients. 

The  exanthem,  commonly  the  first  symptom  of  the  disorder,  occurs  in 
the  form  of  reddish  puncta,  from  which  rapidly  develop  rosy-colored 
maculations,  and  these  become  tensely  distended,  transparent  or  slightly 
yellowish  vesicles,  of  the  average  size  of  a  split  pea,  though  they  are 
ocasionally  smaller  or  may  enlarge  to  the  dimensions  of  a  bean  or 
small  nut.  The  eruption  appears  first  upon  the  upper  segment  of  the 
body,  implicating  the  chest  in  front  and  behind,  the  neck,  the  scalp,  par- 
ticularly the  extremities,  and  quite  sparingly  the  face  also,  which  may, 
however,  entirely  escape.  In  cases  where  the  eruption  is  profuse  it  may 
be  completely  generalized,  involving  largely  the  trunk  and  extrem- 
ities, the  lesions,  upon  the  back  particularly,  being  as  closely  set 
together  as  in  discrete  variola.  In  many,  even  the  majority,  of  cases 
the  exanthem  is  much  less  profusely  developed,  not  more  than  a  dozen  or 
twenty  vesicles  springing  from  the  surface. 

The  vesicles  are  superficial  in  situation,  the  firm  papule  which  precedes 
the  variolous  rash  being  altogether  wanting.  They  are  at  first  transpar- 
ent, their  contents  plainly  showing  through  their  translucent  roof-wall, 
composed  only  of  the  stratum  corneum  of  the  epidermis.  They  are  both 
acuminate  and  globular,  and  occasionally  rest  upon  a  slightly  hypenernic 
integument.  Umbilication  rapidly  occurs  at  the  apex,  and  simultaneously 
their  contents  become  lactescent  and  gradually  sero-purulent.  Occasion- 
ally vesicles  are  transformed  into  genuine,  coffee-bean-sized,  pustules. 
Intermingled  with  these  are  often  seen  illy-developed  and  abortive 
vesicles. 

By  the  end  of  a  period  lasting  from  twelve  hours  to  the  second  or 
third  day  involution  has  usually  begun,  and  the  lesions,  with  and  with- 
out rupture — more  often  the  latter— desiccate,  and  are  thus  transformed 
into^  yellowish  or  yellowish  and  brown,  circular,  circumscribed  crusts 
resting  upon  an  apparently  unaltered  integument.  These  crusts  are  often 
so  firmly  attached  that  they  do  not  fall  spontaneously  before  the  lapse  of 
from  five  to  eight  days.  When  this  exfoliation  is  ended  there  are  left 
slightly  hypersemic  pigmented  patches  of  corresponding  size  where  the 
crusts  had  rested.  A  destructive  process  occasionally  results  upon  the 
surface  of  the  face  at  the  base  of  such  vesiculo-pustular  lesions  as  have 
formed  there,  in  consequence  of  which  a  small  depressed  and  superficial 
cicatrix  is  left,  which  does  not  differ  from  that  resulting  from  discrete 
variola.  These  scars  may  be  superficially  seated  and  transitory  in  cha- 
racter, or  much  deeper  and  persistent  through  life. 

Throughout  the  course  of  the  disease  systemic  symptoms  may  be  alto- 
gether wanting,  or  may  occur  in  a  mild,  and  much  more  rarely  in  a 
severe,  type.  In  some  cases  the  temperature  is  increased  by  one  or  two 
degrees  upon  the  appearance  of  the  exanthem,  and  often  a  febrile  move- 
ment of  moderate  grade  may  persist  for  forty-eight  hours  or  somewhat 
Defervescence,  however,  is  always  rapid  and  perfect.  In  very 


PATHOLOGY.— DIAGNOSIS.  483 

rare  cases  there  is  a  subsequent  successive  new  development  of  scanty 
vesicles,  whose  appearance  is  heralded  by  mild  exacerbations  of  fever. 

Occasionally  the  vesicles  may  be  recognized  upon  the  mucous  surfaces 
of  the  lips,  inside  of  the  cheeks,  tongue,  palate,  conjunctivae,  and  pro- 
genital  regions  of  both  sexes.  Still  more  rarely  the  glands  of  the  throat 
become  slightly  tumid  and  painful. 

The  complexus  of  symptoms,  in  the  large  majority  of  all  these  little 
patients,  is  that  which  pertains  to  a  disorder  of  distinctly  mild  type. 
The  eruptive  lesions  are  scanty  and  productive  of  but  trifling  subjective 
sensations.  Occasionally  they  are  picked  or  scratched,  and  thus  become 
the  seat  of  either  pain  or  pruritus.  In  the  febrile  stage  the  child  is 
noticeably  fretful  for  a  period  of  perhaps  twenty-four  hours.  At  the  end 
of  that  time  older  children  are  frequently  observed  engaged  in  their  cus-r 
tomary  amusements  in  the  nursery. 

Severe  types  and  complications  of  varicella  are  in  general  limited  to 
the  little  patients  who  are  recognized  as  suffering  from  hospitalism. 
Among  these  we  see  erysipelas,  severe  vaccinal  eruptions,  lesions  of 
inherited  syphilis,  and  the  sequelae  of  morebilli  and  scarlatina,  which  the 
disease  both  precedes  and  follows. 

PATHOLOGY. — The  anatomical  structure  of  the  lesions  in  varicella  is 
largely  a  matter  of  inference,  since  there  has  been  but  small  opportunity 
of  studying  the  disorder  as  displayed  in  sections  of  the  morbid  integu- 
ment. Manifestly,  the  exanthem  is  exudative  in  type,  the  serum  in  cir- 
cumscribed areas  lifting  the  superficial  layer  of  the  epidermis  from  the 
deeper  parts  of  the  derm.  Unquestionably,  septa  occur  in  typically 
developed  varicella  chambers,  similar  to  those  seen  in  variola — a  patho- 
logical fact  which  is  the  corner-stone  of  the  doctrine  relating  to  the  unity 
of  the  two  disorders.  The  serum  contained  in  these  septa  possesses  an 
alkaline  reaction.  The  formation  of  a  cicatrix  is  evidently  due  to  the 
intensity  of  the  process  in  certain  exceptional  lesions,  as  a  result  of  which 
the  papillae  of  the  corium  are  superficially  destroyed.  These  sequelae 
are  often  due  to  the  picking  and  scratching  of  the  lesions. 

DIAGNOSIS. — Varicella  is  to  be  distinguished  from  eczema  pustulosum 
by  its  mild  febrile  symptoms,  the  discreteness  of  its  pustular  lesions,  the 
absence  of  itching;  and  of  infiltration  of  the  skin  in  patches,  and  its 
tendency  to  symmetrical  development. 

From  impetigo  and  the  impetigo  contagiosa  of  Fox  of  London  it  will 
often  be  scarcely  differentiated.  Inasmuch  as  these  disorders  are  fre- 
quently recognized  among  children  suffering  from  varicella  or  varicella 
convalescence,  it  can  scarcely  be  doubted  that  these  diseases  have  been  in 
the  past  often  confounded,  and  that  in  many  cases  it  is  practically  impos- 
sible to  distinguish  between  them.  Decided  elevation  of  bodily  tempera- 
ture, umbilication  of  symmetrically-disposed  lesions,  and  a  rapid  involu- 
tion of  the  disease  point  to  varicella.  The  two  forms  of  impetigo  occur 
without  fever,  are  usually  scantily  developed,  and  are  much  more  apt  to 
be  pustular  in  type,  lacking,  moreover,  the  halo  of  the  varicella  lesions. 
The  latter  are  also,  on  an  average,  smaller  and  more  numerous.  The 
two  forms  of  impetigo,  finally,  never  display  the  generalized  eruption  of 
severe  varicella.  The  non-contagious  variety  of  impetigo  is  much  more 
decidedly  pustular  in  its  lesions,  and  the  latter  spring  from  a  deeper  plane 
of  the  epidermis. 


434  VARICELLA. 

As  to  the  eruptions  due  to  vaccinia  and  vaccination,  there  can  be  but 
little  doubt  that  these  also  have  been  frequently  confounded  with  vari- 
cella. Efflorescences  having  origin  in  this  way  are  very  largely  impetigi- 
nous  in  type,  and  the  conditions  named  above  are  then  to  be  regarded  as 
distinctive  differences,  so  far  as  any  distinction  can,  under  these  circum- 
stances, be  recognized.  Impetigo,  impetigo  contagiosa,  and  varicella  are 
all  sufficiently  common  accidents  after  vaccination.  No  reliance  can  be 
placed  upon  characteristics  described  as  connected  with  a  certain  stuck-on 
appearance  of  the  crust  regarded  by  Fox  as  characteristic  of  the  crusts 
in  impetigo  contagiosa.  In  all  these  vesiculo-pustular  disorders  of 
childhood  desiccating  serum  and  sero-pus  upon  the  surface  result  in 
the  formation  of  crusts  which  have  a  similar  (so-called)  stuck-on 
appearance. 

Variola  and  varioloid  of  infants  and  children  are  to  be  distinguished 
from  varicella  by  the  evidence  of  origin  from  such  contagious  maladies ; 
by  the  occurrence  of  prodromal  symptoms ;  by  the  greater  rise  in  tem- 
perature during  the  febrile  stage ;  by  the  typically  papular  stage  of  the 
exauthem  at  its  outset,  and  no  less  typically  pustular  stage  before  the 
occurrence  of  desiccation ;  by  the  confluence  of  lesions  in  confluent 
cases;  and  by  the  much  longer  and  evidently  graver  stadium  of  the 
disease.  Distinctions  between  mild  varioloid  and  severe  varcella  in 
infancy  and  childhood  will  always  tax  to  the  utmost  the  skill  of  the 
diagnostician.  The  sooner  it  is  generally  understood  that  intermediate 
forms  occur  which  cannot  be  positively  assigned  to  the  one  or  to  the 
other  category,  the  better  it  will  be  for  both  the  profession  and  the  laity. 
The  fact  that  in  the  one  case  there  is  generation  of  a  variolous  poison 
capable  of  producing  a  contagious  disease  in  adults,  and  in  the  other  a 
malady  which  is  known  to  affect  children  only,  renders  the  decision 
important.  Scattered  papulo-vesicular  and  vesiculo-pustular  lesions 
appearing  after  a  high  fever,  and  pursuing  a  period  of  evolution  longer 
than  forty-eight  hours,  should  always  awaken  suspicion.  Superficial 
lesions,  on  the  contrary,  distinctly  vesicular  on  the  third  day,  or  com- 
mingled with  minute,  very  superficial  pustules,  should  be  regarded  as 
characteristic  of  varicella. 

The  so-called  varicella  prurigo  of  Hutchison  of  London *  includes 
several  of  the  disorders  considered  above  under  the  titles  impetigo, 
impetigo  ^  contagiosa,  and  the  vaccine  rashes.  The  irritable  condition 
of  the  skin  resulting  from  several  of  the  exanthemata  leaves  it  prone  to 
the  development  of  a  long  list  of  cutaneous  lesions,  some  of  them  accom- 
panied by  pruritus  in  various  grades,  to  each  of  which  might  be  given, 
according  to  the  caprice  of  authors,  a  separate  name. 

PROGNOSIS. — The  prognosis  of  varicella,  per  se,  is  always  favorable. 
Only  in  the  hospital  cases,  complicated  by  erysipelas  and  scarlatina  con- 
valescence, may  grave  results  be  anticipated.  The  milder  attacks  may 
leave  persistent  relics  of  their  career  in  the  form  of  one  or  more  depressed 
and  persistent  cicatrices,  which  become  less  conspicuous  as  the  patient 
approaches  adult  years. 

TREATMENT. — Varicella  is,  in  a  large  proportion  of  cases,  successfully 

ited  by  domestic  management  and  the  simpler  remedies  familiar,  to 

m  charge  of  the  nursery.     Confinement  for  a  brief  time  to  the 

1  Lect.  on  Win.  Surg.,  Lond.,  1878,  p.  15  el  seq. 


TREATMENT.  485 

cradle  or  bed,  and  a  proper  regulation  of  the  temperature  of  the  room 
and  of  the  diet,  are  usually  all  that  is  required.  Special  remedies  may 
be  indicated  in  isolated  cases,  but  certainly  none  such  are  demanded  by 
the  varicella.  Efforts  should  be  made  to  protect  the  face  lesions  from 
the  traumatism  of  picking  and  scratching,  with  a  view  to  prevent 
pitting. 

Isolation  of  patients  is  not  requisite,  nor  any  process  of  disinfection 
other  than  that  which  is  incidental  to  a  fresh  supply  of  pure  air.  Vac- 
cination should  be  practised  alike  in  the  case  of  children  who  have  and 
who  have  not  suffered  from  the  disease. 


SCARLET  FEVER 

BY    J.  LEWIS   SMITH,   M.  D. 


HISTORY. — The  terms  scarlet  fever  and  scarlatina  are  used  synony- 
mously to  designate  one  of  the  most  common  and  fatal  of  the  eruptive 
fevers.  "Whether  this  malady  occurred  prior  to  the  Christian  era  is 
uncertain.  It  is  believed  by  some  that  the  plague  of  Athens,  430  years 
before  Christ,  vividly  described  by  Lucretius,  and  by  Thucydides,  who 
was  attacked  by  it,  was  scarlet  fever  of  a  peculiarly  malignant  type 
(Richardson);  but,  as  will  be  seen  from  the  following  extracts  from 
Thucydides,  the  plague  differed  in  important  particulars  from  scarlatina 
of  the  present  time :  "  Internally,  the  throat  and  the  tongue  were  quickly 
suffused  with  blood,  and  the  breath  became  unnatural  and  fetid.  There 
followed  sneezing  and  hoarseness ;  in  a  short  time  the  disorder,  accompa- 
nied by  a  violent  cough,  reached  the  chest The  body  externally 

was  not  so  very  hot  to  the  touch,  nor  yet  pale :  it  was  of  a  livid  color, 
inclining  to  red,  and  breaking  out  in  pustules  and  ulcers."  Loss  of  sight 
and  gangrene  of  the  extremities  were  common  results  in  those  who  recov- 
ered, and  adults  appear  to  have  been  affected  as  frequently  as  children. 
"  The  dead  lay  as  they  had  died,  one  upon  another,  while  others,  hardly 
alive,  wallowed  in  the  streets  and  crawled  about  every  fountain  craving 
for  water.  The  temples  in  which  they  lodged  were  full  of  the  corpses 
of  those  who  died  in  them."  Lucretius  says  of  this  plague,  "  If  any  one 
for  a  time  escaped  death  (as  was  possible,  either  by  reason  of  the  foul 
ulcers  breaking  or  by  means  of  a  black  discharge  from  the  intestines), 
yet  consumption  and  destruction  awaited  him  at  last ;  or,  as  was  often 
the  case,  an  excessive  flux  of  corrupt  blood,  attended  with  violent  pains 
in  the  head,  issued  from  the  obstructed  nostrils,  and  by  this  outlet  the 
whole  strength  and  substance  of  the  man  passed  away.  He,  moreover, 
who  had  escaped  this  violent  flux  of  foul  blood  was  not  certain  wholly 
to  ^  recover,  for  still  the  disease  was  ready  to  pass  into  his  nerves  and 
joints,  and  into  the  very  genital  organs  of  the  body.  And  of  those  who 
suffered  thus,  some,  fearing  the  gates  of  death,  continued  to  live,  though 
deprived  by  the  steel  of  the  virile  part,  and  some,  though  without  hands 
and  feet,  and  though  they  lost  their  eyes,  yet  persisted  to  remain  in  life, 
so  strong  a  dread  of  death  had  taken  possession  of  them.  Upon  some, 
too,  came  forgetfulness  of  all  things,  so  that  they  knew  not  even  them- 
selves." 

Gangrene  of  the  extremities,  loss  of  sight,  a  violent  cough,  loss  of 
memory,  etc.  are  not  symptoms  of  scarlet  fever,  so  that  in  my  opinion 

486 


ETIOLOGY.  487 

the  plague  of  Athens,  if  correctly  described  by  the  historian,  was  a  dif- 
ferent malady. 

Caspar  Morris,  in  his  essay  on  scarlet  fever,  states  his  belief  that 
Seneca,  who  lived  in  the  first  century  of  the  Christian  era,  described 
an  epidemic  of  the  malignant  form  of  scarlatina  in  his  portrayal  of  the 
pestilence  that  visited  Thebes  during  the  half-mythical  age  of  CEdipus,  six 
centuries  before  Christ.  Seneca's  description  of  the  symptoms  of  this 
plague  is  as  follows : 

Piger  ignavos 

Alligat  artus  languor,  et  segro 
Rubor  in  vultu,  maculteque  caput 
Sparsere  leves ;  turn  vapor  ipsam 
O>rporis  arcem  flammeus  urit 
Multoque  genus  sanguine  tendit 
Oculique  regent,  et  sacer  ignis 
Pascitur  artus.     Resonant  aures, 
Stillatque  niger  naris  aducse 
Cruor ;  at  venas  rumpit  hiantes. 

Languor,  redness  of  the  face,  light  spots  upon  the  head,  distension  of  the 
cheeks  with  blood,  distortion  of  the  eyes,  a  flushed  appearance  of  the 
limbs,  tinnitus  aurium,  and  a  discharge  of  black  blood  from  the  nostrils, 
certainly  indicated  a  very  malignant  form  of  disease,  but  to  believe  that 
it  was  identical  with  the  scarlet  fever  of  the  present  time  requires  con- 
siderable credulity.  From  the  fact  that  it  devastated  Thebes  we  infer 
that  it  occurred  largely  among  adults,  differing,  therefore,  from  the 
modern  scarlet  fever,  whose  victims  are  chiefly  children.  The  same 
uncertainty  hangs  over  epidemics  during  the  first  centuries  of  the 
Christian  era. 

The  first  clear  and  undoubted  portrayal  of  scarlet  fever  is  found  in 
the  medical  literature  of  the  sixteenth  century.  Sydenham  and  his  con- 
temporaries in  the  seventeenth  century  witnessed  epidemics  of  it,  studied 
its  nature  more  thoroughly,  and  consequently  acquired  a  more  accurate 
knowledge  of  it  than  that  possessed  by  their  predecessors.  It  was  in 
this  century  that  measles  and  scarlet  fever  were  differentiated.  During 
the  last  two  hundred  years  scarlatina  has  been  the  subject  of  monographs 
too  numerous  to  mention.  It  has  long  been  regarded  as  one  of  the  most 
important  maladies  of  childhood,  on  account  of  its  frequency  and  the 
great  mortality  that  attends  it,  so  that  numerous  cases  and  many  epi- 
demics are  every  year  related  in  the  medical  journals.  By  this  vast 
accumulation  of  observations  and  the  patient  and  thorough  use  of  the 
microscope  our  knowledge  of  scarlet  fever  has  become  full  and  accurate. 

As  with  most  of  the  infectious  maladies,  scarlet  fever  extended  to  the 
Western  World  through  European  shipping.  It  was  brought  to  North 
America  about  the  year  1735.  Tardily  it  spread  to  South  America, 
where  it  appeared  in  1829,  and  more  recently  it  has  been  established  in 
Australia.  It  entered  Iceland  in  1827,  and  Greenland  in  1847. 

ETIOLOGY. — The  evidence  is  strong  that  scarlet  fever  does  not  originate 
de  novo — that  it  does  not  spring  from  certain  atmospheric  or  telluric  con- 
ditions, but  is  produced  by  a  definite  specific  principle,  since  countries 
have  been  free  from  it  for  ceni  uries  till  it  Avas  imported  by  commerce. 
That  it  appears  in  certain  localities  without  any  known  exposure  is  attrib- 
uted to  the  fact  that  the  poison  is  so  subtle  and  transmissible  that  it  is 


488  SCARLET  FEVER. 

conveved  long  distances  in  articles  of  merchandise,  even  in  small  packages, 
so  tha't  those  who  chance  to  open  them  or  come  in  contact  with  them  are 
infected.  It  is  believed  that  reading  matter  transmitted  through  the  mails 
has  in  many  instances  been  the  medium  of  infection. 

The  theory  that  the  acute  infectious  maladies  are  caused  by  micro- 
organisms, or,  as  they  are  now  designated,  microbes,  commonly  discarded 
at  first  and  believed  to  be  chimerical,  is  rapidly  gaining  ground  in  the 
profession,  and  appears  to  be  fully  established  as  regards  certain  of  them. 
These  parasites,  barely  visible  under  high  powers  of  the  microscope,  and 
ascertained  to  be  vegetable  by  their  behavior  under  certain  chemical  agents, 
exist  in  immense  numbers  in  the  blood,  tissues,  and  secretions  of  patients 
suffering  from  the  infectious  maladies,  especially  in  the  graver  eases  of 
them ;  and  the  microscope  shows  that  these  organisms  vary  in  shape  and 
appearance,  so  as  to  admit  of  classification. 

The  germ  theory  has  now  become  so  important  that  it  cannot  be 
ignored  in  a  monograph  relating  to  so  important  an  infectious  malady 
as  scarlet  fever.  The  relation  of  microbes  to  the  infectious  diseases  has 
been  made  the  subject  of  investigation  by  Pasteur,  Toussaint,  and  others 
in  France,  and  by  many  in  Germany,  with  most  interesting  results.  The 
belief  held  by  many,  and  which  seemed  very  plausible,  was  that  the 
microbes,  instead  of  sustaining  a  causative  relation  to  the  maladies  in 
which  they  occur,  were  the  result  of  these  maladies — that  they  sprang 
into  existence  in  consequence  of  the  vitiated  state  of  the  blood  and  tissue?, 
just  as  fungi  appear  on  decaying  substances  or  as  the  Oidium  albicans 
appears  in  certain  morbid  conditions  of  the  buecal  surface  and  secretions. 
Obviously,  in  order  to  elucidate  this  matter  and  determine  the  relation  of 
these  parasites  to  the  diseases  in  which  they  occur,  it  was  necessary  to 
experiment  on  animals,  but,  unfortunately,  as  a  bar  to  successful  experi- 
mentation many  of  the  most  important  infectious  maladies  which  afflict 
the  human  race,  as  typhus  and  typhoid  fevers,  the  marsh  levers,  and 
syphilis,  do  not  occur  in  animals,'  or  they  occur  in  a  changed  and  miti- 
gated form.  Others,  however,  can  be  produced  in  their  typical  character 
in  animals,  as  diphtheria,  and  others  still  originate  in  animals  and  are 
transmitted  from  them  to  man,  as  anthrax  or  splenic  fever  of  the  her- 
bivora  and  hydrophobia.  Very  interesting  and  important  results  have 
been  produced  by  experimental  researches  with  the  microbes  of  certain 
of  these  diseases,  which,  if  applicable  to  the  common  and  fatal  infectious 
maladies  of  an  analogous  nature  in  man,  may  yet  result  in  immense  bene- 
fit in  mitigating  the  virulence  of  those  affections  which  are  the  scourge  of 
childhood  and  which  sensibly  diminish  the  increase  of  population.  It 
has  l>een  found  possible  to  cultivate  the  microbes  contained  in  the  blood, 
tames,  ami  secretions  in  certain  of  the  infectious  diseases,  ami  after  a 
series  of  cultivations,  so  that  these  organisms  are  far  removed  from  the 
animal  substance  which  contained  them,  and  with  which  they  were  so 
intimately  associated  in  the  individual,  they  have  been  employed  for 

K-ulation— with  this  important  result,  that  the  primary  disease  was 
Tins  seems  to  indicate  beyond  question  the  causative  rela- 
tion of  these  parasites  to  the  diseases  in  which  they  occur.  Experiments 
with  the  result  which  I  have  stated  have  been  made  with  the  microbes  of 
lever,  chicken  cholera,  murrain,  and  certain  other  maladies. 

lasteur  employs  ;ls  the  media  for  cultivation— (1st)  urine  neutralized 


ETIOLOGY.  489 

by  a  few  drops  of  potash  solution ;  (2d)  a  liquid  prepared  by  boiling  for 
twenty  or  thirty  minutes  the  yeast  of  beer  in  water,  neutralizingfand 
filtering ;  and  (3d)  chicken  tea,  prepared  by  boiling  equal  parts  of  water 
and  the  lean  of  muscles  a  quarter  of  an  hour,  filtering,  and  neutralizing. 
A  small  drop  of  infected  blood  is  placed  in  the  liquid  of  cultivation,  and 
the  microbes  which  it  contains  multiply  so  abundantly  that  the  liquid 
becomes  turbid  in  a  short  time,  and  they  are  found  in  all  parts  of  it,  A 
drop  of  this  liquid  is  added  to  another  portion  of  the  medium,  and  this 
also  soon  becomes  turbid  from  the  immense  development  of  organisms 
which  have  the  same  microscopic  appearance  and  character  as  those  in 
the  drop  of  blood.  The  process  is  repeated  many  times,  until  the 
microbes  are  far  removed  from  their  original  source"  in  the  blood  and 
tissues,  and  a  drop  of  the  last  cultivation,  whether  it  be  the  fiftieth  or 
the  hundredth,  is  inserted  under  the  skin  of  a  healthy  animal  selected 
for  the  experiment  If  it  be  true,  as  stated  by  the  experimenters,  that 
the  original  disease  is  thus  reproduced  with  the  microbes  of  at  least  three 
or  four  distinct  maladies,  this  age  is  distinguished  by  one  of  the  most 
important  discoveries  ever  made  in  pathological  studies.  It  remains  to 
ill -i ermine  whether  this  great  discovery  is  of  general  applicability  to  the 
infectious  diseases  with  which  man  is  afflicted.  If  so,  it  is  not  improb- 
able that  we  are  on  the  eve  of  finding  a  method  by  which  some  at  least 
of  these  maladies  may  be  prevented  or  mitigated,  as  small-pox  has  been 
since  the  time  of  Jenuer.  The  result  of  experiments  made  by  Pas- 
teur with  the  microbes  of  that  fatal  malady  of  *he  herbivora,  known 
under  the  various  names  of  splenic  fever,  anthrax,  wool-sorter's  disease, 
and  charbon,  encourages  this  belief.  Originating  among  the  herbivorous 
animals,  it  has  in  many  instances  been  contracted  by  individuals  who 
have  rapidly  perished.  Many  engaged  in  assorting  alpaca  and  mohair 
have  lost  their  lives  by  it>  some  with  all  the  symptoms  of  profound 
blood-poisoning,  without  external  lesions,  and  others  with  redness  and 
swelling  at  some  point  of  infection  where  a  sore  or  abrasion  existed,  but 
with  speedy  blood-contamination. 

The  microbe  of  this  malady,  the  Bacillus  anthracis,  occurs  in  the  form 
of  straight  filaments  with  little  movement  or  only  with  oscillation,  and 
producing  bright-shining  spores.  Now  comes  a  very  interesting  and 
important  result  of  experimentation :  Pasteur  states  if  several  days  elapse 
between  the  cultivations  the  virulence  of  the  parasite  diminishes,  so  that 
he  has  been  able  to  produce  by  inoculation  with  it  a  mild  and  never  fetal 
form  of  eharbon.  which  affords  immunity  in  the  animal  from  any  subse- 
quent attaek.  This  opinion  was  sustained  by  a  trial  experiment  on  six:} 
sheep.  Toussaint  and  Chaveau  claim  that  they  produce  a  similar  attenu- 
ation of  the  virus  by  detibrinating  infected  blood,  heating  it  to  55°  C. 
(lol°  F.V  and  filtering  it.  These  experiments  awaken  the  hope  that  the 
time  will  come  when  the  acute  infectious  maladies  in  man,  scarlet  fever 
among  others,  will  be  rendered  less  virulent.  That  one  of  them — to  wit, 
small-pox — has  tor  nearly  a  century  been  under  our  control  certainly 
encourages  the  belief  that  there  is  some  way  to  mitigate  others  of  the 
same  class  which  are  equally  fatal  if  not  so  loathsome, 

AJ  vet.  observers  do  not  agree  in  regard  to  the  parasite  which  is  sup- 
posed to  sustain  a  causative  relation  to  scarlet  fever.  Klebs  states  that 
it  is  highly  probable  that  both  measles  and  scarlet  fever  are  produced  by 


490  SCARLET  FEVER. 

micrococci,  and  he  has  sketched  the  design  and  described  the  development 
of  a  microbe  which  he  designates  the  Monas  scarlatiuosum. 

The  London  Medical  Times  and  Gazette  for  Jan.  28,  1882,  contains 
an  account  of  the  supposed  discovery  of  the  scarlatinous  microbe  by 
Ekluud  of  Stockholm,  an  authority  in  the  microscopic  examination  of 
parasites.  He  says  that  scarlet  fever  is  rarely  absent  from  the  Swedish 
capital  and  from  the  barracks  and  dwellings  on  the  isle  of  Skeppsholni. 
In  the  urine  of  scarlatinous  patients  he  has  constantly  found  a  prodigious 
number  of  discoid  corpuscles,  oval  or  round,  their  diameter  being  less 
than  y-^j-  millimetre  and  from  ^j  to  ^  that  of  a  red  blood-cell.  They 
are  colorless  or  yellowish  white,  surrounded  by  a  distinct  cell-wall,  each 
containing  a  well-defined  nucleus  of  a  deeper  hue.  Sometimes  one  or  more 
microbi  may  be  seen.  They  exhibit  rotatory  or  oscillatory  movements, 
especially  observed  when  a  drop  of  water  is  added  to  the  fluid.  They 
multiply,  as  he  has  frequently  seen,  by  fission — first  in  the  microbes, 
next  in  the  nucleus,  aud  lastly  in  the  cell- wall.  He  cannot  say  whether 
they  develop  into  a  mycelium.  At  any  rate,  the  development  of  fine 
filaments  seems  to  be  exceptional.  He  has  never  seen  them  adhere  in 
moniliform  chains  nor  massed  as  zooglsea.  He  considers  them  to  be 
veritable  schizomycetes,  and  proposes  the  name  Plox  scindens. 

Eklund  asserts  that  he  has  found  these  same  organisms  in  vast 
numbers  in  the  soil-  and  ground-water  of  the  isle  of  Skeppsholni,  in  the 
mud  of  the  trenches  dug  for  the  water-mains,  and  in  the  greenish  mould 
upon  the  walls  of  the  old  baracks,  where  scarlet  fever  was  most  rife.  He 
states  that  scarlet  fever  has  occurred  in  children  after  drinking  milk 
mixed  with  the  ground-water  of  the  island,  and  he  observed  a  case  which 
followed  immersion  in  one  of  the  trenches  of  the  island  and  the  drying 
of  the  clothes  in  a  small  room.  In  another  instance  scarlet  fever  broke 
out  in  a  block  immediately  after  exposure  of  the  ground-water  by 
excavations. 

It  is  evident  that  the  discovery  of  this  microbe  under  such  circum- 
stances does  not  prove  that  it  is  the  cause  of  the  disease.  This  can  only 
be  determined  by  inoculation,  or  by  experiments  which  furnish  the  con- 
ditions of  scientific  exactness.  Although  great  progress  has  been  made 
in  parasitology  during  the  last  decade,  it  is  evident  that  several  years  of 
observation  and  experimentation  must  elapse  before  it  is  clearly  and 
definitely  ascertained  whether  or  to  what  extent  microbes  cause  scarlet 
fever  and  the  other  exanthematic  fevers  with  which  it  is  classified. 

Whether  the  specific  principle  of  scarlet  fever  be  a  micro-organism  or 
a  chemical  substance,  its  mode  of  action  and  eifects  have  been  ascertained 
by  clinical  observations.  Without  doubt  it  commonly  enters  the  system 
by  the  breath,  but  it  may  .enter  in  the  ingesta,  and  it  infects  the  blood. 
That  it  resides  in  the  blood  has  been  ascertained  by  inoculation  with  this 
liquid,  by  which  scarlet  fever  has  been  reproduced  in  its  typical  form. 
From  the  blood  it  enters  the  tissues  and  secretions.  Hence  handkerchiefs 
or  linen  containing  the  saliva  or  mucus  of  a  patient,  the  epidermic  scales 
shed  abundantly  in  the  desquamative  period,  and  probably  also  the 
urinary  and  fecal  evacuations,  contain  the  poison,  so  as  to  be  highly  infec- 
tious. Even  the  discharge  of  a  scarlatinous  otorrhcea  is  thought  by  some 
to  be  contagious  for  a  considerable  time. 

Scarlatina  is  communicable  not  only  by  direct  exposure  to  a  patient, 


ETIOLOGY.  .       491 

but  also  by  exposure  to  objects  which  happen  to  be  in  his  room  during 
his  illness,  and  to  which  the  poison  becomes  attached,  such  as  clothing, 
books,  and  toys ;  small  packages,  even  letters,  it  is  believed,  from  cases 
which  have  occurred,  sometimes  convey  and  disseminate  the  contagious 
principle. 

In  England  observations  have  been  made  which  show  that  scarlatina 
has  been  communicated  by  infected  milk.  The  disease  occurred  in  the 
family  of  a  milkman,  and  the  milk,  before  it  was  distributed,  remained 
for  a  time  in  a  kitchen  which  had  been  occupied  by  the  patients.  This 
milk  was  taken  by  twelve  families,  and  in  six  of  these  the  disease 
occurred  almost  simultaneously  at  a  time  when  few  cases  were  occurring 
in  the  locality.  There  had  been  no  direct  exposure  to  the  carrier  of  the 
milk  nor  to  members  of  the  affected  family  (Taylor).  In  another 
instance  a  woman  and  her  son  had  scarlet  fever  while  they  were  serving 
milk  to  several  families,  and  the  disease  appeared  in  all  these  families 
except  one,  which  consisted  of  old  people  (Bell).  It  is  known  that  milk 
absorbs  volatile  substances  so  as  to  be  flavored  by  them,  as  is  shown  in 
the  experiment  of  placing  it  in  an  open  vessel  in  a  box  with  a  pineapple  ; 
and  it  may  in  a  similar  manner  become  infected  by  the  specific  principle 
of  scarlet  fever,  or  it  may  be  infected  by  detached  particles  of  epidermis ; 
which  is  not  improbable  when  one  convalescing  from  scarlet  fever  is 
allowed  to  milk  the  cows  or  prepare  the  milk  for  distribution. 

The  scarlatinous  virus  surpasses  that  of  any  other  eruptive  fever 
except  small-pox  in  its  tenacious  attachment  to  objects  and  its  portability 
to  distant  localities.  Hence  in  the  literature  of  the  disease  are  the  records 
of  many  cases  in  which  the  poison  was  conveyed  long  distances,  retaining 
its  virulence  to  the  full  extent  and  causing  an  outbreak  of  the  malady  in 
the  localities  to  which  it  was  carried.  In  New  York,  so  frequently  has 
scarlet  fever  as  well  as  measles  and  diphtheria  been  contracted  from  the 
persons  or  clothing  of  well  children  who  come  from  infected  houses,  that 
the  Health  Board  now  excludes  from  the  public  schools  all  children  who 
come  from  such  houses,  even  though  they  live  on  separate  floors  from 
those  occupied  by  the  sick.  In  one  instance  that  came  under  my  notice 
a  washerwoman  whose  child  had  scarlet  fever  communicated  the  disease  to 
an  -infant  in  the  household  where  she  was  employed,  by  placing  her  shawl 
over  the  cradle  in  which  it  was  lying.  A  physician  of  my  acquaintance 
went  from  a  scarlet-fever  patient  to  a  family  several  streets  distant,  and 
took  one  of  their  children  upon  his  lap.  After  the  usual  incubative 
period  this  child  sickened  with  a  fatal  form  of  the  malady,  and  the 
remaining  children  of  the  household  were  in  time  affected.  In  New 
York  scarlet  fever  has  seemed  to  me  to  be  not  infrequently  communi- 
cated through  school-books,  which,  profusely  illustrated  by  pictures  and 
rendered  attractive  to  the  young,  are  often  allowed  to  lie  upon  the  bed  of 
a  scarlatinous  patient  and  be  handled  by  him  during  convalescence,  or 
even  during  the  course  of  the  fever  if  it  be  mild.  The  young  librarian 
of  the  circulating  library  of  a  Sunday-school,  whose  pupils  came  largely 
from  the  tenement-houses,  was  occupied  a  considerable  part  of  a  day 
in  covering  and  arranging  the  books.  After  about  the  usual  incubative 
period  of  scarlet  fever  he  sickened  with  the  disease.  His  two  sisters  were 
immediately  removed  to  a  rural  township  three  hundred  miles  away,  and 
to  an  isolated  house  where  scarlatina  had  never  occurred.  About  one 


492  SCARLET  FEVER. 

mouth  after  his  recovery,  and  after  his  room  had  been  disinfected  by 
burning  sulphur  and  his  bed-clothes  and  linen  had  been  thoroughly 
washed,  and  all  articles  suspected  to  hold  the  poison  had  been  either 
disinfected  or  destroyed,  the  brother  visited  his  sisters  in  the  country. 
Three  weeks  subsequently  to  his  arrival  one  of  these  sisters  sickened 
with  scarlet  fever,  and  a  week  later  the  other  also.  It  seems  that  the 
exposure  must  have  occurred  several  days  after  his  arrival  in  the  country 
from  some  book  or  other  infected  article  in  his  possession.  About  two 
months  elapsed  after  the  last  case  ;  the  family  had  returned  to  the  city, 
the  infected  room  in  the  country-house  had  been  thoroughly  fumigated 
by  burning  sulphur  from  morning  till  evening,  when  a  little  girl  from 
an  inland  city  remained  a  few  days  in  this  house,  and  probably  often 
entered  the  room  where  the  young  ladies  had  been  sick.  In  a  few  days 
she  also  sickened  with  a  fatal  form  of  scarlatina.  Such  histories  and 
experiences  are  not  infrequent.  They  are  common  during  epidemics  of 
scarlet  fever.  They  indicate  an  extraordinary  attachment  of  the  scar- 
latinous poison  to  objects,  and  show  that  it  is  not  gaseous  nor  readily 
volatilized. 

A  striking  example  of  this  fixity  of  the  poison  occurred  in  the  prac- 
tice of  the  late  Kearney  Rogers,  formerly  a  prominent  and  much 
esteemed  surgeon  of  New  York  City.  Six  children  in  a  family  had 
scarlet  fever.  Three  and  a  half  months  subsequently  another  child, 
living  at  a  distance,  was  allowed  to  return  home  and  occupy  the  apart- 
ment in  which  the  sickness  had  occurred.  One  week  subsequently  to  the 
date  of  the  return  this  child  sickened  with  the  same  malady.  Elliot- 
son  states  that  a  patient  with  scarlet  fever  was  admitted  into  one  of  the 
wards  of  St.  Thomas's  Hospital,  and  for  two  years  subsequently  young 
persons  who  were  admitted  into  the  ward  were  apt  to  take  the  disease. 
Richardson  of  London  relates  the  following  experiences  of  a  family 
whom  he  attended  in  a  rural  district  :  "  At  a  short  distance  from  one  of 
our  villages  there  was  situated  on  a  slight  eminence  a  small  clump  of 
laborers'  cottages,  with  the  thatch  peering  down  on  the  beds  of  the 
sleepers.  A  man  and  his  wife  lived  in  one  of  these  cottages  with  four 
lovely  children.  The  poison  of  scarlet  fever  entered  the  poor  man's 
door,  and  at  once  struck  down  one  of  the  flock."  The  remaining  chil- 
dren were  now  removed  some  miles  away,  and  after  several  weeks  one 
of  them  was  allowed  to  return.  Within  twenty-four  hours  it  also  took 
the  disease,  and  quickly  died.  The  walls  of  the  cottage  were  now  thor- 
oughly cleaned  and  whitewashed,  the  floors  scoured,  and  all  the  wearing 
apparel  either  destroyed  or  washed.  Four  months  elapsed  after  the  last 
sickness  when  one  of  the  remaining  children  returned.  "  He  reached  his 
father's  cottage  early  in  the  morning  ;  he  seemed  dull  the  next  day,  and 
at  midnight  I  was  sent  for,  to  find  him  also  the  subject  of  scarlet 
fever  The  disease  again  assumed  the  malignant  type,  and  this  child 
Richardson  believes  that  the  contagium  was  attached  to  the 
thatch,  which  could  not  be  thoroughly  disinfected.  The  fact  of  this 
•emarkable  long-continued  attachment  of  the  poison  to  objects,  indi- 
cating by  this  fixity  that  it  is  a  solid,  is  consonant  with  the  theory  that 
it  is  an  organism. 


PERIOD.—  The  duration  of  the  incubative  period  varies 
fterent  cases.     It  is  sometimes  less  than  twenty-four  hours,  as  in 


INCUBATIVE  PERIOD. 


493 


the  above  case  reported  by  Richardson ;  in  the  following  well-known 
case,  observed  by  Trousseau,  it  was  one  day.  A  girl  arrived  in  Paris 
from  Pau,  where  there  was  no  scarlet  fever,  and  occupied  the  same 
apartment  with  her  sister,  who  was  sick  with  this  disease.  Twenty-four 
hours  after  her  arrival  she  also  wras  attacked  with  the  same  malady. 

Russeberger  attended  a  child  who  was  exposed  at  noon  to  scarlet 
fever,  and  took  the  disease  on  the  following  night.  B.  W.  Richardson 
(Clinical  Essays,  1861,  vol.  i.  p.  94)  gives  his  own  experience:  He  had 
applied  his  ear  to  the  chest  of  a  patient  suffering  from  scarlet  fever,  and 
was  conscious  of  a  peculiar  odor  emitted  from  the  patient.  He  was 
immediately  nauseated  and  chilly,  and  from  that  moment  he  dated  the 
beginning  of  an  attack  of  scarlet  fever.  In  the  Transactions  of  the 
Clinical  Society  of  London,  vol.  xi.  1878,  the  late  Charles  Murchison 
gives  the  statistics  of  75  cases,  showing  the  incubative  period,  as  follows : 

In  4  cases  it  was  not  more  than  24  hours. 


2 
8 
4 
1 
4 
1 
1 

31 

2 

17 


30 
36 
40 
41 
58 
54 

2£  days. 
„  f  within  (time  not  accu- 1    .  , 
\        rately  ascertained)  J  *  ' 

the  incubation  did  not  exceed  \\  days. 
«  a          «  «         K       a 


In  three  cases  Murchison  believes  that  the  incubation  was  precisely  fixed 
at  thirty-six  hours,  three  days,  and  four  and  a  half  days. 

Watson  says  that  a  man  reached  Devonshire  on  mid-day  to  see 
his  daughter,  who  had  scarlet  fever.  Two  days  later  he  was  also 
attacked.  Rehn  saw  a  child  who  was  attacked  two  days  after  its  grand- 
mother returned  from  a  case  of  scarlet  fever ;  and  Zengerle,  a  girl  of  ten 
years,  residing  at  Wangen,  where  there  was  no  scarlet  fever,  who  took 
the  disease  two  days  after  her  mother  had  returned  from  visiting  a  family 
affected  with  it.  Loochner  states  that  a  boy  aged  four  and  a  half  years 
was  attacked  one  and  a  half  days  after  admission  into  the  infected  wards 
of  a  hospital.  Armistead,  in  his  annual  report  on  the  health  of  the 
Newmarket  rural  district,  states  that  three  children,  coming  from  a  dif- 
ferent part  of  the  district,  visited  "Westley,  and  stayed  next  door  to  a 
child  who  had  scarlet  fever  six  weeks  previously,  and  who  was  allowed 
to  play  with  these  children  on  the  evening  of  Aug.  13th  and  morning 
of  the  14th.  The  family  then  returned  home,  and  on  the  18th,  four 
days  after  the  exposure,  all  three  children  sickened  with  scarlet  fever 
(Brit  Med.  Jour.,  Sept.  30,  1882). 

Ordinarily,  therefore,  the  incubative  period,  though  varying  in  different 
cases,  is  within  six  days.  Many  cases,  however,  occur  in  which  it  seems 
to  be  longer  Thus  in  my  practice  scarlet  fever  appeared  in  a  family  on 
April  26,  1882.  The  patient  was  immediately  removed  to  the  third  floor 
and  the  other  children  to  the  basement.  All  Communication  between  the 
infected  room  and  the  basement  was  forbidden,  but  on  May  8th,  twelve 
days  after  the  separation,  one  of  these  children  sickened  writh  the  disease. 


494  SCARLET  FEVER. 

Many  observers— among  whom  may  be  mentioned  Niemeyer  and  Cop- 
land—believe that  the  incubative  period  may  be  longer  than  one  week, 
but  on  account  of  the  subtlety  of  the  poison  and  the  many  modes  of 
transmission,  it  is  possible  that  in  the  instances  of  an  apparently  long 
incubative  period  there  were  other  and  unsuspected  exposures.  When 
scarlet  fever  has  been  communicated  by  inoculation,  as  in  the  experiments 
of  Rostan  and  others,  the  incubative  period  has  been  about  seven  days, 
but  Gerhardt  states  that  a  man  was  attacked  four  days  after  an  abscess 
was  opened  by  a  knife  used  upon  a  scarlatinous  patient.  This  variation 
in  the  incubative  period,  which  also  occurs  in  some  other  infectious  dis- 
eases, as  diphtheria,  is  probably  due  mostly  to  individual  differences, 
some  being  more  susceptible  than  others ;  but  it  may  be  due  partly  to 
those  obscure  meteorological  conditions  which  we  designate  the  epidemic 
influence.  Probably,  as  a  rule,  when  the  disease  is  quickly  developed 
after  exposure,  the  attack  is  more  severe  than  when  several  days  elapse. 

CONTAGIOUSNESS. — The  area  of  the  contagiousness  of  scarlet  fever 
is  small.  It  apparently  embraces  only  a  few  feet.  Therefore,  close 
proximity  is  the  necessary  condition  of  its  propagation.  Hence  many 
who  are  exposed,  particularly  of  those  who  are  remotely  exposed,  do  not 
contract  the  disease.  There  is  also  an  idiosyncrasy  in  some  children,  so 
that  they  resist  infection  even  when  repeatedly  and  closely  exposed.  In 
the  New  York  Medical  Record  for  March  23,  1878,  C.  E.  Billington 
states  that  of  90  children  in  26  families  who  were  exposed  to  scarlet 
fever,  43  contracted  the  disease  and  47  escaped ;  whereas,  as  is  well 
known,  comparatively  few  unprotected  children  escape  pertussis,  variola, 
varicella,  or  measles  if  exposed  to  either  of  these  diseases.  By  strict 
isolation,  therefore,  the  spread  of  scarlet  fever  is  more  easily  prevented 
than  that  of  most  other  acute  infectious  maladies.  In  the  New  York 
Foundling  Asylum  for  a  number  of  years  children  with  scarlet  fever 
were  isolated  in  a  small  room  attached  to  one  of  the  wards.  •  The  door 
between  the  two  rooms  was  closed,  and  not  opened  during  the  continu- 
ance of  the  sickness.  Entrance  into  the  small  room  was  through  another 
door,  and  a  nurse  was  assigned  to  the  scarlet-fever  cases,  with  strict  direc- 
tions that  she  should  not  mingle  with  the  other  children.  These  simple 
precautions  were  found  sufficient  in  the  various  epidemics  of  scarlet  fever 
which  occurred  in  the  city  to  prevent  the  spread  of  the  malady  through 
this  institution;  whereas,  similar  measures  were  much  less  effectual  in 
arresting  the  spread  of  measles  and  pertussis.  Consequently,  an  outbreak 
of  scarlet  fever  in  this  institution  was  usually  limited  to  a  few  cases,  while 
the  extension  of  measles  and  pertussis  was  arrested  with  difficulty  till  a 
more  efficient  quarantine  was  established. 

VARIATIONS  IN  TYPE.— The  type  of  scarlet  fever  varies  greatly  in 
different  epidemics,  and  frequently  also  in  cases  which  occur  in  the  same 
epidemic,  even  in  the  same  family.  One  child  may  have  scarlatina  so 
mildly  that  little  treatment  is  required  and  convalescence  soon  begins, 
while  another  has  the  malignant  form,  and  soon  succumbs,  notwithstand- 
ing the  prompt  employment  of  the  most  efficient  and  appropriate  meas- 
Ordmarily,  however,  if  the  first  case  in  a  family  be  very  severe, 

^equent^cases  will  present  a  similar  type;  but  there  are  notable  excep- 

This  variation  in  type  in  different  years  and  different  epidemics  is 

probably  not  equalled  in  any  other  infectious  malady.     Consecutive  epi- 


SURGICAL  AND   OBSTETRICAL  SCARLATINA.  495 

demies  may  present  this  variation,  or  the  same  type  may  continue  for  a 
series  of  years,  and  then,  from  some  unknown  cause,  change  to  one  milder 
or  more  severe.  In  England,  during  Sydenham's  life,  scarlet  fever  was 
so  mild  that  he  regarded  it  as  a  trivial  affection,  requiring  little  attention, 
like  rotheln  of  the  present  time,  but  after  the  death  of  Sydenham,  Mor- 
ton and  his  contemporaries  in  London  found,  to  their  sorrow,  that  the 
type  of  scarlet  fever  was  very  different  from  that  described  by  Syden- 
ham's  pen.  The  late  Graves  of  Dublin  and  his  contemporaries  treated 
a  mild  type  of  scarlet  fever  with  a  very  small  percentage  of  deaths — 
much  less  than  that  during  the  preceding  generation — and  they  attributed 
their  success  to  their  greater  knowledge  and  more  appropriate  use  of 
remedies  than  their  ancestors  possessed  and  employed.  By  and  by  the 
type  changed,  the  mortality  of  former  years  was  restored,  and  they  dis- 
covered that  their  previous  success  in  saving  life  had  been  due  not  to 
their  skill,  but  to  the  mild  form  of  the  malady.  A  distinguished  physi- 
cian of  New  York  treated  more  than  fifty  cases  of  scarlet  fever  in  one  of 
the  institutions  without  a  single  death.  A  few  months  afterward  the 
type  of  the  malady  changed,  and  his  own  son  perished  from  it. 

SURGICAL  AND  OBSTETRICAL  SCARLATINA. — After  surgical  opera- 
tions, and  sometimes  in  surgical  cases  not  requiring  operative  measures,  a 
scarlatinous  efflorescence  occasionally  appears  upon  the  whole  or  nearly 
the  whole  body,  and  remains  for  several  days.  The  following  were  cases 
of  the  kind  alluded  to.  They  occurred  in  Guy's  Hospital,  and  were 
published  by  H.  G.  Howse  in  Guy's  Hospital  Reports  for  1879  :  On 
March  15,  1878,  Jacobson  performed  osteotomy  upon  a  child  suffer- 
ing from  extreme  rachitis.  The  operation  was  followed  by  a  moderate 
febrile  movement  (100°  to  101°),  and  after  three  days  by  the  appearance 
of  an  efflorescence,  with  sore  throat  and  the  strawberry  tongue.  The 
osteotomy  had  been  performed  under  carbolic  acid  spray  and  with  all  the 
details  of  antiseptic  surgery.  The  rash  soon  faded,  the  temperature  fell, 
and  the  child,  temporarily  separated  from  the  other  patients  from  the  sus- 
picion that  the  disease  was  scarlet  fever,  was  brought  back  to  the  ward. 
The  subsequent  history  confirmed  the  diagnosis  of  scarlet  fever,  for  the 
skin  desquamated,  and  on  April  1st  abundant  albumen  was  found  in  the 
urine.  The  case  terminated  favorably.  Three  months  previously  the 
same  operation  had  been  performed  on  the  other  leg,  writh  no  unfavorable 
symptoms.  On  April  5th,  three  weeks  after  the  osteotomy,  a  lipoma  was 
removed  from  another  patient  aged  twenty-one  years.  The  following  day 
the  temperature  rose  to  101°,  and  remained  at  that  till  April  8th,  when 
it  suddenly  increased  to  103°,  and  a  rose-rash  occurred  over  the  body, 
with  sore  throat.  On  April  9th,  Howse  excised  the  elbow-joint  of  a  girl 
of  sixteen  years  having  pulpy  disease.  On  the  10th  her  temperature 
began  to  increase,  and  on  the  llth  reached  105.8°.  Toward  evening  a 
roseoloid  eruption  appeared  over  her  body,  and  she  was  isolated.  On 
April  12th,  Dr.  H.  excised  a  fibroid  bursa  patellae  from  a  woman  of 
twenty-nine  years.  On  the  following  day  her  temperature  was  99°,  but 
on  the  14th  it  rose  to  100°,  and  on  the  evening  of  the  15th  she  had  rigors 
and  headache.  On  the  morning  of  the  16th  the  temperature  was  102.5°, 
and  a  roseoloid  eruption  occurred  over  the  face  and  chest.  The  surgeons 
now  perceived  that  an  epidemic  of  the  so-called  surgical  scarlatina  was 
occurring,  so  as  to  justify  the  postponement  of  other  operations. 


49G  SCARLET  FEVER. 

In  the  same  volume  of  Guy's  Hospital  Reports,  James  F.  Gooclharl 
gives  the  histories  of  nearly  thirty  cases  of  this  disease  occurring  dur- 
ing a  series  of  years  in  the  same  hospital.  The  patients  were  chiefly 
children,  having  the  most  diverse  surgical  ailments,  among  which  may  be 
mentioned  hip  disease  and  abscess,  genu  valgum  _  without  operation, 
necrosis  of  femur,  hydrocele  with  explorative  operation,  a  scald,  a  sinus 
over  the  great  trochanter,  spinal  disease  with  abscess,  tenotomy  for  club- 
foot,  and°vesical  calculus  with  operation.  The  most  common  disease  was 
caries  or  necrosis  with  abscess.  In  cases  operated  on  the  intervals 
between  the  operations  and  the  occurrence  of  the  efflorescence  varied  from 
two  days  to  more  than  two  weeks.  Goodhart,  after  a  careful  exami- 
nation of  these  cases,  came  to  the  conclusion  that  they  were  for  the  most 
part  examples  of  true  scarlet  fever,  especially  as  a  considerable  propor- 
tion of  them  occurred  in  groups,  and  there  was  a  known  exposure  of 
some  of  the  patients  to  children  admitted  into  the  hospital  with  the 
sequelae  of  scarlet  fever. 

In  the  British  Mcd.  Jour,  for  Jan.,  1879,  George  May,  Jr.,  reported 
a  case  of  efflorescence  in  surgical  practice  which  appears  to  have  been 
scarlatinous.  A  child  was  operated  on  for  the  radical  cure  of  hernia 
on  Dec.  4th.  Toward  the  close  of  the  same  day  he  became  restless, 
vomited,  and  his  pulse  on  the  following  day  rose  to  136.  Forty- 
eight  hours  after  the  operation  a  rash  appeared  on  the  chest  and  arms, 
the  abdomen  became  tense  and  painful,  and  on  the  following  day  he  died. 
The  poison,  however,  in  this  case  may  have  been  septic. 

Hillier  remarks  (Diseases  of  Children) :  "  In  the  hospital  for  sick 
children,  of  the  children  who  contract  scarlatina  a  very  large  proportion 
have  been  the  subjects  of  a  surgical  operation  within  a  week  before  the 
rash  appears."  Gee  says  (Reynolds's  System  of  Medicine}:  "It  has 
been  doubted  by  some  whether  the  scarlatiniform  rash  which  sometimes 
follows  operations  is  really  scarlatinal.  The  eruption  appears  from  the 
second  to  the  sixth  day  after  the  operation,  and  in  the  cases  which  have 
caused  the  doubt  is  very  fugitive  and  the  first  and  only  symptom.  Yet 
that  the  disease  really  is  scarlet  fever  would  seem  to  be  proved  by  the 
following  observations:  first,  that  the  disease  occurs  in  epidemics; 
secondly,  that  in  a  given  epidemic  a  severe  case  occasionally  relieves  the 
monotonous  recurrence  of  the  very  mild  form ;  thirdly,  that  a  precisely 
similar  scarlatinilla  attacks  in  the  same  epidemic  patients  who  have  not 
been  subjected  to  operation  and  who  have  no  open  sore;  and  lastly,  by 
way  of  a  veritable  experimentum  crucis,  that,  however  freely  these 
patients  are  exposed  to  ordinary  scarlet  fever  contagion  afterward,  they 
do  not  contract  that  disease."  Paget  and  other  distinguished  London 
surgeons  who  have  observed  this  complication  of  surgical  cases,  believe 
that  the  patients  have  been  previously  exposed  to  the  scarlatinous  poison, 
and  that  the  surgical  diseases  or  operations  furnish  favorable  con- 

tions  for  the  occurrence  of  scarlet  fever,  so  that  the  exposure,  which 
probably  would  have  been  without  result  in  ordinary  health,  causes  an 
outbreak  of  the  malady. 

Those  who  have  reported  cases  of  this  form  of  efflorescence  have  for 
the  most  part  neglected  to  state  whether  the  patients  had  had  scarlet 
fever  previously,  knowledge  of  which  would  have  aided  in  the  diagnosis  ; 
but  from  an  examination  of  the  histories  of  cases,  especially  those  pub- 


SURGICAL  AND   OBSTETRICAL  SCARLATINA.  497 

lished  in  the  London  journals  in  the  last  four  or  five  years,  there  can,  I 
think,  be  little  doubt  that  surgical  maladies  of  a  certain  kind,  especially 
traumatism,  do  produce  a  state  of  system  which  predisposes  to  scarlet 
fever,  so  that  this  class  of  patients  are  especially  liable  to  contract  it. 
Therefore,  in  my  opinion,  a  considerable  proportion  of  reported  cases 
of  surgical  scarlatina  are  genuine,  but  in  a  considerable  number,  perhaps 
an  equal  number  of  such  cases,  the  histories  and  symptoms  indicated  a 
septic  rather  than  scarlatinous  efflorescence,  and  in  not  a  few  instances, 
when  consultations  have  been  held,  opinions  differed,  some  diagnosticating 
scarlet  fever,  others  septicaemia.  In  some  of  the  cases  I  find  it  stated 
that  the  fauces  presented  the  normal  appearance.  Now,  faucial  redness  is 
so  generally  present  in  scarlet  fever,  antedating  that  of  the  skin  and 
coexisting  with  it,  that  its  absence  is  strong  evidence  that  the  disease  is 
not  scarlatinous.  Moreover,  when,  as  was  true  of  certain  of  the  reported 
cases,  the  rash  appeared  irregularly  upon  the  surface,  and  faded  away  in 
two  or  three  days  with  the  abatement  of  the  fever,  and  the  conditions 
for  septic  absorption  were  present,  the  efflorescence  was  probably  septi- 
csemic. 

The  following  were  apparently  cases  of  septicaemia  efflorescence :  A 
child  aged  five  years  (Brit.  Med.  Jour.,  Feb.  15,  1879)  had  inflammation 
of  the  lymphatic  glands  in  the  groin,  which  suppurated.  At  the  time 
when  the  abscess  was  fully  formed  a  rash  appeared  over  the  entire  body. 
It  consisted  of  numerous  red  points,  but  was  paler  than  that  of  ordinary 
scarlet  fever  ;  temperature  never  above  99°;  no  sore  throat  nor  -desqua- 
matiou  of  cuticle.  No  child  exposed  to  her  took  scarlet  fever,  and  her 
sickness  could  not  be  traced  to  infection.  In  the  British  Med.  Jour., 
Jan.  4,  1879,  L.  Braxton  Hicks  states  that  his  son,  attending  school 
at  Reading,  was  seized  with  a  severe  attack  of  pyrexia,  accompanied  on 
the  second  day  by  delirium  and  the  occurrence  of  a  rash  like  scarlet  fever 
over  the  entire  surface.  He  had  no  decided  redness  of  the  fauces,  though 
it  was  perhaps  slightly  flushed.  The  right  buttock  was  swollen  from 
inflammation,  and  a  large,  deep-seated  abscess  formed  near  the  tuberosity 
of  the  ischium.  When  the  delirium  abated  the  boy  said  that  he  was 
standing  the  day  before  the  fever  began  with  his  legs  far  apart,  when  a 
schoolfellow  stretched  them  farther  by  suddenly  pulling  on  one  of  them. 
The  rash,  which  was  nearly  universal,  lasted  three  days,  and  was  not 
followed  by  desquamation.  No  case  of  scarlet  fever  occurred  in  the 
school  before  or  afterward.  In  the  same  volume  of  the  British  Medical 
Journal,  Surgeon  Frolliott  of  the  East  India  Service  relates  the  case  of  a 
private,  aged  twenty-three  years,  and  three  years  in  India,  who,  when  on 
duty  in  the  Punjab,  was  injured  by  the  explosion  of  an  Afghan  powder- 
magazine.  The  accident  occurred  Dec.  21, 1878.  On  Dec.  25th  a  bright 
scarlet  rash  appeared  upon  the  abdomen  and  spread  over  the  entire  body. 
The  following  day  the  eruption  was  very  vivid,  like  a  boiled  lobster,  and 
it  lasted  five  days.  The  temperature,  which  in  the  beginning  had  been 
101°,  abated  to  the  normal  after  the  rash  appeared.  No  soreness  of 
throat  nor  redness  of  the  buccal  surface  occurred,  but  the  epidermis 
desquamated  even  from  the  palms  of  the  hands  and  soles  of  the  feet. 
Now,  the  febrile  movement  of  scarlet  fever  does  not  cease  while  the 
efflorescence  is  distinct.  It  does  not  even  diminish  when  the  eruption 
appears,  while  in  the  above  case  it  fell  to  the  normal — a  common  occur- 

VOL.  I.— 32 


498  SCARLET  FEVER. 

rence  in  septioemia,  even  when  the  blood-poisoning  is  profound.  More- 
over, scarlet  fever  is  so  rare  in  India  that  Frolliott,  after  twelve  years' 
service,  had  only  heard  of  one  case  among  Europeans  and  natives.  The 
surgeons  who  consulted  over  the  case  of  this  private  disagreed  in  opinion, 
some  regarding  the  disease  as  septicsemic,  others  as  scarlatinous.  But  a 
better  knowledge  of  the  clinical  history  of  scarlet  fever  on  the  part  of 
these  army  surgeons  would,  I  think,  have  removed  all  doubt  as  to 
the  diagnosis. 

It  is  the  opinion  of  some  reputable  surgeons  that  the  exposure  of 
traumatic  patients  to  the  scarlatinous  poison  sometimes  aggravates  the 
inflammation  of  wounds,  causing  them  to  assume  an  unhealthy  appear- 
ance even  though  no  scarlatina  be  produced.  The  late  Solly  made 
the  remark,  "  Whenever  a  case  of  surgery  in  private  practice  takes  on  a 
hio-hly  phlegmonous  appearance  I  am  always  sure  to  find  break  out,  in 
the  inmates  of  the  house,  either  erysipelas  or  scarlet  fever  "  (British  Med. 
Jour.,  Feb.  15,  1879).  We  will  see  that  the  scarlatinous  poison  some- 
times causes  pharyngitis  or  nephritis  without  producing  the  general  dis- 
ease. In  a  similar  manner  it  seems  that  it  may  aggravate  open  wounds, 
intensifying  the  inflammation  in  them,  while  there  is  no  efflorescence  or 
other  symptom  to  show  that  scarlatina  itself  is  present.  The  poison 
appears  to  act  entirely  locally  in  such  cases. 

Paget,  in  his  Clinical  Lectures,  says :  "  I  think  it  not  improbable 
that  in  some  cases  results  occurring  with  obscure  symptoms  within 
two  or  three  days  after  operations  have  been  due  to  the  scarlet-fever 
poison,  hindered  in  some  way  from  its  usual  progress."  Playfair, 
in  his  remarks  on  the  puerperal  state,  adds :  "  Mr.  Spencer  Wells  in- 
forms me  that  he  has  seen  cases  of  surgical  pyaemia  which  he  had  reason 
to  believe  originated  in  the  scarlatinal  poison ;  and  his  well-known  suc- 
cess as  an  ovariotomist  is  no  doubt,  in  a  great  measure,  to  be  attributed  to 
his  extreme  care  in  seeing  that  no  one  likely  to  come  in  contact  with  his 
patients  has  been  exposed  to  any  such  source  of  infection."  Opinions 
like  these,  held  by  such  prominent  members  of  the  profession  and  sus- 
tained by  many  observations,  should  certainly  induce  physicians  to  pre- 
vent, so  far  as  possible,  any  exposure  of  their  surgical  patients,  especially 
if  they  have  any  sores  or  wounds,  whether  by  traumatism  or  the  scalpel, 
to  the  scarlatinal  poison. 

^  OBSTETRICAL  SCARLATIXA. — Women  during  convalescence  after  child- 
birth are  very  liable  to  contract  scarlet  fever.  In  the  New  York  Infant 
A.sylum,  which  has  maternity  wards,  a  woman  was  admitted  from  a 
house  in  which  scarlet  fever  was  prevailing,  and  assigned  to  a  cot  next 
that  occupied  by  one  of  the  waiting  women,  who  was  confined  soon  after- 
ward. Her  labor  was  favorable,  but  three  days  afterward  she  took 
scarlet  fever,  and  another  lying-in-patient  contracted  it  from  her.  The 
sore  throat  and  desquamation  were  characteristic.  It  has  come  to  my 
knowledge  that  a  physician  of  New  York,  in  whose  family  scarlet  fever 
was  occurring,  attended  three  women  in  succession  in  their  confinement, 
and  all  contracted  scarlet  fever,  which  presented  the  characteristic  symp- 
toms, and  two  of  them  died.  Experienced  and  cautious  physicians  of 
New  York,  aware  of  the  danger,  do  not  go  directly  from  a  scarlatinous 
patient  to  an  obstetrical  case,  but  avoid  the  risk  by  intermediate  visits  to 
other  patients  or  by  remaining  for  a  time  in  the  open  air. 


OBSTETRICAL  SCARLATINA.  499 

Playfair,  remarking  on  this  subject,  says :  "  There  is  good  reason  to 
believe  that  the  contagiura  of  zymotic  diseases  may  produce  a  form  of 
disease  indistinguishable  from  ordinary  pueq>eral  septicaemia,  and  pre- 
senting none  of  the  characteristic  features  of  the  specific  complaint  from 
which  the  contagium  was  derived.  This  is  admitted  to  be  a  fact  by  the 
majority  of  our  most  eminent  British  obstetricians,  although  it  does  not 
seem  to  be  allowed  by  continental  authorities,  and  it  is  strongly  contro- 
verted by  some  writers  in  this  country.  It  is  certainly  difficult  to  recon- 
cile this  with  the  theory  of  septicaemia,  and  we  are  not  in  a  position  to 
give  a  satisfactory  explanation  of  it.  I  believe,  however,  that  the  evi- 
dence in  favor  of  the  possibility  of  puerperal  septicaemia  originating  in 
this  way  is  too  strong  to  be  assailable.  The  scarlatinal  poison  is  that 
regarding  which  the  greatest  number  of  observations  has  been  made. 
Numerous  cases  of  this  kind  are  to  be  found  scattered  through  our 
obstetric  literature,  but  the  largest  number  are  to  be  met  with  in 
a  paper  by  Braxton  Hicks.  Out  of  68  cases  of  puerperal  disease 
seen  in  consultation,  no  less  than  37  were  distinctly  traceable  to  the  scar- 
latinal poison.  Of  these,  20  had  the  characteristic  rash  of  the  disease, 
but  the  remaining  17,  although  the  history  clearly  proved  exposure  to 
the  contagium  of  scarlet  fever,  showed  none  of  its  usual  symptoms,  and 
were  not  to  be  distinguished  from  ordinary  typical  cases  of  the  so-called 
puerperal  fever.  On  the  theory  that  it  is  impossible  for  the  specific  con- 
tagious diseases  to  be  modified  by  the  puerperal  state,  we  have  to  admit 
that  one  physician  met  with  17  cases  of  puerperal  septicaemia  in  which, 
by  a  mere  coincidence,  the  contagion  of  scarlet  fever  had  been  traced, 
and  that  the  disease  nevertheless  originated  from  some  other  source — 
a  hypothesis  so  improbable  that  its  mere  mention  carries  its  own  refu- 
tation." 

Parturition,  like  traumatism,  furnishes  in  an  eminent  degree  the  con- 
ditions in  which  septic  poisoning  occurs,  and  the  efflorescence  which  often 
accompanies  septicaemia  bears,  as  we  have  seen,  a  very  close  resemblance 
to  that  of  scarlet  fever.  Hence  in  many  instances  the  same  difficulty  is 
present  in  making  a  differential  diagnosis  between  septic  and  scarlatinous 
blood-poisoning  in  obstetrical  cases  which  occurs  in  surgical  practice. 
But,  according  to  my  observations,  an  efflorescence  occurring  during 
the  week  following  parturition  is  in  most  instances  septic.  It  is  only  in 
exceptional  cases  that  it  is  scarlatinous,  and  there  is  little  danger  that 
the  accoucheur,  engaged  in  general  practice  and  visiting  scarlatinous 
patients,  will  communicate  scarlet  fever  through  his  person  or  clothing  if 
he  exercise  proper  precautions.  His  short  stay  in  the  sick  room  and  his 
out-door  exercise  in  visiting  cases  prevent  infection  of  his  person  or  dress. 
But  if,  as  Playfair  believes,  the  scarlatinal  poison  sometimes  produces  in 
parturient  women  a  puerperal  fever  in  which  the  characteristic  scarlatinal 
symptoms  are  lacking,  and  which,  in  the  present  state  of  our  knowledge, 
is  not  distinguishable  from  ordinary  septic  fever,  certainly  the  scarlati- 
nous virus  sustains  a  much  more  frequent  causative  relation  to  childbed 
fever  than  has  been  heretofore  supposed. 

Infants  under  the  age  of  six  months  do  not  ordinarily  contract 
scarlet  fever,  although  fully  exposed,  and  those  under  four  months 
nearly  possess  immunity.  Still,  this  disease  has  been  observed  in  new- 
born infants,  contracted,  apparently,  through  the  placental  circulation. 


500 


SCAELET  FEVER. 


Tourtual  states  that  a  woman  waited  upon  her  own  husband  and  child, 
both  of  whom  had  scarlet  fever,  during  the  eighth  and  ninth  months  of 
her  pregnancy,  till  near  her  confinement.  Though  she  had  no  symptoms 
of  scarlet  fever,  her  infant  had  unusual  redness  of  the  skin  and  buccal 
surface  and  difficulty  of  swallowing  up  to  the  fifth  day.  On  the  ninth 
day  desquamation  began,  and  at  a  later  stage  the  nails  of  the  fingers  and 
toes  separated.  A  case  having  a  history  in  some  respects  similar  is 
related  by  Megnert,  but  the  symptoms  were  anomalous  for  scarlet  fever, 
and  the  disease  may  have  been  ordinary  septic  fever.  On  the  other  hand, 
in  one  instance  in  my  practice  a  mother  had  scarlet  fever,  beginning  about 
the  third  day  after  her  confinement,  and  although  she  suckled  her  infant 
and  it  was  constantly  in  bed  with  her,  it  had  no  symptoms  of  scarlet  fever, 
although  it  became  affected  immediately  afterward  by  a  severe  form  of 
eczema,  probably  from  the  altered  quality  of  the  milk;  and  in  two 
instances  observed  by  Murchison  new-born  infants  remained  healthy, 
although  their  mothers  suffered  from  scarlet  fever. 

After  the  age  of  six  months  the  liability  to  scarlet  fever  increases  till 
the  close  of  infancy,  children  between  the  ages  of  six  mouths  and  one 
year  being  less  liable  to  contract  the  malady  than  daring  the  second  year, 
and  those  in  the  second  year  being  less  liable  to  it  than  those  in  the  third 
year.  Murchison  collected  the  statistics  of  deaths  from  scarlet  fever  in 
England  and  Wales  during  a  series  of  years  ending  with  1861.  The 
number  of  deaths  aggregated  148,829,  and  the  percentage  of  dcatlis  at 
different  ages  was  as  follows  : 

Deaths  under  1  year,  6.7  per  cent, 

between    1  and  2  years,  14.09 

2  3       '      16.00 

3  4      '      15.13 

4  5      '      11.9 

5  10      '      25.9 


10 
15 
25 


15 
25 
35 


5.8 
2.6 
0.8 


over  age  of  35  years,  0.8 

Among  the  deaths  were  ten  cases  above  the  age  of  eighty-five  years,  so 
that  scarlet  fever,  though  especially  a  disease  of  childhood,  may  occur  in 
any  decade  of  lift ;  but  old  age,  like  early  infancy,  almost  possesses 
immunity  from  it. 

I  have  preserved  the  records  of  the  ages  of  145  consecutive  cases 
occurring  in  private  practice.  If  we  add  to  these  58  cases  observed  by 
Prof.  Octerlony  (Amer.  Jour,  of  Med.  Sci.,  July,  1882)  we  have  the  sta- 
tistics of  the  ages  of  203  cases,  which  are  embraced  in  the  following 


Under  1  year,                3 

From  1  to    2  years,    25 

2 

3 

43 

3 

5 

'         57 

5 

10 

1         53 

10 

15 

1         13 

15 

20 

'           3 

20 

30 

'           4 

30 

40 

'           2 

Total,  ~203 

CLINICAL  FACTS  REGARDING  SCARLET  FEVER.  501 

CLINICAL  FACTS  REGARDING  SCARLET  FEVER. — As  a  rule,  scarlet 
fever  occurs  but  once,  one  attack  conferring  immunity  from  the  disease 
for  life  ;  but  there  are  exceptions.  In  1869, 1  attended  a  child  with  fatal 
scarlet  fever  who  three  years  previously,  it  was  stated,  had  passed  through 
a  first  attack  with  all  the  characteristic  symptoms.  The  following  case 

occurred  in  a  family  attended  by  the  late  Dr.  Herzog :  R ,  a  boy  of 

six  years,  had  scarlet  fever  in  a  mild  form  in  January  and  February, 
1875,  followed  by  moderate  desquamation.  In  July  of  the  same  year 
he  was  kicked  by  a  horse  in  the  street,  receiving  a  deep  scalp-wound 
which  required  three  stitches.  Three  days  afterward  he  had,  to  appear- 
ance, a  second  attack  of  scarlet  fever,  attended  by  high  febrile  movement, 
and  followed  also  by  desquamation.  It  was  believed  by  Dr.  H.  to  be  a 
genuine  case,  and  was  so  treated.  I  am  not  able  to  state  as  regards  the 
presence  of  soreness  of  the  throat,  and  doubt  arises  whether  this  second 
attack  may  not  have  been  septioemic.  In  April,  1876,  a  third  attack 
occurred,  which  I  saw  from  the  beginning.  It  was  accompanied  by  all 
the  characteristic  symptoms — injection  of  the  fauces,  an  efflorescence  con- 
tinuing the  usual  time,  followed  by  desquamation  and  albumiuuria,  the 
latter  continuing  several  weeks.  Richardson  states  that  three  distinct 
attacks  occurred  in  his  own  person,  and  a  student  attending  the  lecture  at 
which  this  was  mentioned  informed  the  doctor  that  he  also  had  had 
scarlet  fever  three  times. 

Sometimes  a  second  attack  occurs  so  soon  after  the  first  that  it  has  been 
described  as  a  relapse.  The  following  was  a  case  in  point  in  the  prac- 
tice of  Godneff  (Heditz.  Vestnik.,  No.  iv.,  N.  Y.  Med.  Rec.,  April  30, 
1881) :  A  youth  of  seventeen  years  contracted  scarlet  fever  while  taking 
care  of  a  child.  It  began  with  a  chill,  and  he  had  the  usual  efflorescence, 
sore  throat,  and  tumefaction  of  the  cervical  glands.  An  exudation 
appeared  upon  his  tonsils  and  uvula,  and  his  temperature  reached  104°. 
The  urine  contained  a  trace  of  albumen,  the  rash  in  due  time  faded,  and 
the  epidermis  exfoliated.  On  the  fifteenth  day,  when  he  was  about  ready 
to  leave  the  hospital,  he  again  had  a  chill,  followed  by  fever.  The  tem- 
perature reached  105.2°,  the  rash  reappeared  over  the  entire  surface 
except  the  face,  diphtheritic  exudations  occurred  upon  the  fauces,  and  the 
urine,  the  quantity  of  which  was  diminished,  again  became  albuminous. 
This  second  efflorescence  faded  on  the  twenty-fourth  day,  and  on  the 
twenty-seventh  exfoliation  began.  Hillier  says  :  "  I  have  seen  a  young 
woman  in  the  fever  hospital  suffering  from  a  second  attack  of  scarlatina, 
the  first  attack  having  occurred  five  weeks  previously.  She  had  quite 
recovered  from  her  first  illness,  and  was  acting  as  nurse.  In  botli  seizures 
the  rash,  the  sore  throat,  and  other  symptoms  were  characteristic.  The 
relapse  or  recurrence  was  less  severe  than  the  primary  disease."  Cases 
of  a  fourth,  or  even  of  a  greater  number  of  attacks,  have  been  reported. 
The  first  seizure  is  sometimes  milder,  but  in  other  instances  is  more 
severe,  than  those  which  follow. 

Exposure  to  the  scarlatinous  poison  not  infrequently  produces  pharyn- 
gitis without  the  occurrence  of  scarlatina,  and  the  inflammation  is  apt  to 
be  severe,  accompanied  by  pain  in  swallowing  and  marked  febrile  move- 
ment. This  phlegmasia  is  distinguished  from  scarlet  fever  by  its  shorter 
duration  and  the  absence  of  the  efflorescence.  It  occurs  in  adults  as  well 
as  in  children,  and  in  those  who  have  had,  as  well  as  in  those  who  have  not 


502  SCARLET  FEVER. 

had  scarlatina.  So  far  as  I  have  observed,  it  is  very  seldom  accompanied 
or  followed  by  any  of  the  complications  or  sequelae  so  common  in  and 
after  scarlet  fever.  It  cannot  be  distinguished  from  ordinary  pharyngitis 
except  in  the  manner  in  which  it  occurs,  and  one  attack  does  not  pre- 
clude another.  The  late  George  B.  Wood  made  the  remark  that  he 
never  attended  a  case  of  scarlet  fever  without  suffering  from  sore  throat. 
The  following  were  examples  of  this  form  of  pharyngitis  :  On  Jan.  17th, 
1882,  I  was  called  to  a  boy  of  three  years  with  severe  scarlet  fever,  ush- 
ered in  by  convulsions.  On  the  following  day  his  sister,  aged  seven  and 
three-fourths  years,  whom  I  had  attended  a  year  previously  during  a 
severe  attack  of  scarlatina,  and  who  had  been  almost  constantly  with  the 
brother,  became  very  ill,  with  a  temperature  of  103.5°.  Examination 
revealed  severe  inflammation  of  the  fauces,  without  pseudo-membrane 
or  any  other  exudation  except  muco-pus.  On  Jan.  19th  an  older 
brother,  nine  years,  whom  I  had  attended  in  scarlet  fever  three  years 
previously,  was  affected  in  the  same  way,  his  temperature  being  104° 
and  his  respiration  guttural  and  noisy,  especially  during  sleep,  in  conse- 
quence of  the  great  amount  of  faucial  swelling.  At  times  he  was  delir- 
ious. The  inflammation  in  both  cases  began  to  abate  about  the  third 
day,  and  had  disappeared  by  the  close  of  the  week.  That  the  contagium 
of  scarlet  fever  may  be  received  into  the  system  and  cause  pharyngitis, 
while  the  patient  has  immunity  from  scarlet  fever  through  a  previous 
attack,  and  that  this  inflammation  may  occur  any  number  of  times,  as  in 
the  case  of  Dr.  Wood,  are  remarkable  facts. 

Now  and  then  cases  occur  which  appear  to  show  that  the  scarlatinous 
poison  may  affect  the  kidneys,  producing  nephritis,  while  there  is  no 
other  manifestation  of  its  influence.  Thus  in  my  practice  a  lady  of  about 
forty-five  years  constantly  attended  her  son,  sleeping  by  his  side,  during 
an  attack  of  scarlet  fever.  Her  health  had  previously  been  good.  When 
the  boy  was  convalescent,  as  her  appetite  failed  and  she  was  indisposed,  a 
careful  examination  revealed  the  fact  that  she  had  albuminuria,  although 
she  had  had  no  sore  throat  or  other  symptom  of  scarlet  fever.  After 
several  weeks  of  treatment  her  disease  was  removed,  and  she  has 
remained  well  since.  In  the  British  Med.  Jour,  for  Nov.  29,  1879,  it 
is  stated  that  in  a  family  four  girls  were  found  to  be  suffering  from 
desquamative  nephritis.  One  of  them  had  recently  had  scarlet  fever, 
but  the  other  three  had  presented  no  symptoms  whatever  of  this  disease. 
Such  cases,  although  probably  rare,  appear  to  show  that,  as  the  scarlat- 
inous poison  may  produce  inflammation  of  the  fauces  without  the  occur- 
rence of  scarlet  fever,  so  it  may  cause  nephritis  without  producing  the 
general  disease,  or  apparently  disturbing  the  functions,  or  changing  the 
state  of  other  parts,  except  the  kidneys. 

SYMPTOMS. — ORDINARY  FORM.  Scarlet  fever  usually  begins  abruptly, 
so  that  the  exact  time  of  its  commencement  can  be  fixed.  If  any  pre- 
monitory symptoms  occur,  they  are  slight,  so  as  scarcely  to  attract  atten- 
tion, as  languor  or  the  appeaYance  of  fatigue.  A  dusky  aspect  of  the 
surface  may  occasionally  be  observed  during  the  few  hours  preceding  the 
attack.  In  some  children  the  first  symptom  is  chilliness,  and  occasion- 
ally a  distinct  chill  occurs.  In  the  adult  a  chill  is  ordinarily  the  first 
symptom.  With  or  without  the  initial  chilliness,  febrile  movement 
occurs,  of  variable  intensity  according  to  the  severity  of  the  type,  and 


SYMPTOMS.  603 

accompanied  by  such  symptoms  as  usually  arise  in  a  febrile  state  of 
sy&tem,  as  cephalalgia,  anorexia,  and  thirst.  The  pulse  rises  to  110, 120, 
or  more  per  minute,  the  temperature  to  102°,  103°,  or  104°;  the  skin  is 
hot,  face  flushed,  and  the  eyes  bright.  Even  in  cases  that  are  not  malig- 
nant or  grave,  and  that  give  indications  of  a  favorable  result,  there  is 
often  more  or  less  stupor,  with  transient  delirium  and  sudden  starting  or 
twitching  of  the  extremities,  showing  that  the  cerebro-spinal  axis  is 
involved. 

Vomiting  is  a  common  symptom  in  the  beginning  of  scarlet  fever, 
occurring  before  the  appearance  of  the  efflorescence.  It  therefore  has 
diagnostic  value  when  the  nature  of  the  case  is  still  doubtful.  In  some 
patients  it  is  an  initial  symptom,  but  in  others  some  hours  have  elapsed 
when  it  occurs.  I  recorded  its  presence  or  absence  in  214  patients,  with 
the  following  result:  present  in  162  patients,  absent  in  52.  In  severe 
forms  of  the  disease  it  is  rarely  absent,  and  if  it  do  not  occur  it  is  probable 
that  the  case  will  be  mild,  requiring  little  treatment  and  having  a  favor- 
able termination.  In  epidemics  of  unusual  mildness  the  number  of  cases 
without  vomiting  may  be  in  excess  of  those  in  which  this  symptom 
occurs.  It  appears  to  be  due  to  functional  disturbance  of  the  cerebro- 
spinal  system,  and  it  may  therefore  be  properly  regarded  as  a  nervous 
symptom.  In  severe  cases  the  vomiting  is  apt  to  be  repeated,  not  only 
on  the  first  but  on  subsequent  days,  and  we  shall  see  that  in  cases  of  great 
gravity,  in  which  a  fatal  termination  is  not  improbable,  persistent  vomit- 
ing,  by  which  the  food  and  stimulants  so  urgently  required  are  rejected, 
interferes  seriously  with  successful  treatment.  In  a  few  cases  embraced 
in  my  statistics  nausea  without  vomiting  was  recorded.  The  bowels  in 
ordinary  scarlatina  act  regularly  or  are  slightly  constipated.  Diarrhrea, 
which  so  commonly  accompanies  the  persistent  vomiting  in  malignant 
cases,  if  it  occur  in  this  form  of  the  malady  is  slight  and  transient  and 
due  to  accidental  causes.  The  food,  if  it  be  given  in  the  liquid  form  and 
cool,  is  usually  taken  readily,  on  account  of  the  thirst,  except  when 
deglutition  is  rendered  painful  by  the  pharyngitis. 

The  symptoms  pertaining  to  the  nervous  system  vary  according  to  the 
severity  of  the  disease  and  the  temperament  of  the  patient.  Many, 
children  during  the  progress  of  the  common  form  of  scarlet  fever 
present  a  dull  or  apathetic  appearance.  They  lie  much  of  the  time 
with  their  eyes  closed ;  others  are  more  restless,  and  not  a  few,  if  the 
fever  be  considerable,  have  occasional  twitching  of  the  limbs  and  more 
or  less  headache.  Eclampsia  sometimes  occurs  on  the  first  day,  especially 
in  those  predisposed  to  it,  even  when  the  siibsequent  course  of  the  dis- 
ease is  mild  and  favorable.  This  complication,  very  grave  and  usually 
fatal  when  it  occurs  at  a  later  stage,  is  in  most  instances,  when  it  takes 
place  on  the  first  day,  readily  controlled  by  proper  remedies  and  with 
little  detriment  to  the  patient.  But  if  it  be  attended  by  high  elevation 
of  temperature  and  marked  drowsiness,  approaching  the  comatose  state, 
it  is  very  serious  upon  the  first  as  well  as  upon  subsequent  days.  Nervous 
symptoms  occurring  in  the  beginning  of  scarlet  fever,  when  it  has  the 
ordinary  favorable  type,  begin  to  abate  in  three  or  four  days,  but  if  they 
supervene  at  a  later  date,  and  especially  in  the  declining  stage,  they^ possess 
more  gravity,  since  they  then  not  infrequently  result  from  and  indicate 
renal  complication. 


504  SCARLET  FEVER. 

Early  in  the  disease,  nearly  as  soon  as  the  commencement  of  the  fever, 
the  faucial  and  buccal  surfaces  become  inflamed,  as  shown  by  redness, 
swelling,  and  tenderness.  The  physician  summoned  in  the  beginning 
of  an  attack  will  already,  at  his  first  visit,  observe  hyperaemia  of  the 
fauces,  with  points  of  deeper  injection  than  over  the  general  faucial  sur- 
face, and  soon  the  buccal  surface  also  participates.  The  inflammation  at 
first  produces  preternatural  dryness,  and  this  is  followed  by  a  viscid 
secretion.  The  papillae  of  the  tongue  enlarge  and  become  prominent, 
giving  rise  to  the  appearance  known  as  strawberry  tongue  which  is  so 
common  in  scarlet  fever.  This  state  of  the  buccal  and  faucial  membrane 
continues  throughout  the  disease.  A  thin  fur  appears  upon  the  tongue 
on  the  first  day,  and  it  increases  on  the  second  and  third  days,  after  which 
it  is  apt  to  be  detached,  exposing  the  surface  of  the  organ,  which  has  a 
deep  red  hue,  but  in  not  a  few  patients  the  fur  remains  or  is  reproduced 
as  soon  as  shed.  Except  in  the  mildest  cases  the  Sclmeiderian  membrane 
also  participates  in  the  inflammation  as  the  disease  advances,  so  that  a 
thin,  irritating  discharge,  containing  leucocytes  or  pus-cells,  flows  from 
the  nostrils.  The  skin  is  hot  and  dry,  and  cutaneous  transpiration  nearly 
checked.  The  respiratory  system  is  rarely  involved  in  any  notable  man- 
ner unless  there  be  a  complication.  Many  have  no  cough  whatever, 
while  others  have  a  slight  cough,  due  to  the  fact  that  the  inflammation, 
of  a  catarrhal  form,  has  extended  from  the  fauces  to  the  surface  of  the 
glottis.  Slight  acceleration  of  respiration,  corresponding  with  the  degree 
of  fever,  may  also  be  observed.  The  kidneys  commonly  act  regularly 
and  normally  during  the  first  days,  any  serious  impairment  of  their 
functions  being  rare  before  the  close  of  the  first  week. 

"When  the  symptoms  described  above  have  continued  from  six  to 
eighteen  hours  the  efflorescence  appears.  It  is  first  observed  about  the 
ears,  neck,  and  shoulders,  in  reddish  patches  fading  into  the  normal  hue. 
These  patches  extend  and  unite,  and  in  the  course  of  a  few  hours  the 
trunk  and  upper  extremities,  and  finally  the  legs,  are  covered.  The 
scarlatinous  rash  usually,  when  fully  developed,  resembles  that  produced 
by  external  heat  or  the  application  of  a  sinapism.  It  has  been  likened 
.to  the  appearance  of  a  boiled  lobster,  but  there  are  numerous  minute 
points  of  a  deeper  or  duskier  hue  than  the  surface  generally.  In  many 
patients  the  rash  appears,  especially  over  the  abdomen  and  lower  extrem- 
ities, as  minute,  thickly-set  points,  with  the  skin  of  normal  appearance 
between  them.  Henoch  of  Berlin  says  of  scarlet  fever:  "In  general, 
the  moderate  grades  of  eruption  prevail,  the  skin,  when  seen  from  a  dis- 
tance, presenting  a  diffuse,  more  or  less  scarlet  redness,  while  on  closer 
inspection  it  is  found  that  this  redness  is  composed  of  innumerable  red 
points  closely  situated  together,  and  separated  from  one  another  by  very 
small  paler  portions  of  skin.  The  dark-red  points  appear  to  correspond 
to  the  hair-follicles."  On  passing  the  finger  over  the  efflorescence  no 
distinct  prominences  are  observed,  but  a  sensation  of  roughness  is 
sometimes  imparted  from  engorgement  of  the  cutaneous  papilla.  The 
rash  disappears  on  pressure,  but  it  immediately  reappears  when  the 
pressure  is  removed.  Its  slow  return  is  evidence  of  sluggish  circulation, 
and  it  indicates  a  grave  and  dangerous  form  of  the  malady.  The  color 
is  then  usually  a  dusky  instead  of  a  bright  red.  The  efflorescence  is 
most  marked  in  dependent  part.«,  as  along  the  back,  over  the  chest  and 


SYMPTOMS.  505 

abdomen,  and  in  the  flexures  of  the  joints.  Parts  pressed  upon  by  the 
bed-clothes,  which  confine  and  intensify  the  heat,  present  a  deeper  color- 
ation than  other  portions  of  the  surface.  Often,  especially  in  mild  cases, 
the  rash  is  absent  from  portions  of  the  surface  where  it  commonly 
appears,  while  it  presents  a  typical  character  elsewhere.  Tardy  and 
incomplete  establishment  of  the  rash  when  the  symptoms  indicate  an 
attack  of  ordinary  or  more  than  ordinary  severity  is  commonly  due  to 
some  perturbating  cause,  especially  diarrhoea.  In  the  London  Lancet  for 
Aug.  16,  1879,  cases  are  related  of  supposed  scarlet  fever  without  the 
rash,  cases  in  which  pharyngitis  and  stomatitis  with  the  strawberry 
tongue  occurred,  without  efflorescence  upon  the  skin ;  but  it  is  to  be 
remembered,  as  stated  above,  that  the  inflammations  which  commonly 
attend  or  follow  scarlet  fever,  particularly  the  pharyngitis  and  nephritis, 
not  infrequently  occur  in  those  who  have  already  had  scarlatina,  and 
occur  more  than  once  from  fresh  exposure  to  scarlatina  patients.  These 
inflammations,  occurring  under  such  circumstances,  appear  to  be  purely 
local  maladies,  produced  by  the  scarlatinous  virus ;  and  it  seems  to  me 
a  question  whether,  in  the  so-called  scarlatina  without  efflorescence,  the 
inflammations  which  are  present,  and  which  undoubtedly  have  a  scarlat- 
inous origin,  are  not  local  in  their  nature,  instead  of  being  local  mani- 
festations of  the  constitutional  disease.  The  burning  and  itching  sensa- 
tion produced  by  the  rash  increases  the  restlessness  of  the  patient,  and  is 
sometimes  the  most  annoying  of  the  symptoms. 

The  temperature  in  the  common  favorable  forms  of  scarlet  fever 
usually  varies  from  101°  in  the  mildest  cases  to  103°  or  104°  in  those 
more  severe.  If  it  attain  105°  or  over,  the  case  is  properly  designated 
grave  or  severe.  The  febrile  movement  commonly  fluctuates  but  little 
from  day  to  day  till  the  fourth  or  fifth  day,  when,  if  the  case  be  favor- 
able and  no  complication  occur,  it  begins  to  decline.  The  temperature 
is  as  high  in  the  beginning  of  the  attack  as  subsequently. 

The  symptoms  pertaining  to  the  digestive  system  during  the  initial 
period  of  scarlet  fever  have  been  sufficiently  described.  The  subsequent 
symptoms  referable  to  this  system  do  not  differ  materially  from  those 
present  in  the  beginning,  except  the  absence  of  vomiting.  The  lips  are 
dry  and  often  cracked.  The  inflammation  of  the  mouth  and  throat  con- 
tinues, with  anorexia  and  thirst.  With  the  decline  of  the  disease  the 
appetite  gradually  returns,  but  it  is  not  till  the  close  of  the  second  week 
that  it  is  fully  restored.  Great  and  continued  disturbance  of  the  digestive 
apparatus,  seriously  interfering  with  the  nutrition,  pertains  to  the  malig- 
nant forms  of  scarlet  fever. 

The  urine  is  high-colored,  and  in  robust  children  during  the  first  days 
of  scarlet  fever  it  frequently  deposits  urates  on  cooling.  Gee,  who  has 
carefully  investigated  the  state  of  the  urine  in  scarlet  fever,  says  that 
the  quantity  of  water  is  diminished  and  the  urea  is  not  necessarily 
increased  during  the  pyrexia ;  that  the  chloride  of  sodium  is  diminished 
till  the  fourth,  fifth,  or  sixth  day,  and  that  the  phosphoric  acid  is  dimin- 
ished during  the  climax  of  the  pyrexia,  though  not  during  the  first  three 
or  four  days.  In  one  case  he  made  a  daily  estimation  of  the  amount  of 
uric  acid,  and  found  it  greatly  diminished  on  the  second  and  third  days, 
normal  on  the  fourth,  and  much  increased  on  the  fifth.  He  believes  tnat 
similar  variations  are  common  in  the  quantity  of  the  products  excreted 


506  SCARLET  FEVER. 

in  the  urine.  Bile  may  also  appear  in  the  urine,  coincident  with  a 
yellow  tinge  of  the  conjunctiva.1 

The  duration  of  scarlet  fever  varies  in  different  cases.  If  the  attack 
be  very  mild,  with  little  efflorescence,  the  febrile  movement  may  decline 
by  the  fourth  or  fifth  day ;  but  if  the  disease  be  severe,  little  or  no 
amelioration  of  symptoms  may  occur  before  the  twelfth  or  fourteenth 
day,  even  when  no  complication  has  occurred  to  increase  the  tempera- 
ture or  cause  aggravation  of  symptoms.  Octerlony,  who  estimated  the 
duration  of  scarlet  fever  from  the  commencement  of  febrile  symptoms  to 
"  the  disappearance  of  fever,  with  marked  improvement  in  leading  syrn- 
torns,"  .  .  .  .  "  found  that  the  average  duration  of  the  disease  in  forty 
cases  was  six  and  one-sixth  days.  The  minimum  duration  in  a  very 
slightly-marked  case  was  three  days :  the  maximum  duration  was  four- 
teen days."  In  general,  prolongation  of  fever  beyond  the  usual  time  is 
due  to  some  complication — more  frequently  to  unusually  severe  pharyn- 
gitis, with  accompanying  cellulitis,  than  to  any  other  cause. 

The  malady  whose  commencement  was  so  abrupt  declines  gradually. 
In  ordinary  cases,  by  the  close  of  the  first  week  or  in  the  beginning  of 
the  second  the  rash  becomes  less  and  less  distinct,  and  finally  disappears, 
as  do  also  the  redness  and  swelling  of  the  buccal  and  faucial  surfaces. 
The  engorgement  of  the  tonsils  and  of  the  papillae  of  the  tongue  sub- 
sides, the  appetite  returns,  the  countenance  brightens  and  becomes  natural, 
and  the  child,  who  during  the  height  of  the  fever  scarcely  noticed  objects 
or  noticed  them  with  indifference  or  even  repugnance,  can  be  amused  as 
before  his  sickness. 

Desquarnation  succeeds.  This  begins  at  about  the  sixth  day,  and  is  not 
completed  till  the  tenth  or  twelfth  day ;  often  not  till  the  close  of  the 
third  or  in  the  fourth  week.  The  amount  of  desquamation  corresponds 
with  the  intensity  and  duration  of  the  efflorescence,  or  rather  of  the  der- 
matitis which  produces  the  efflorescence.  If  the  efflorescence  have  been 
slight  and  partial,  it  will  be  slight,  perhaps  scarcely  appreciable,  but  if 
the  rash  have  been  general,  full,  and  protracted,  exfoliation  occurs  upon 
every  part.  It  begins  about  the  face  and  neck,  and  within  a  day  or  two 
appears  upon  other  parts.  Where  the  skin  is  thin  the  epidermis  as  it  is 
detached  presents  a  furfuracous  appearance ;  where  it  is  thick,  as  upon  the 
palms  of  the  hands  or  soles  of  the  feet,  it  separates  in  layers  of  consider- 
able thickness. 

Such  is  a  brief  description  of  scarlet  fever  when  it  pursues  its  normal 
course  without  any  disturbing  element,  but  there  is  no  other  disease  in 
which  complications  and  sequelae  so  frequently  occur.  The  liability  to 
them  renders  the  prognosis  in  every  case  doubtful.  They  largely  increase 
the  percentage  of  deaths.  They  occur  both  in  mild  and  severe  forms  of 
scarlatina. 

The  difference  in  type  in  different  cases  and  epidemics  has  already  been 
alluded  to.  Scarlet  fever  is  sometimes  so  mild,  and  its  symptoms  so  slight, 
that  the  diagnosis  is  necessarily  uncertain.  In  the  spring  of  1 8fifi  I  was 
called  to  an  infant  thirteen  months  old  who  had  slight  pharyngitis  and 
an  indistinct  rash  over  a  part  of  the  surface.  In  two  days  the  eruption 
had  disappeared,  and  the  health  within  a  day  or  two  later  was  apparently 
fully  restored.  Diagnosis  would  have  been  doubtful  except  for  sequelae 
1  Article  on  scarlatina  in  Eeynolds's  System  of  Medicine. 


GRAVE  FORM.  507 

which  clearly  indicated  the  scarlatinous  nature  of  the  attack.  In  another 
instance  two  children  passed  through  the  entire  course  of  scarlet  fever 
playing  every  day  in  the  street.  Although  the  intelligent  grandmother 
saw  the  rash  upon  them,  its  nature  was  not  suspected,  as  it  was  mid- 
summer and  cases  of  prickly  heat  common,  till  nearly  two  weeks  after- 
ward, when  one  of  the  children  had  nephritis  and  anasarca  ending  fatally. 
In  cases  so  mild  as  these  the  heat  of  surface  is  but  slightly  increased,  the 
pulse  but  little  accelerated,  and  the  rash  usually  does  not  occupy  so  much 
of  the  surface  as  in  ordinary  cases  ;  the  appetite  is  not  lost,  though  dimin- 
ished, and  the  thirst  is  moderate. 

Between  scarlet  fever  so  mild  that  it  terminates  in  four  or  five  days, 
and  that  of  the  grave  or  malignant  type  presently  to  be  described,  all 
grades  of  severity  exist.  Scarlet  fever  occurs  in  all  forms  from  mild  to 
severe,  but  certain  symptoms  characterize  grave  or  malignant  cases — 
symptoms  which  are  absent  or  much  less  prominent  in  ordinary  scarlet 
fever.  Therefore  the  grouping  of  cases  according  to  the  type  is  proper, 
and  facilitates  the  studying  of  the  disease. 

GRAVE  FORM  (malignant  scarlet  fever). — This  form  of  the  disease  is 
in  some  epidemics  common,  while  in  others  it  is  rare.  The  symptoms 
which  characterize  it  are  severe  from  the  beginning,  those  of  the  nervous 
system  predominating  at  first,  such  as  intense  cephalalgia,  restlessness  or 
stupor,  sudden  twitching  of  the  muscles,  and  perhaps  delirium,  or  even 
convulsions.  Many  pass  rapidly  into  coma  and  die  within  two  or  three 
days,  succumbing  to  the  intensity  of  the  scarlatinous  poison  while  the 
malady  is  still  in  its  commencement.  The  rash  is  dusky.  It  disappears  by 
pressure,  and  returns  slowly  when  the  pressure  is  removed,  showing  extreme 
sluggishness  of  the  capillary  circulation.  Some  patients  are  very  drowsy, 
lying  in  a  semi-comatose  state  except  when  aroused,  and  if  aroused  are 
very  restless.  Others  are  constantly  restless.  If  placed  in  one  position 
on  the  bed,  they  throw  themselves  in  another  in  a  half-conscious  or 
unconscious  state.  They  do  not  speak,  or  they  mutter  like  those  affected 
by  the  graver  forms  of  typhus,  calling  the  names  of  playmates  or  talking 
incoherently  about  things  which  interested  them  when  well.  The  ther- 
mometer placed  in  the  axilla  is  found  to  rise  above  103°,  which  is  a  safe 
average,  to  105°  or  even  107°,  and  the  heat  of  the  surface  is  pungent 
except  when  the  case  approaches  a  fatal  termination,  when  the  extremities, 
ears,  and  nose  may  be  cool  while  the  trunk  and  head  are  extremely  hot. 
The  pulse  from  the  first  is  rapid,  ranging  from  130  as  the  minimum  in  a 
malignant  case  to  a  frequency  which  can  scarcely  be  counted.  A  very 
frequent  pulse  is  nearly  always  feeble  and  compressible.  Irritability  of 
the  stomach  is  one  of  the  most  common  symptoms  in  grave  cases,  so  that 
many  patients  immediately  reject  the  nutriment  and  stimulants  which  are 
so  urgently  required  to  sustain  the  vital  powers.  The  vomiting,  there- 
fore, if  frequent  and  severe,  greatly  increases  the  danger,  and  in  not  a  few 
instances  this  symptom  is  associated  with  diarrhoea,  which  also  tends  to 
increase  the  prostration. 

Severe  and  dangerous  nervous  symptoms,  due  to  the  intensity  or 
activity  of  the  scarlatinous  poison,  occur  chiefly  within  the  first  three  or 
four  days.  Grinding  the  teeth,  sudden  muscular  twitching,  delirium, 
convulsions,  and  profound  stupor  occur  for  the  most  part  within  this 
time.  Afterward  the  danger  is  mainly  from  exhaustion,  unless  in  the 


508  SCARLET  FEVER. 

second  week  or  subsequently,  when  nervous  symptoms  may  arise  from 
uraemia. 

Those  who  survive  the  onset  of  malignant  scarlet  fever  often  have  in 
the  course  of  a  few  days  severe  pharyngitis,  with  extension  of  the  inflam- 
mation to  the  lymphatic  glands  and  connective  tissue  around  the  angle 
of  the  jaw.  These  inflammations  cause  more  or  less  external  swelling. 
The  faucial  turgesceuce  around  the  entrance  of  the  larynx,  with  the 
accompanying  secretion  of  viscid  mucus  or  muco-pus,  often  causes  noisy 
respiration,  and  many  at  this  stage  of  the  attack  breathe  with  the  mouth 
constantly  open  to  facilitate  the  ingress  of  air. 

Ordinarily,  no  discharge  occurs  at  first  from  the  nasal  surface,  but  as 
the  disease  continues,  if  the  type  remain  severe,  defluxion  of  thin  muco- 
pus  takes  place  from  the  Schneiderian  surface,  which  frequently  excoriates 
the  cheek.  The  lips  also  are  apt  to  be  sore  and  swollen. 

In  malignant  cases  the  disease  is  more  protracted  than  when  the  type 
is  mild.  Thus  in  a  recent  case  in  my  practice  the  rash  was  still  distinct 
at  the  close  of  the  second  week,  though  the  temperature  had  fallen  from 
105°  to  102°  and  some  desquamation  had  appeared.  Long  continuance 
of  the  febrile  movement  is,  however,  ofteuer  attributable  to  some  inflam- 
matory complication  than  to  the  primary  disease. 

In  all  epidemics  of  a  severe  type  cases  now  and  then  occur  in  which 
the  poison  is  so  intense,  or  it  acts  with  such  frightful  energy,  that  death 
occurs  even  within  the  first  day.  The  patient  is  overpowered  at  the  outset 
of  the  disease  by  the  virulence  of  the  specific  principle,  perishing  in  coma, 
preceded  perhaps  by  convulsions.  The  autopsy  in  such  cases  reveals  hyper- 
semia  of  the  brain  and  cranial  sinuses,  blood  of  a  dark-red  color,  capillary 
hemorrhages  in  various  parts,  a  flabby  heart,  and  perhaps  some  engorge- 
ment of  the  spleen  and  kidneys. 

Usually,  malignant  scarlet  fever  exhibits  its  severe  type  from  the  first, 
but  cases  sometimes  occur  which  seem  mild  and  favorable  for  a  few  days, 
when  severe  symptoms  suddenly  supervene.  This  change  from  a  mild 
to  a  dangerous  disease  is,  however,  most  frequently,  I  think,  due  to  some 
complication. 

IRREGULAR  FORMS. — Deviation  from  the  normal  type  in  scarlet  fever 
is  usually  due  to  some  perturbating  cause,  which  is  often  a  pre-existing 
or  co-existing  disease,  or  a  disordered  state  of  system  through  causes  dis- 
tinct from  the  scarlatinous  disease.  Thus,  a  little  girl  in  my  practice  had 
the  symptoms  of  scarlet  fever,  such  as  febrile  movement  and  inflamma- 
tion of  the  buccal  and  faucial  surfaces,  nearly  a  week  before  the  scarlat- 
inous eruption  appeared.  During  this  time  the  patient  had  an  intestinal 
catarrh,  with  diarrhoea,  which  declined  when  the  rash  occurred.  This 
intestinal  disease  was  the  apparent  cause  of  the  irregularity  in  the  malady. 
If  scarlatina  occur  during  a  severe  attack  of  entero-colitis  attended  by 
purging,  the  defluxion  from  the  external  surface  may  be  such  that  no 
efflorescence  appears.  Severe  scarlet  fever  itself  sometimes  appears  to 
cause  gastro-intestinal  catarrh  so  as  to  produce  an  afflux  of  blood  toward 
the  intestinal  tract  and  away  from  the  skin.  Practitioners  occasionally 
meet  cases  like  the  following,  which  I  recall  to  mind :  In  a  family 
where  scarlatina  was  prevailing  a  little  child  early  after  the  commence- 
ment of  symptoms  which  seemed  to  be  plainly  referable  to  this  exan- 
thern  was  seized  with  vomiting  and  purging,  which  continued  till  death 


IRREGULAR  FORMS.  509 

occurred  on  the  third  day.  No  efflorescence  appeared  upon  the  skin,  but 
the  symptoms  indicated  the  presence  of  severe  intestinal  catarrh,  com- 
plicating and  masking  scarlatina.  We  are  aided  in  the  diagnosis  of  such 
cases  by  observing  the  faucial  redness,  and  we  may  discover  a  faint 
efflorescence  upon  parts  of  the  surface,  as  about  the  groin  or  in  the  flex- 
ures of  the  joints.  In  another  instance  an  infant  in  the  warm  months 
having  protracted  entero-colitis,  the  usual  summer  epidemic  of  the  cities, 
had  the  characteristic  symptoms  of  scarlet  fever,  which  was  present  in 
the  family,  but  the  diarrhrea  continued  and  no  rash  appeared. 

In  one  who  is  much  reduced  by  an  antecedent  disease,  as  phthisis,  or 
who  has  a  disease,  chronic  or  acute,  which  produces  a  decided  afflux  of 
blood  away  from  the  surface  and  toward  the  interior  of  the  body,  the 
eruption  is  commonly  tardy  in  its  appearance,  indistinct,  or  wholly 
absent.  Thus,  severe  inflammations  of  internal  organs  not  infrequently 
render  scarlet  fever  irregular.  On  the  other  hand,  some  maladies  occur- 
ring in  connection  with  this  exanthem  do  not  change  its  symptoms,  but 
themselves  undergo  modification.  Pertussis  may  be  cited  as  an  example, 
the  cough  of  which  is  sometimes  modified  by  an  intercurrcnt  attack  of 
scarlet  fever,  the  symptoms  of  the  latter  disease  undergoing  little  change. 

Scarlet  fever  may  also  be  irregular  without  any  apparent  perturbating 
cause.  In  1867  I  attended  a  young  lady  whose  previous  health  had  been 
good,  and  whose  brother  was  sick  at  the  time  with  scarlet  fever.  She 
had  considerable  febrile  movement,  with  severe  pharyngitis,  and,  though 
her  surface  was  repeatedly  examined,  no  efflorescence  was  seen.  Two  weeks 
subsequently  she  was  affected  with  severe  nephritis,  anasarca,  effusion 
into  at  least  one  of  the  pleural  cavities,  oedema  of  the  lungs,  and  probably 
hydro-pericardium,  the  case  ending  fatally.  Rilliet  and  Barthez  state 
that  a  second  attack  of  scarlet  fever  is  more  apt  to  be  irregular  than  the 
first.  Probably  this  opinion  is  correct,  especially  if  only  a  short  time 
have  elapsed  between  the  two  seizures.  Still,  as  we  have  already  stated, 
both  seizures  may  be  typical,  and  the  second  more  severe  than  the  first. 

It  would  be  impossible  to  make  a  clear  and  positive  diagnosis  of  cer- 
tain cases  of  irregular  scarlet  fever,  in  which  cerebral,  pulmonary,  or 
gastro-intestiual  symptoms  predominate,  were  it  not  for  the  fact  that  they 
occur  in  connection  with  other  cases  of  scarlet  fever  or  are  followed  by 
sequela3  which  evidently  have  a  scarlatinous  origin. 

Occasionally,  the  eruption,  if  it  be  intense  or  if  a  certain  condition  of 
system  be  present  in  the  patient,  is  accompanied  by  more  or  less  extrava- 
sation of  blood-corpuscles  from  the  capillaries,  so  that  the  redness  does 
not  entirely  disappear  on  pressure,  usually  in  points.  In  rare  instances 
certain  of  the  exanthematic  fevers  present  an  extreme  hemorrhagic  cha- 
racter, so  as  to  be  beyond  the  reach  of  remedies,  and  of  necessity  speedily 
fatal.  Hemorrhagic  cases  of  this  severe  form  are  probably  more  common 
in  variola  than  in  the  other  fevers,  but  I  have  met  a  notable  case  in  what 
was  diagnosticated  scarlatina.  In  June,  1881,  a  man  in  his  thirty-second 
year,  whose  previous  health  had  not  been  good,  though  he  had  no  defined 
ailment  and  had  been  able  to  follow  his  occupation  of  harness-maker, 
suddenly  became  very  ill,  with  high  febrile  movement  and  faucial  inflam- 
mation, attended  by  marked  prostration.  After  some  hours  an  intense 
eruption  of  a  scarlatinous  appearance  covered  nearly  the  entire  surface, 
and  on  the  following  day  hemorrhages  began  to  occur.  The  urine  con- 


510  SCARLET  FEVER. 

tained  a  large  proportion  of  blood ;  each  conjunctiva  was  raised  by  hem- 
orrhages underneath  (ecchymosis),  so  that  its  natural  color  was  lost  and 
the  eyelids  closed  with  difficulty ;  and  blood  flowed  from  the  nostrils, 
gums,  and  under  the  skin,  forming  hemorrhagic  points  and  blotches. 
One  of  the  consulting  physicians,  perceiving  the  resemblance  to  hemor- 
rhagic variola  as  described  by  Hebra,  suspected  that  we  had  a  case  of 
this  formidable  malady  to  deal  with,  but  the  time  for  the  appearance  of 
the  variolous  eruption  passed  by  without  its  occurrence.  Death  took 
place  on  the  fifth  day.  The  temperature  during  the  sickness  was  high, 
though  the  record  of  it  has  been  mislaid.  Fortunately,  such  severe  hem- 
orrhagic cases,  which  are  necessarily  fatal,  are  rare. 

COMPLICATIONS  AND  SEQUEL  JE. — Scarlet  fever,  if  its  type  be  severe, 
is  in  itself  dangerous  to  life.  Many,  as  we  have  seen,  perish  from  its 
direct  effects  when  it  produces  profound  blood-poisoning.  But,  while  the 
ordinary  epidemics  of  this  malady  are  necessarily  attended  by  a  large 
mortality  from  the  virulence  and  depressing  effect  of  the  specific  princi- 
ple, unfortunately,  of  all  the  diseases  of  modern  times,  scarlatina  ranks 
first  as  regards  the  number  aud  gravity  of  its  complications  and  sequela?, 
so  that  nearly  or  quite  as  many  perish  from  these  as  from  the  direct  effect 
of  the  poison. 

Nervous  accidents  occur  chiefly  at  two  periods — to  wit,  in  the  first  days, 
when  they  are  due  to  the  severity  and  malignancy  of  the  malady  and  to  the 
impressible  nervous  temperament  of  the  child,  and  in  the  declining  stage, 
or  after  the  termination  of  the  fever,  when  they  occur  from  uraemia.  If  the 
type  be  malignant,  delirium,  jactitation,  profound  stupor,  and  convulsions 
frequently  occur  on  the  first  and  second  days ;  and  they  are  symptoms 
which  properly  excite  the  utmost  alarm  and  demand  all  the  resources  of 
our  art,  since  they  indicate  a  form  of  the  disease  which  is  apt  to  end  in 
speedy  death.  The  eyes  have  a  dull  or  wild  expression,  the  conjunctiva 
is  suffused,  the  heat  of  surface  pungent,  the  pulse  rapid  and  compressible 
or  feeble,  rising  above  150,  even  to  200,  per  minute,  and  the  temperature 
is  always  elevated  to  a  degree  that  involves  danger,  the  thermometer  not 
infrequently  indicating  105°  or  106°.  But  this  severe  form  of  scarlet 
fever,  attended  by  so  great  elevation  of  temperature,  is  much  less  dan- 
gerous than  in  former  times,  even  though  it  be  complicated  by  delirium 
aud  convulsions,  since  we  no  longer  hesitate  to  reduce  bodily  heat,  when 
excessive,  by  the  free  use  of  cold  baths,  and  have  discovered  potent  agents 
in  the  bromides  and  chloral  for  controlling  convulsions.  Nevertheless, 
not  a  few  perish  in  the  commencement  of  scarlet  fever  with  predomi- 
nating cerebral  symptoms,  as  delirium  or  eclampsia,  followed  by  coma, 
under  the  best  possible  treatment.  Sometimes  the  symptoms  have  closely 
simulated  those  of  acute  meningitis,  and  if  the  rash  have  been  delayed 
and  the  sore  throat  is  as  yet  slight,  the  physician  may  suspect  that  he  is 
dealing  with  this  disease ;  but  autopsies  in  such  cases  show  no  inflamma- 
tory lesions,  but  only  congestion  of  the  cerebral  and  menmgeal  vessels. 

As  is  stated  in  a  preceding  page,  in  every  case  of  normal  scarlet  fever 
inflammation  of  the  faucial  surface  is  present,  as  indicated  by  redness, 
tenderness,  and  increased  secretion  of  mucus  or  muco-pus.  It  precedes 
the  efflorescence  on  the  skin,  and  is  announced  by  pain  in  swallowing  and 
on  pressure  with  the  fingers  behind  and  below  the  angles  of  the  jaw. 
In  that  form  of  scarlet  fever  which  has  been  designated  anginose  the 


COMPLICATIONS  AND  SEQUELS.  511 

pharyngitis  is  severe,  and  is  a  prominent  element  in  the  malady,  the 
uvula,  the  pillars  of  the  fauces,  and  the  faucial  surface  in  general  being 
infiltrated  and  swollen.  Nevertheless,  this  inflammation,  with  the  accom- 
panying tumefaction,  is  properly  a  part  of  the  disease,  rather  than  a 
complication,  if  it  abates  with  the  subsidence  of  the  scarlet  fever  or 
begin  to  abate  soon  after,  and  if  it  produce  but  slight  destructive  change 
in  the  tissues  of  the  neck.  The  secretions  from  the  fauces  may  be  foul 
and  offensive ;  even  superficial  ulcerations  or  gangrene  may  occur  upon 
the  faucial  surface,  causing  it  to  present  a  dark  brown  or  jagged  appearance, 
and  the  tissues  of  the  neck  may  be  infiltrated  to  a  certain  extent,  and  we 
designate  the  disease  a  form  of  scarlet  fever  under  the  title  anginose.  But 
when  this  condition  is  greatly  aggravated,  so  that  there  is  extensive  infil- 
tration and  swelling  of  the  tissues  of  the  neck,  with  an  amount  of  ulcer- 
ation  or  gangrene  which  in  itself  involves  danger,  continuing  after  the 
primary  disease  abates,  prolonging  the  fever  and  reducing  the  strength,  it 
is  proper  to  regard  the  state  of  the  throat  as  a  complication.  In  addition 
to  the  pharyngitis,  which  is  severe  as  described  above,  the  sides  of  the 
neck  around  the  angles  of  the  jaw  become  swollen,  hard,  and  tender. 
The  inflammation  has  been  propagated  to  the  deeper  structures  of  the 
neck.  Poisonous  substances,  the  result  of  decomposition  or  vitiated  secre- 
tions, traverse  the  lymphatic  vessels  from  the  faucial  surface,  and,  being 
intercepted  in  the  lymphatic  glands,  cause  adenitis,  and  the  inflammation 
extends  from  the  glands  to  the  adjacent  connective  tissue,  which  becomes 
hard,  tender,  swollen,  and  infiltrated  with  inflammatory  products.  This 
tumefaction  sometimes  begins  by  the  second  or  third  day,  but  it  is  usually 
about  the  close  of  the  first  week  or  in  the  beginning  of  the  second  week 
that  it  becomes  so  considerable  as  to  constitute  a  source  of  danger  and 
anxiety.  It  is  in  most  cases  bilateral,  though  one  side  may  begin  to  swell 
before  the  other  and  remain  larger  throughout. 

In  severe  cases  of  this  complication  the  tumefaction  extends  from  ear 
to  ear,  filling  up  the  space  below  and  around  the  angles  of  the  jaw  and 
under  the  chin.  Not  only  is  deglutition  difficult,  but  it  is  difficult  to 
open  the  mouth  sufficiently  to  inspect  the  fauces,  and  attempts  to  do  so 
cause  much  pain.  The  lymphatic  glands,  which  lie  in  the  inflamed  area 
and  participate  in  the  inflammation,  are  greatly  enlarged  by  hyperplasia, 
the  round  granular  lymph-cells  multiplying  so  abundantly  that  the  glands 
increase  to  many  times  their  normal  size.  Most  of  the  tumefaction  is, 
however,  due  to  extension  of  the  inflammation  to  the  connective  tissue  of  the 
neck.  The  cellulitis,  which  resembles  that  occurring  in  other  conditions,  is 
attended  by  distension  of  the  capillaries,  the  abundant  formation  of  young 
round  cells,  and  transudation  of  serum  (Billroth).  A  moderate  amount 
of  tumefaction  may  disappear  by  resolution,  but  if  it  be  considerable  it 
seldom  abates  in  this  way,  but  by  the  tedious  and  exhausting  process  of 
suppuration  or  gangrene.  If  the  swelling  at  its  most  prominent  point 
present  a  reddish  hue,  all  hope  of  producing  resolution  must  be  aban- 
doned; it  cannot  be  effected  by  any  medicine  or  appliance  within  the 
resources  of  our  art.  The  abscess  which  forms  is  apt  to  be  diffuse,  so  as 
to  involve  danger  of  pyasmia,  unless  it  be  soon  opened  and  properly 
washed  out.  With  the  discharge  of  the  pus  the  swelling  gradually 
softens  and  declines.  In  other  cases  gangrene  results.  The  vessels  in 
the  inflamed  part  are  compressed  by  the  inflammatory  products,  so  that 


512  SCARLET  FEVER. 

they  no  longer  convey  the  blood  which  is  required  for  the  purpose  of 
nutrition.  It  is  a  law  of  the  economy  that  whenever  the  circulation 
ceases,  the  tissues  which  receive  their  nutritive  supply  through  the 
obstructed  vessels  lose  their  vitality.  Hence  gangrene  occurs  in  all 
that  portion  of  the  swelling  in  which  the  circulation  is  arrested.  The 
skin  over  it  peels  off,  the  dead  tissue  underneath  is  brown  or  dark,  and 
soon,  if  life  be  prolonged,  the  slough  begins  to  separate.  The  prognosis 
as  regards  this  complication  depends  largely  on  the  size  of  the  slough. 
If  it  be  large,  death  will  probably  result,  since  the  strength  of  the  system 
is  already  reduced  by  the  primary  disease,  and  the  reparative  process  will 
necessarily  be  slow,  while  abundant  suppuration  tends  to  increase  the 
exhaustion.  In  some  of  the  worst  cases  of  cervical  gangrene  which  I 
have  seen  the  slough  has  laid  bare  the  muscles  and  vessels  of  the  neck, 
producing  in  one  case  a  cavity  or  excavation  sufficiently  large  to  admit  a 
hen's  egg.  Often  the  slough  extends  under  the  skin,  so  that  the  deepest 
recesses  of  the  cavity  are  not  visible,  and  occasionally  in  cases  which 
have  ended  fatally  in  my  practice  severe  hemorrhage  occurred  from  the 
concealed  vessels.  If  the  ulcerative  or  gangrenous  process  extends  so 
deeply  into  the  tissues  of  the  neck  that  hemorrhages  occur,  death  is  the 
common  result ;  but  if  the  destructive  action  be  of  moderate  extent  and 
other  conditions  favorable,  we  may  expect  recovery  through  cicatrization, 
with  perhaps  some  deformity  by  contraction  of  the  cicatrix. 

•When  the  inflammation  of  the  connective  tissue  of  the  neck  is  exten- 
sive, involving  both  the  lateral  and  anterior  regions  of  the  neck,  the 
patient  is  in  a  perilous  state.  The  cellulitis,  when  extensive  and  accom- 
panied by  much  swelling,  may  produce  oedema  of  the  glottis,  may  obstruct 
respiration  by  compressing  the  air-passages  or  the  laryngeal  nerves,  may 
cause  compression  of  the  jugular  veins,  and  thus  give  rise  to  dangerous 
cerebral  symptoms,  or  may  lay  bare  and  injure  important  muscles  and 
nerves,  as  we  have  seen.  If  the  ulceration  or  gangrene  be  extensive, 
and  death  do  not  occur  by  hemorrhage  from  arterial  or  venous  twigs, 
septic  poisoning  may  occur,  increasing  still  more  the  fatal  nature  of  the 
malady. 

Some  cases  of  this  complication  are  melancholy  in  the  extreme,  as  one 
related  by  Cremen,  in  which  ulceration  of  the  pharynx  occurred,  allow- 
ing the  escape  of  food  and  preventing  deglutition.  In  severe  scarlatinous 
pharyngitis  the  inflammation  is  apt  to  extend  along  the  Eustachian  tube, 
causing  its  occlusion.  This  accident  will  be  considered  when  we  treat 
of  otitis  media,  another  grave  complication.  It  often  also  extends  into 
the  nares,  causing  catarrh  of  the  Schneiderian  mucous  membrane,  witli 
discharge  of  muco-pus  from  this  surface.  Not  infrequently  ulceration  or 
gangrene  occurs  in  the  faucial  surface,  producing  more  or  less  destruction 
of  tissue  and  forming  excavations  which  connect  with  the  throat,  while 
the  cutaneous  surface  retains  its  integrity  and  is  not  even  reddened. 
The  following  case  shows  how  grave  the  complication  which  we  are  now 
considering  sometimes  is  when  the  external  surface  of  the  neck  is  not 
involved,  and  how  the  inflammation  by  extension  outward  from  the 
fauces  may  involve  the  middle  ear. 

Case  1. — Annie  K ,  aged  two  and  a  half  years,  an  inmate  of  the  New 

York  Foundling  Asylum,  was  well,  except  an  eczema  of  the  scalp,  until 
the  night  of  April  3,  1882,  when  she  was  attacked  with  vomiting  and 


COMPLICATIONS  AND  SEQUELS.  513 

diarrhoea.  She  was  feverish  and  drowsy,  and  at  2  p.  M.  on  the  4th  the 
scarlatinous  efflorescence  appeared  \ipon  her  neck,  body,  and  lower  ex- 
tremities; tongue  coated;  pharynx  red;  temperature  (axillary)  103°; 
pulse  160.  The  symptoms  and  aspect  indicated  a  grave  form  of  the 
malady,  and  the  usual  sustaining  treatment  was  ordered.  On  April  5th 
the  temperature  was  102°,  pulse  144,  tongue  less  coated,  eruption  fading, 
less  stupor,  no  albumen  in  urine.  April  6th,  morning  temperature  102°, 
pulse  160;  passed  a  restless  night;  stools  thin  and  too  frequent;  has 
grayish  patches  in  the  throat :  P.  M.  temperature  103|-0,  pulse  150.  April 
7th,  the  diarrhoea  continues,  and  she  has  a  copious  muco-purulent  dis- 
charge from  the  nostrils;  P.  M.  temperature  103f°,  pulse  160.  April 
10th,  the  temperature  has  continued  at  about  103°;  the  patient  is  very 
sick,  with  a  constant  foul-smelling  discharge  from  the  nostrils ;  breath 
very  offensive ;  temperature  103.5°,  pulse  about  180.  April  12th,  general 
appearance  a  little  better,  but  the  posterior  surface  of  the  fauces  is  com- 
pletely covered  by  a  thick  pseudo-membrane ;  had  four  loose  stools  last 
night ;  temperature  and  pulse  the  same  as  at  last  record ;  a  dark,  offen- 
sive, and  jagged  coating  over  the  fauces,  and  a  dark,  foul  discharge  from 
the  nostrils,  as  before ;  examination  of  the  chest  negative.  April  14th, 
is  much  prostrated ;  temperature  104.5°,  pulse  rapid  and  weak ;  respira- 
tion noisy,  diminished  resonance  over  lower  two-thirds  of  left  side  of 
chest ;  ulcers  upon  the  mouth  and  tongue ;  fauces  red  and  ulcerated. 
April  17th,  pulse  150,  temperature  100.5°;  general  appearance  somewhat 
better,  but  the  diarrhoea  continues,  and  patches  of  a  diphtheritic  cha- 
racter have  appeared  upon  the  lips ;  moist  rales  in  left  side  of  chest.  The 
symptoms  continued  nearly  the  same  until  April  23d,  when  she  died. 
A  dull  percussion  sound  and  distinct  bronchial  respiration  were  observed 
in  the  left  scapular  region  during  the  last  days  of  her  life. 

Autopsy  nine  hours  after  death  by  the  curator,  Dr.  "W.  P.  Northrup : 
Body  well  nourished ;  the  tissues  have  a  jaundiced  hue ;  lips  sore ;  on 
turning  the  head  to  one  side  pus  runs  from  the  left  ear  and  dirty  rnuco- 
pus  from  the  mouth.  Brain  normal ;  on  opening  the  petrous  portion  of 
the  left  temporal  bone  the  middle  ear  is  found  full  of  pus,  which  com- 
municated freely  with  the  external  ear  through  a  perforated  membrana 
tympani ;  the  Eustachian  tube  cannot  be  traced  in  the  sloughy  tissue, 
and  a  passage  filled  with  pus  extends  from  the  ear  to  the  fauces ; 
opposite  the  greater  coruua  of  the  hyoid  bone  are  two  deep  ulcers,  each 
having  about  the  diameter  of  a  ten-cent  piece,  with  sloughy  and  offensive 
base  and  sides ;  the  left  ulcer  communicates  by  a  ragged  and  wide  sinus 
with  a  dark  and  sloughy  cavity  of  about  four  drachms  capacity ;  this 
cavity  is  located  in  the  neck  under  the  angle  of  the  jaw,  apparently 
occupying  the  site  of  a  disintegrated  gland,  and  it  opens  upon  the 
surface  of  the  fauces.  The  surface  of  the  larynx  has  a  dusky,  dirty 
appearance,  sprinkled  with  little  cheesy-looking  spots,  and  covered 
by  a  dirty,  foul-appearing  liquid,  as  if  some  of  the  ichorous  pus 
had  escaped  into  it  from  the  neck ;  about  one  and  a  half  inches  below 
the  vocal  chords  there  is  an  unmistakable  pseudo-membrane;  below 
this,  near  the  bifurcation,  the  trachea  has  a  bright-red  color,  as  if  a 
pseudo-membrane  had  been  peeled  from  it,  leaving  the  surface  raw. 
The  detachment  of  a  pseudo-membrane  from  this  part,  if  it  did  occur, 
must  have  been  ante-mortem,  for  the  organ  had  been  carefully  handled 

VOL.  I.— 33 


514  SCARLET  FEVEE. 

in  making  the  autopsy.  Between  the  apex  of  the  left  lung  and  the 
median  line  the  tissues  of  the  neck,  dissected  upward,  are  found  indu- 
rated, yellow,  and  giving  an  offensive  odor,  showing  that  the  cervical 
cellulitis  had  extended  downward  farther  than  usual.  The  bronchial 
glands  have  undergone  hyperplasia,  being  enlarged  and  hard.  The 
right  lung  is  normal;  about  one-half  of  the  left  lower  lobe  is 
consolidated,  and  when  cut  is  found  to  be  gangrenous  and  offensive. 
The  liver  is  apparently  somewhat  enlarged;  spleen  normal  in  size; 
gastric  mucous  membrane  has  a  congested  appearance  and  is  covered 
with  mucus;  meseuteric  glands  enlarged,  pale,  and  firm;  Foyer's 
patches  swollen  and  pale;  at  lower  end  of  ileum  some  pigmentation 
of  these  glands ;  in  large  intestine  the  solitary  glands  are  enlarged,  and 
a  few  of  them  pigmented ;  kidneys  pale,  cortex  thickened,  and  markings 
indistinct.  Microscopical  Examination. — In  the  pia  mater  perhaps  a 
little  increase  of  cells;  meninges  of  brain  otherwise  normal.  The 
trachea  shows  well-marked  diphtheritic  inflammation ;  it  contains  a  film 
of  pseudo-membrane;  evidences  of  inflammation  occur  also  upon  the 
laryngeal  surface,  though  less  marked  than  in  the  trachea.  The  solidified 
portion  of  the  lung  exhibits  the  ordinary  lesions  of  broncho-pneumonia, 
with  some  interstitial  change.  In  the  kidneys  we  find  parenchymatous 
nephritis,  with  some  cell-growth  in  the  Malpighian  bodies. 

The  above  case  has  been  related  at  length,  not  only  because  it  shows 
how  severe  and  destructive  the  inflammation  of  the  throat,  extending 
into  the  tissues  of  the  neck,  sometimes  is,  but  because  four  other  com- 
plications or  sequelae  were  also  present — to  wit,  otitis  media,  diphtheria, 
nephritis,  and  pneumonia.  We  see  from  the  above  case  how  formidable 
a  disease  scarlet  fever  sometimes  is  when  attended  by  the  inflammations 
to  which  it  so  frequently  gives  rise,  for  a  child  older  and  stronger  than 
this,  if  thus  affected,  would  necessarily  have  perished  with  the  best  possi- 
ble treatment. 

In  localities  where  diphtheria  is  endemic,  as  in  New  York  City 
and  Paris,  scarlet  fever  is  often  complicated  by  a  pseudo-membranous 
inflammation  of  the  fauces  and  air-passages.  In  severe  cases  of 
scarlet  fever  the  Schneiderian  as  well  as  the  faucial  surface  is  cov- 
ered with  it,  so  that  it  can  be  readily  seen  on  inspecting  the  anterior 
narcs.  Occasionally,  the  pseudo-membrane  appears  upon  the  laryngeal 
and  tracheal  surfaces,  as  in  the  case  which  I  have  related  above  and  in 
others  presently  to  be  related,  causing  dangerous  embarrassment  of  respir- 
ation. This  complication  sometimes  begins  almost  at  the  commencement 
of  scarlet  fever,  but  in  most  instances  it  does  not  occur  before  the  third 
or  fourth  day,  and  it  sometimes  does  not  appear  till  in  the  declining 
stage  of  the  fever.  When  it  begins,  it  intensifies  the  febrile  movement 
and  produces  general  aggravation  of  symptoms. 

The  common  opinion  is,  that  whenever  a  pseudo-membrane  occurs 
upon  the  inflamed  mucous  surface  in  scarlatina  true  diphtheria  has  super- 
vened ;  but  there  are  those  who  hold  that  scarlet  fever  itself,  when  the 
inflammations  which  attend  it  are  severe,  may  give  rise  to  pseudo-mem- 
branes, so  that  what  seems  to  be  diphtheritic  is  but  an  element  in  the 
primary  disease.  My  convictions  are  strong  that  when  pseudo-mem- 
branes occur  on  any  of  the  inflamed  mucous  surfaces  in  scarlet  fever,  true 
diphtheria  has,  with  few  exceptions,  supervened  if  the  patient  live  in  a 


COMPLICATIONS  AND  SEQUELAE. 


515 


locality  where  diphtheria  is  prevalent.  That  scarlet  fever  may  occur  in 
an  individual  along  with  another  acute  infectious  malady  is  shown 
by  abundant  cases.  It  often  occurs  with  varicella,  and  J.  Herzog 
relates  the  following  case,  in  which  measles  and  scarlet  fever  coex- 
isted : l  A  boy  aged  eight  years  had  measles,  with  the  usual  catarrhal 
symptoms,  and  on  the  fourth  day,  as  the  temperature  was  returning 
to  the  normal,  it  rose  again  suddenly,  and  the  scarlatinal  rash  and 
sore  throat  appeared.  In  due  time  these  subsided,  and  desquamation 
occurred.  I  have  seen  a  similar  case  in  consultation  during  the  current 
year,  so  that  there  is  nothing  improbable  in  the  theory  that  scarlet  fever 
may  coexist  with  other  infectious  maladies ;  and  it  is  admitted  that  diph- 
theria, like  erysipelas,  may  complicate  the  most  diverse  constitutional 
diseases.  Moreover,  when  a  child  with  pertussis,  measles,  typhoid  fever, 
or  tuberculosis  suddenly  develops  a  high  fever  with  the  occurrence  of  a 
pseudo-membranous  inflammation  upon  the  fauces  or  air-passages,  all 
admit  that  diphtheria  has  supervened,  since  such  inflammation  is  not  an 
element  in  any  form  or  type  of  either  of  these  diseases ;  and  I  see  no 
reason  in  the  nature  of  the  disease  why  scarlet  fever  should  not  be  equally 
liable  to  this  complication. 

The  elaborate  treatise  by  Sanne*  of  Paris  on  diphtheria  contains  a 
chapter  entitled  "  Secondary  Diphtheria."  In  it  the  author  says,  what 
all  who  are  familiar  with  diphtheria  will  agree  to,  that  secondary  diph- 
theria does  not  differ  in  nature  from  the  primary  form,  and  that  it 
exhibits  a  tendency  "  to  occupy  the  organs  which  are  themselves  the  seat 
of  the  more  pronounced  local  determinations  of  the  primitive  malady. 
....  Diphtheria  is  seen  in  the  course  or  sequel  of  numerous  diseases. 
Some  appear  to  have  a  special  proclivity  for  engendering  diphtheria; 
these  are  specific  maladies :  measles,  scarlet  fever,  pertussis."  I  have 
tabulated  as  follows  Sanne's  statistics  of  secondary  diphtheria : 

Diphtheria  complicating  measles.  100  cases,  83  deaths,  15  cures,  2  doubtful, 

scarlet  fever,      43     "       22      "       17     "       4        " 
pertussis,  20     "       12       "        6     "        2 

"  "  typhoid  fever,      8    "        8       " 

tuberculosis,       19     '        19 

SannS's  statistics  relating  to  the  seat  of  scarlatinous  diphtheria  are  as 
follows : 

Fauces  alone 

with   larynx 

'      nasal  fossa 

'      larynx  and  nasal  fossa 

'      larynx  and  bronchi 

'      nasal  fossa  and  lips 

'      lips  and  skin 
unaffected, 

Diphtheria  generalized, 
Larynx  only  affected, 
Nasal  fossa 

The  opinion  of  so  good  an  observer  as  Sanne",  that  when  in  scarlet  fever, 
pseudo-membranous  exudation  appears  upon  the  mucous  surfaces  which 
are  the  seat  of  scarlatinous  inflammation,  diphtheria  has  supervened,  and 
not  a  croupous  form  of  scarlatinous  plilegmasia,  carries  with  it  great 
1  Berl  Em.  Woch.,  1882,  No.  7. 


attacked,  15  cases. 

.    4 

8. 

4 

1 

1 

1 

3 

o 

2 

1 

< 

516  SCARLET  FEVER. 

weight.  That  it  was  diphtheria  in  four  instances  in  my  practice  I  had 
sufficient  proof,  for  this  disease  became  dissociated  from  scarlet  fever, 
and  extended  to  other  members  of  these  families  as  idiopathic  dip- 
htheria. 

Nevertheless,  one  of  the  most  difficult  problems  which  we  have  to 
deal  with  in  certain  cases  is  to  distinguish  diphtheritic  from  non-diph 
theritic  inflammation ;  and  I  see  no  reason  why  the  scarlatinous  inflam- 
mation when  intense  may  not  be  sometimes  membranous ;  and  those  no 
doubt  err  who  ignore  this,  and  consider  every  inflammation  attended 
by  a  pellicular  exudation  diphtheritic.  We  know  that  in  some  cases  of 
dysentery  a  fibrinous  exudation  occurs  upon  the  surface  of  the  colon ;  that 
in  croupous  pneumonia  fibrin  exudes  into  the  bronchioles  and  alveoli  of 
the  lungs ;  and  that  physicians  in  localities  where  there  is  no  diphtheria 
meet,  though  at  long  intervals,  cases  which  they  designate  croupous 
pharyngitis  and  laryngitis ;  and  it  seems  to  me  that  the  intense  inflam- 
mation of  anginose  scarlatina  probably  sometimes  produces  the  same 
exudation.  Moreover,  it  is  very  difficult  to  distinguish  in  the  swollen 
fauces  between  a  membranous  exudation  and  ulceration  or  superficial  gan- 
grene so  common  in  malignant  scarlet  fever.  The  grayish-white  surface, 
jagged  and  foul,  may  be  the  one  or  the  other,  an  exudation  or  a  sphacelus, 
and  in  certain  instances  it  is  impossible  to  discriminate  between  the  two 
conditions  at  the  bedside. 

Diphtheria  complicating  scarlet  fever  sometimes  begins  nearly  simul- 
taneously with  the  latter.  Henoch  states  that  exceptionally  he  has 
observed  suspicious  patches  upon  the  fauces  before  the  appearance 
of  the  scarlatinous  eruption  upon  the  skin ;  and  he  adds :  "  I  have 
had  repeated  opportunities  of  observing  this  unusual  beginning.  In 
such  cases  we  must  ask  ourselves  whether  the  first  affection  was  really 
connected  with  the  second,  or  whether  the  former  was  a  true  primary 
diphtheria,  rapidly  followed  by  scarlatina.  This  opinion  is  favored  by 
the  fact  that  I  have  only  observed  such  cases  in  the  hospital,  in  which 
infection  with  various  forms  of  contagion  can  scarcely  be  avoided." 

But  usually  it  is  not  till  the  third  or  fourth  day  of  scarlet  fever  that 
this  complication  begins.  The  patient  has  been  progressing  favorably 
with  the  scarlet  fever,  till  on  a  certain  day  a  marked  aggravation  of 
symptoms  occurs.  A  higher  temperature,  more  pungent  heat,  and  the 
physiognomy  of  a  more  serious  malady  arc  present.  On  inspecting  the 
fauces  to  discover  the  cause  we  observe  a  pellicle  forming  over  the  tonsils 
and  perhaps  other  portions  of  the  faucial  surface.  Often  the  entire 
aspect  of  the  case  changes  by  the  occurrence  of  this  complication,  a  mild 
case  of  scarlet  fever  becoming  grave  and  fatal  in  consequence.  Thus  in 
a  case  which  I  saw  with  Dr.  Hardy  of  New  York  the  membranous 
inflammation  of  diphtheria,  commencing  upon  the  fauces  oil  the  third 
day  of  scarlet  fever,  extended  to  the  Schneiderian  membrane,  and  thence 
along  the  left  lachrymal  sac  to  the  eyelids,  producing  redness  and  swell- 
ing along  the  side  of  the  nose  and  upon  the  cheek  like  that  of  erysipelas. 
A  thick  diphtheritic  pellicle  occurred  upon  the  under  surface  of  each 
eyelid  on  the  left  side,  with  great  tumefaction  of  both  lids,  gangrene  of 
the  cornea,  and  destruction  of  the  eye.  The  case  soon  ended  fatally. 

The  diphtheritic  inflammation  sometimes  extends  to  the  larynx  and 
trachea,  producing  hoarseness  and  more  or  less  obstruction  to  respira- 


COMPLICATIONS  AND  SEQUELS.  517 

tioii.  A  thin  film  or  flakes  of  fibriuous  exudation,  rendering  the  respi- 
ration noisy,  developed  on  the  laryugeal  or  tracheal  surface,  is,  I  think, 
not  infrequent  in  diphtheria  complicating  scarlet  fever,  but  the  rapid 
development  of  a  thick  and  firm  pseudo-membrane,  so  as  to  imperil  the 
life  of  the  patient  from  the  stenosis  in  the  air-passages,  has  been  much 
less  frequent  in  my  practice  than  it  is  in  primary  diphtheria  and  in 
diphtheria  complicating  measles  or  pertussis.  The  following  were  cases 
of  this  severe  complication  occurring  in  a  recent  epidemic  in  the  New 
York  Foundling  Asylum.  In  these  cases  the  respiration  was  noisy,  but 
the  obstruction  to  breathing  seemed  to  be  due  to  infiltration  and  swelling 
around  the  aperture  of  the  glottis,  rather  than  to  diphtheritic  croup, 
which  the  autopsies  showed  to  be  present. 

Case  2. — A  child  aged  three  and  a  half  years,  who  previously  had 
symptoms  of  mild  catarrhal  croup,  with  moderate  redness  of  the  fauces, 
sickened  with  scarlet  fever  on  Oct.  1,  1882,  the  rash  being  profuse  and 
soon  covering  nearly  the  entire  body.  The  axillary  temperature  was 
103°,  pulse  140 ;  slight  stridor  in  breathing  and  some  cough ;  fauces 
very  red,  but  free  from  membrane.  Oct.  2d,  restless,  sleeping  but  little ; 
has  vomited  four  times.  Oct.  3d,  temp.  103.5°,  pulse  120 ;  fauces  much 
swollen ;  still  vomiting ;  rash  abundant.  4  P.  M.,  temp.  104.3°,  pulse 
128 ;  tongue  clean ;  some  discharge  from  nares ;  urine  not  albuminous, 
but  its  quantity  diminished.  Oct.  4th,  aspect  that  of  very  severe  sick- 
ness ;  profuse  discharge  from  nostrils ;  fauces  of  a  deep  red  color,  and  a 
diphtheritic  pellicle  over  tonsils  and  uvula  ;  tumefaction  along  the  sides 
of  the  neck ;  temp.  104°,  pulse  140 ;  breathing  moderately  stridulous ; 
urine  is  passed  more  freely  than  yesterday ;  evening  temp.  105°.  Oct. 
6th,  croupy  symptoms  more  marked ;  tonsils  and  uvula  greatly  swollen, 
so  that  the  fauces  are  almost  occluded ;  temp.  103.5° ;  breathing  difficult, 
but  apparently  sufficient  oxygen  is  received ;  profuse  nasal  discharge, 
and  other  symptoms  as  before.  About  1.30  P.  M.  he  was  raised  to  take 
some  milk,  and  suddenly  became  asphyxiated.  His  face  was  dusky,  his 
eyes  protruded,  and  he  voided  urine  and  feces.  Dr.  Swift,  who  attended 
the  child,  and  to  whom  I  am  indebted  for  this  history,  immediately  per- 
formed tracheotomy,  which  gave  temporary  relief  by  the  expulsion  of  a 
considerable  quantity  of  pseudo-membrane  through  the  opening.  On 
the  following  day  the  respiration  again  became  obstructed  at  some  point 
below  the  cauula,  so  that  it  could  not  be  removed ;  the  features  grew 
livid,  and  death  occurred  in  convulsions  twenty-six  hours  after  the  tra- 
cheotomy. 

The  autopsy  was  made  by  Dr.  "W.  P.  Northrup,  curator  of  the  asylum, 
who  found  the  pharynx  covered  by  a  membrane  which  was  traced  to 
the  posterior  uares ;  larynx,  trachea,  and  bronchial  tubes  as  far  as  the 
third  divisions  also  covered  with  membrane;  portions  of  the  tracheal 
surface  denuded,  and  the  mucous  membrane  underneath  of  a  bright  red 
color  and  smooth ;  tonsils  sloughy  and  fetid ;  mucous  membrane  of 
smaller  bronchial  tubes  very  red  and  covered  with  viscid  mucus  and  pus ; 
a  portion  of  the  left  lung,  extending  from  the  root  posteriorly  to  the  sur- 
face, gangrenous,  discolored,  and  honeycombed  ;  two  or  three  intensely 
hypersemic  spots,  as  large  as  a  bean,  in  left  lung ;  right  lung  congested, 
but  not  consolidated  ;  slight  catarrh  of  stomach  ;  circumscribed  areas  of 
congestion  in  intestines ;  solitary  glands  of  intestines  swollen,  and  some 


518  SCARLET  FEVER. 

of  them  ulcerated  ;  spleen  of  normal  size,  rather  pale ;  liver  congested 
and  somewhat  enlarged. 

Case  3. — Katie,  aged  six  and  a  third  years,  was  returned  to  the  asylum 
on  Nov.  18th.  Three  days  later  (Nov.  21st)  she  had  sore  throat,  red- 
dened fauces,  coated  tongue,  and  a  faint  rash  upon  the  neck,  chest,  and 
arms ;  eyes  injected ;  temperature  102°.  In  the  afternoon  temperature 
103°;  eruption  still  faint.  Nov.  22d,  temperature  103.5°;  an  eruption 
on  chest,  abdomen,  arms,  and  legs  in  patches.  Evening,  temperature 
104°;  voice  clear.  Nov.  23d,  temperature  103.5°;  tongue  red;  fauces 
deeply  reddened,  but  without  any  visible  pseudo-membrane;  eruption 
of  a  scarlatinous  appearance  over  the  back  and  abdomen ;  on  the  extrem- 
ities dusky,  livid  patches.  P.  M.,  temperature  104°;  is  slightly  delirious ; 
eruption  abundant.  Nov.  24th,  temperature  103.5°;  eruption  well  out 
on  abdomen ;  it  is  the  same  as  yesterday  upon  the  extremities,  except 
perhaps  a  little  more  dusky ;  still  no  pseudo-membrane  to  be  seen  upon 
the  fauces ;  is  restless  and  delirious.  P.  M.,  during  the  day  has  been  very 
restless,  suffering  from  dyspnoea;  no  croupy  voice  nor  croupy  cough, 
though  the  dyspnoea  continues,  and  a  pseudo-membrane  is  now  visible 
over  the  tonsils  and  adjacent  faucial  surface ;  eruption  dusky ;  skin  cool ; 
pulse  very  frequent  and  feeble.  From  this  time  she  sank  steadily,  and 
died  at  11.30  P.  M.  During  her  sickness  her  urine  seemed  to  be  dimin- 
ished, but  it  was  not  properly  examined. 

Autopsy  Nov.  25th  by  Dr.  "W.  P.  Northrup,  curator :  Points  of  red- 
ness, apparently  a  hemorrhagic  eruption,  over  the  face,  shoulders,  and 
parts  of  the  trunk ;  a  few  of  the  same  on  the  extremities ;  no  pseudo- 
membrane  visible  in  nostrils  or  in  buccal  cavity ;  brain  not  examined. 
Naso-pharyux  covered  by  a  thick  fibre-purulent  membrane.  Larynx 
contains  a  well-marked  pseudo-membrane,  but  not  continuous.  Trachea 
covered  by  a  pseudo-membrane,  continuous  over  most  of  its  surface, 
but  in  places  broken  and  flaky.  Where  it  is  detached  the  mucous 
membrane  is  seen  underneath,  dusky  and  deeply  injected.  At  the  root 
of  the  lungs  the  pseudo-membrane  can  be  traced  along  the  tubes  about 
an  inch  in  all  directions.  Lungs  cedematous,  with  deep  congestion  in 
places,  but  apparently  no  pneumonia;  about  two  drachms  of  clear, 
straw-colored  fluid  in  pericardium;  a  few  stringy  decolorized  clots  in 
the  cavities  of  the  heart;  left  ventricle  contracted.  The  heart-fibres, 
carefully  examined,  microscopically,  in  the  laboratory,  are  fouud  to 
be  normal,  not  having  undergone  granular  or  fatty-  degeneration. 
Liver  normal  in  size;  pale-yellow  areas  upon  the  superior  surface, 
<iither  from  anaemia  or  fatty  deposition.  Kidneys  of  usual  size,  capsule 
not  adherent;  pyramids  congested;  cortex  pale;  markings  distinct. 
Spleen  enlarged  about  one-third ;  consistence  normal.  Stomach  and 
intestines  not  examined. 

Case  4-. — Scarlet  fever  complicated  by  diphtheria,  nephritis,  and  broncho- 
pneumonia.  (History  by  house  physician,  Dr.  Swift.)  Phoebe,  aged  three 
and  a  quarter  years,  was  delicate,  biit  in  her  usual  health  till  Oct.  29,  1882, 
when  she  became  languid  and  vomited  several  times,  and  her  tongue  was 
coated.  Oct.  30th,  occasional  vomiting;  fauces  reddened;  tongue  coated. 
Oct.  31st,  remains  languid;  fauces  deeply  reddened;  a  faint  scarlatinous 
eruption  over  back,  wrists,  and  feet;  temperature  100.5°.  P.  M.,  eruption 
of  scarlet  fever  well  out  over  the  surface;  tongue  cleaner.  Nov.  1st, 


COMPLICATIONS  AND  SEQUELJE.  519 

rash  over  entire  body ;  temperature  100.2°.  Nov.  2d,  fauces  deep-red  ; 
tonsils  and  uvula  swollen ;  diarrhoea  and  vomiting.  Nov.  3d,  tempera- 
ture 102.5°;  the  eruption,  which  has  been  bright  red,  is  now  more  dusky. 
Nov.  5th,  temperature  104.5°;  dusky-red  color  of  the  eruption;  skin 
beginning  to  desquamate  in  places ;  urine  normal ;  a  discharge  from 
nostrils.  Nov.  6th,  temperature  103.5°;  eruption  still  present,  but  skin 
of  abdomen  and  back  desquamating ;  has  otorrhcea  on  both  sides ;  fauces 
deeply  hypersemic,  but  no  pseudo-membrane  visible  upon  them.  Nov. 
7th,  temperature  103°;  respiration  and  cough  have  a  slight  croupy  cha- 
racter; other  symptoms  as  yesterday.  Nov.  8th,  temperature  101°.  A 
careful  inspection  of  the  fauces  shows  that  it  contains  no  pseudo-mem- 
brane ;  nostrils  discharging  a  dark-brownish  liquid ;  examination  of 
urine  negative.  Nov.  llth,  eruption,  which  appears  to  have  been  hem- 
orrhaghic  in  points,  is  fading  and  the  desquamation  is  less.  Nov.  14th, 
nostrils  still  discharging ;  glands  of  neck  swollen.  Nov.  16th,  temper- 
ature 103°;  sp.  gr.  of  urine  1010,  no  casts,  nor  albumen ;  the  chest 
seems  clear ;  less  discharge  from  nostrils ;  fauces  clean  and  but  slightly 
inflamed.  Nov.  17th,  18th,  temperature  103.5°;  vomits;  lungs  healthy, 
but  breathes  with  considerable  effort,  though  without  stridor ;  urine 
diminished ;  its  sp.  gr.  1020,  albuminous,  contains  blood-corpuscles  and 
granular  casts.  Nov.  19th,  is  very  pallid ;  temperature  104°;  very 
restless ;  vomits ;  urine  diminished ;  bowels  freely  open.  Nov.  20th, 
respiration  still  embarrassed  ;  subcrepitant  rales  over  the  entire  chest  and 
percussion  resonance  not  clear  ;  temperature  102.5°.  Nov.  21st,  physical 
signs  the  same ;  temperature  103.5°;  respiration  80.  Nov.  22d,  urgent 
dyspnoea ;  dulness  on  percussion  over  top  of  right  lung  and  over  lower 
part  of  left  lung ;  is  delirious ;  no  perspiration ;  urine  scanty ;  bowels 
freely  open.  From  this  date  the  dyspnoea  became  more  urgent,  and 
death  occurred  at  4  P.  M.  on  the  23d. 

Autopsy  by  Dr.  W.  P.  Northrup,  curator:  Body  well  nourished; 
slight  oedema  of  both  legs ;  swelling  at  angles  of  jaws,  most  marked 
on  left  side.  Vessels  of  brain  moderately  injected;  otherwise  appear- 
ance normal.  Cicatrizing  ulcers  on  both  sides  of  fauces;  a  diph- 
theritic pseudo-membrane  on  septum  of  nose,  larynx  normal.  Trachea, 
upper  half  apparently  normal ;  a  thin  film  of  pseudo-membrane  extends 
from  just  above  the  bifurcation  upward  to  nearly  the  middle  of  trachea. 
About  an  ounce  of  fluid  in  each  pleural  cavity;  on  the  right  side 
a  few  loose  flakes  of  fibrin  floating  in  the  serum,  and  consolidation  of 
lung  at  apex ;  collapse  in  one  or  two  places.  Left  side,  recent  adhesions 
over  whole  of  posterior  surface  and  base ;  surface  of  lower  lobe  dark,  and 
when  it  is  detached  strings  of  fibrin  adhere  to  it,  and  it  is  consolidated. 
The  cut  surface  shows  marked  oedema,  injection,  increase  of  mucus  in 
bronchi,  and  disseminated  miliary  tubercles  in  every  part ;  no  tubercles 
in  the  pleura,  and  none  elsewhere  in  the  body  except  in  the  left  lung ; 
tubercles  in  the  lower  lobe  larger  and  more  thickly  grouped  than  in  the 
upper  lobe.  Decolorized  clots  in  heart,  extending  from  ventricles  into 
auricles  of  both  sides.  The  capacity  of  the  ventricles  seems  normal. 
Liver  and  spleen,  normal.  Kidneys  rather  large ;  capsules  not  adherent ; 
superficial  veins  injected.  The  cut  surface  shows  congested  pyramids 
and  pale  cortex ;  markings  indistinct  and  irregular ;  about  four  ounces  of 
clear  straw-colored  fluid  in  abdominal  cavity,  and  the  solitary  follicles  of 


520  SCARLET  FEVER. 

large  intestines  show  pigmentation ;  two  simple  intussusceptions,  each 
three-fourths  inch  in  length,  in  small  intestines. 

Coryza  frequently  commences  at  or  about  the  time  of  the  pharyn- 
gitis. The  inflammation  of  the  Schneiderian  membrane  is  continuous 
posteriorly  with  that  of  the  fauces,  and  is  announced  by  redness  and 
swelling,  inability  to  breathe  freely  through  the  nostrils,  and  an  irri- 
tating iehorous  discharge.  Simple  coryza  in  itself  involves  little  danger, 
though  it  is  an  unpleasant  complication,  and  in  the  nursing  infant  it  may 
interfere  with  sucking.  Diphtheritic  coryza,  on  the  other  hand,  which 
is  frequently  present  when  diphtheria  complicates  scarlet  fever,  involves 
danger,  since  it  is  apt  to  cause  ulcerations,  hemorrhages,  and  septic 
poisoning.  "When  the  local  symptoms  are  unusually  severe  and  the  dis- 
charge abundant,  it  is  probable  that  inflammation  has  in  some  cases 
extended  to  the  antrum  of  Highmore. 

Inflammation  of  the  middle  ear  is  another  unpleasant  and  not  infre- 
quent complication.  It  is  attributed  to  extension  of  the  catarrh  from  the 
pharynx  along  the  Eustachian  tube  to  the  tympanum.  In  a  considerable 
proportion  of  cases  of  otitis  media  this  tube  is  occluded  by  the  infiltration 
and  swelling  of  its  mucous  membrane,  so  that  the  muco-pus  escapes  with 
difficulty  or  is  retained.  Hence  severe  earache,  an  increase  of  the  febrile 
movement,  and  outward  bulging  of  the  membrana  tympani  occur.  Some- 
times headache  or  other  cerebral  symptoms  arise,  probably  from  the  fact 
that  the  meningeal  artery,  which  supplies  the  meninges,  is  connected  by 
anastomosing  branches  with  the  tympanum.  In  one  of  the  cases  related 
above  it  will  be  recollected  that  the  ulceration  and  abscess  extended  from 
the  fauces  to  the  middle  ear,  the  entire  Eustachian  tube  having  disappeared 
in  the  ulcerative  process. 

Frequently,  the  otitis  escapes  detection,  its  symptoms  being  masked  or 
obscured  by  the  general  disease,  until  the  membrana  tympaui  is  perfo- 
rated and  otorrhcea  begins ;  but  by  careful  examination  the  nature  of  the 
complication  can  usually  be  ascertained  before  the  ear  is  injured  to  this 
extent,  for  a  patient  too  young  to  speak  will  often  press  with  the  fingers 
against  the  painful  ear  or  lie  with  the  ear  pressed  upon  the  pillow,  evi- 
dently having  an  increase  of  suffering  if  placed  in  any  other  position. 
One  old  enough  to  speak  and  in  proper  mental  condition  makes  known 
the  earache  as  soon  as  it  occurs. 

The  mucous  membrane  of  the  tympanum,  red  and  swollen  from  inflam- 
mation, secretes  muco-pus  abundantly ;  and  this,  pent  up  in  the  cavity, 
must  obtain  an  exit  before  relief  occurs.  It  is  well  if  this  secretion 
-pe,  though  with  difficulty,  down  the  Eustachian  tube.  The  destruc- 
tive action  of  the  pus  upon  the  delicate  structure  of  the  ear  is  often  such 
that,  within  a  few  days,  irreparable  harm  is  done  and  more  or  less  deaf- 
ness results.  Relief  can  occur,  if  the  Eustachian  tube  remain  closed,  only 
by  perforation  of  the  membrane  and  the  discharge  of  the  secretions  into 
the  external  meatus.  When  this  occurs  the  inflammation  in  the  most 
favorable  Ceases  gradually  abates,  the  aperture  in  the  drum  closes,  and 
the  integrity  of  the  auditory  apparatus  is  preserved.  In  severe  cases  the 
mastoid  cells  participating  in  the  inflammation  become  filled  with  rnuco- 
pus  and  tender  to  the  touch,  and  often  the  collateral  oedema  causes  tume- 
faction and  narrowing  of  the  external  ear,  which  subside  with  the  dis- 
charge of  pus  from  the  tympanum. 


COMPLICATIONS  AND  SEQUELS.  521 

Unfortunately,  there  is  for  many  a  more  melancholy  history — a  more 
destructive  inflammation,  involving  permanent  impairment  or  total  loss 
of  hearing.  This  is  especially  apt  to  occur  in  strumous  and  feeble  chil- 
dren. All  grades  of  inflammation  and  destructive  action  occur  in  differ- 
ent cases.  The  perforation  in  the  drum-membrane  may  be  large  or  the 
membrane  may  be  completely  destroyed,  and  the  detached  ossicles  escape 
one  by  one  into  the  external  meatus,  and  in  a  few  instances,  fortunately 
rare,  this  occurs  in  both  ears,  producing  complete  and  permanent  deaf- 
ness. In  my  own  practice  this  has  never  occurred,  but  I  have  met  one 
or  two  adults  who  were  totally  deaf  from  this  cause. 

The  mucous  membrane  which  lines  the  bony  wall  of  the  middle  ear 
has  the  function  of  the  periosteum,  and  therefore,  when  inflamed  and 
subjected  to  pressure,  is  liable  to  ulcerate.  As  in  other  parts  of  the  skel- 
eton under  similar  conditions,  superficial  caries  or  necrosis  of  the  under- 
lying bone  is  apt  to  occur.  The  carious  or  necrotic  process  may  extend 
to  the  mastoid  cells.  An  offensive  otorrhoea,  continuing  for  months  or 
years,  indicates  the  persistence  of  this  pathological  state  of  the  tympanum, 
which  is  rendered  so  obstinate  by  the  presence  of  dead  bone.  A  mo- 
ment's survey  of  the  anatomical  relations  of  the  middle  ear  shows  the 
danger  to  which  these  patients  are  liable.  A  thin  bony  septum,  per- 
forated with  blood-vessels  and  sometimes  containing  congenital  apertures, 
separates  the  tympanum  from  the  cranial  cavity  above.  Posteriorly  lie 
the  mastoid  cells,  connected  with  the  tympanum  by  one  large  and  seve- 
ral small  apertures.  Anteriorly  is  the  commencement  of  the  Eustachian 
tube  and  in  close  proximity  to  the  tympanum  lies  the  carotid  canal,  and  at 
one  point  also  the  superior  petrosal  sinus.  Virchow  has  shown  how  inflam- 
mation extending  from  the  ear  in  otitis  media  sometimes  produces  such 
compression  of  the  veins  or  sinuses  by  the  swelling  from  the  infiltration 
and  exudation  that  the  circulation  is  arrested,  and  the  fibrin  contained  in 
the  blood  of  these  vessels  is  precipitated,  forming  thrombi,  with  the  most 
disastrous  effect  upon  the  individual.  Pus  may  also  burrow  in  the 
interstices  of  the  bone,  causing  great  pain,  or  the  pent-up  secretions,  hav- 
ing no  outlet  for  escape,  may  in  time  undergo  caseous  degeneration,  pro- 
ducing the  conditions  in  which  tuberculosis  so  often  originates. 

Death  not  infrequently  occurs  in  chronic  otitis  media  in  another  way. 
The  otorrhoea,  after  mouths  or  years,  suddenly  ceases,  the  child  complains 
of  constant  severe  headache  and  is  feverish,  and  the  case  ends  in  coma, 
preceded  perhaps  by  convulsions.  Meningitis  has  occurred,  produced  by 
extension  of  the  inflammation  through  the  thin  bony  septum  which 
divides  the  tympanum  from  the  cranial  cavity,  and  at  the  autopsy  hyper- 
aemia  of  the  meninges,  fibrin,  pus,  perhaps  softening  of  the  brain  and  an 
abscess,  are  formed  in  the  portion  of  the  encephalon  adjacent  to  the  tym- 
panum. Therefore,  otitis  media,  though  it  often  ends  favorably,  is  in 
many  patients  an  obstinate,  dangerous,  and  even  fatal  sequel  of  scarlet 
fever. 

The  complication  known  as  scarlatinous  rheumatism  is  regarded  by 
some  as  a  synovitis,  but  its  symptoms,  especially  its  shifting  from 
joint  to  joint,  seem  to  ally  it  to  the  rheumatic  affections.  In  some 
epidemics  it  is  common.  It  usually  begins  toward  the  close  of  the 
first  week  or  in  the  second  week,  and  its  common  seat  is  in  the  ankle, 
plialangeal,  and  wrist  joints.  It  is  attended  by  very  little  swelling  in 


522  SCARLET  FEVER. 

most  patients,  though  the  joints  are  tender  and  painful  on  pressure.  It 
does  nut  seem  to  retard  convalescence  materially,  though  it  produces  suf- 
fering and  involves  danger  as  regards  the  heart.  It  subsides  in  a  few 
davs  with  the  ordinary  treatment  of  acute  rheumatism,  and  even  without 
special  treatment,  the  chief  danger  being  that,  as  in  idiopathic  rheuma- 
tism, endocarditis  may  arise,  with  permanent  crippling  of  the  valves. 
The  following  was  a  case  of  valvular  disease  having  this  origin.  It 
occurred  in  my  practice. 

Case  5. — Freddy  M.,  aged  four  years,  sickened  with  scarlet  fever 
March  6,  1879.  The  usual  vomiting  occurred  on  the  first  day, 
and  the  temperature  was  104°.  The  case  progressed  favorably  till 
March  14th,  when  he  complained  of  pain  in  both  wrists,  both  ankles, 
and  both  knees.  On  March  17th  the  general  condition  was  good,  the 
urine  contained  no  albumen,  and  apparently  few  u rates,  but  he  still  had 
pain  in  the  joints  of  the  upper  and  lower  extremities  and  in  the  back ; 
pulse  140,  temp.  103°  ;  breathes  with  a  slight  moan  ;  urates  in  the  urine, 
but  no  albumen.  A  distinct  mitral  regurgitant  murmur  is  now  heard 
for  the  first  time.  Under  the  use  of  salicylate  of  sodium  the  pain  in  the 
joints  soon  ceased,  but  the  mitral  murmur  is  permanent. 

The  following  prescription  is  for  a  child  of  five  years  : 
Ij*.  Ol.  Gaultherise    feiss ; 
Sodii  Salicylat.     5\\\ ; 
Syrupi  f'sii ; 

Aquae  fsiv.     M. 

S.  Give  one  teaspoonful  every  four  hours. 

Of  the  serous  inflammations  occurring  in  scarlet  fever,  pericarditis  has 
been,  according  to  Ililliet  and  Barthez,  most  frequently  observed.  In 
this  country  it  is  probably  more  frequent  than  is  usually  supposed,  but 
it  is  less  frequently  detected  than  pleuritis,  the  symptoms  of  which  are 
more  conspicuous.  It  is  apt  to  occur  in  connection  with  endocarditis. 

The  following  case,  showing  the  liability  to  pericarditis  and  other 
serous  inflammation  which  exists  in  scarlet  fever,  occurred  in  my  practice: 

Case  6. — C ,  girl  a-^ed  five  years  and  ten  months,  sickened  with  se- 
vere scarlet  fever  on  April  4th.  Was  delirious;  pulse  158;  had  vomiting 
and  constipation.  April  10th,  pulse  varies  from  124  to  153,  no  delirium ; 
a  considerable  quantity  of  urates  in  the  urine.  April  llth,  has  to-day, 
for  the  first  time,  severe  pain  in  the  epigastrium,  with  tenderness  and 
moderate  distension.  Otherwise  symptoms  favorable,  but  severe  ;  pulse 
140  ;  respiration  moderately  accelerated,  and  vesicular  in  every  part  of 
the  chest.  From  this  date  the  symptoms  continued  about  the  same  till 
April  14th,  when  the  dyspnoea  became  more  marked  and  the  action  of 
the  heart  rapid  and  tumultuous.  The  epigastric  pain,  distension,  anil 
tenderness  continued;  the  percussion  sound  was  dull  over  the  lower  part 
of  the  chest;  the  dyspnoea  became  rapidly  worse,  although  the,  pulse  had 
considerable  volume;  and  at  5  P.M.  death  occurred.  At  the  autopsy 
about  one  ounce  of  turbid  serum,  with  a  soft  deposit  of  fibrin,  was 
found  in  the  pericardium.  Each  pleural  cavity  contained  from  six  to 
eight  ounces  of  transparent  serum,  and  both  lungs  were  readily  inflated, 
except  a  little  of  the  posterior  portion  of  each  lower  lobe,  which  could 
not  be;  no  fibrinous  exudation  over  the  lungs.  The  liver  extended 
four  inches  below  the  margin  of  the  ribs,  and  upon  its  convex 


COMPLICATIONS  AND  SEQUELS.  523 

surface  in  the  epigastrium,  corresponding  with  the  seat  of  the  pain,  was 
a  rough  patch  of  fibrin  about  one  and  a  half  inches  in  diameter.  The 
bronchial  mucous  membrane  was  moderately  injected,  as  was  also  that 
of  the  colon,  and  the  kidneys  appeared  hyperaemic. 

Among  the  serous  inflammations  which  complicate  or  follow  scarlet 
fever,  pleuritis  is  one  of  the  most  important.  It  usually  begins  in 
the  desquamative  stage,  and  is  apt  to  be  suppurative  on  account  of  the 
feeble  state  of  the  patient  when  it  commences.  It  has  always,  in  my 
practice,  been  tedious,  as  all  empyemas  are,  and  it  does  not  differ  in 
its  clinical  history  from  the  idiopathic  disease.  I  have  met  cases  of 
scarlatinous  empyema  in  which,  from  opposition  of  the  family  or  for 
other  reasons,  thoracentesis  was  not  performed,  and  death  occurred; 
others  in  which  this  operation  effected  a  cure,  and  one  at  least  in  which 
the  patient  recovered  by  escape  of  pus  through  a  bronchial  tube.  The 
pleuritis  is  seldom  latent,  or  so  masked  by  the  symptoms  of  the  general 
disease  that  it  is  apt  to  be  overlooked.  On  the  other  hand,  the  cough, 
embarrassment  of  respiration,  and  pain  referred  to  the  affected  side 
render  diagnosis  easy. 

Dilatation  of  the  heart  is  common  in  grave  cases  of  scarlet  fever, 
such  cases  as  are  properly  termed  malignant.  It  is  indicated  by  a 
feeble  and  quick  pulse.  Acute  infectious  maladies,  especially  those 
of  a  malignant  type  and  accompanied  by  high  febrile  movement,  are 
very  apt  to  cause  pareuchymatous  degenerations  in  organs,  prominent 
among  which  is  granulo-fatty  degeneration  of  the  muscular  fibres  of  the 
heart.  This  weakens  very  much  the  contractile  power  of  these  fibres. 
But  early  in  malignant  cases,  probably  before  the  muscular  fibres  are 
damaged,  the  contractile  power  of  the  heart  is  feeble  from  impaired 
innervation,  the  result  of  the  general  weakness.  Hence  this  organ, 
when  weakened  by  structural  change  and  insufficiently  stimulated  through 
diminished  innervation,  may  not  fully  empty  itself  during  the  systole, 
and  consequently  it  becomes  dilated.  Dilatation  of  the  heart  and  imper- 
fect contraction  of  the  auricular  and  ventricular  walls  are  apt  to  result  in 
the  formation  of  clots  in  the  cavities  of  the  heart ;  and  this  appears  to  be 
the  immediate  cause  of  death  in  not  a  few  instances.  An  ante-mortem 
clot  occurring  in  any  of  the  cavities  of  the  heart  necessarily  seriously 
obstructs  the  circulation,  unless  it  be  of  small  size.  Hence  the  dyspnoea, 
which  may  occur  perhaj>s  suddenly,  and  the  change  of  pulse  to  one  of 
marked  feebleness  and  frequency.  *  Large,  firm  white  clots  are  most  fre- 
quently found  in  the  right  cavities.  They  interlace  with  the  chordae 
teudiuese,  lie  even  within  the  auriculo-ventricular  opening,  and  send  pro- 
longations into  the  pulmonary  artery  and  the  cavae.  Associated  with  the 
white  clots  are  dark,  soft  clots  and  fluid  blood.  The  left  cavities  may  be 
contracted  and  empty,  or  they  may  contain  dark,  soft  clots  or  white  ante- 
mortem  clots.  Clots  in  the  'left  ventricle  are  sometimes  prolonged  into 
the  aorta  as  far  as  the  brachio-cephalic  branches,  while  those  in  the  left 
auricle  may  extend  to  the  pulmonary  veins.  If  dilatation  of  the  heart 
be  so  sreat  that  clots  form  in  its  cavities,  speedy  death  is  probable. 
Sometimes  a  patient  passes  through  scarlet  fever  and  appears  in  a  fair 
way  to  recover,  when  he  succumbs  to  some  exhausting  sequel  distinct 
from  the  heart,  and  at  the  autopsy  the  heart  is  found  dilated  and  <*mtam; 
ing  whitish  clots,  which  are  probably  aute-mortem,  and  which  hastened 


524  SCARLET  FEVEE. 

death  by  obstructing  the  circulation.  Under  such  circumstances  this 
state  of  the  heart  is  attributable  in  great  measure  to  the  complication 
which  lias  weakened  its  contractile  power. 

The  following  was  a  case  in  point.  It  occurred  in  the  New  York 
Foundling  Asylum  : 

Case  7. — R.  A.,  aged  three  years,  had  scarlet  fever,  beginning  March  23, 
1882.  The  symptoms  were  favorable  at  first,  but  serious  complications 
and  sequelae  occurred,  which  were  fatal.  The  record  of  April  18th  reads : 
"  Appears  well  nourished,  but  is  anaemic ;  has  otorrhoea ;  no  oedema  ; 
skin  desquamating ;  dulness  on  percussion  over  upper  third  of  right  side 
of  chest,  anteriorly  and  posteriorly  ;  mucous  rales  and  rude  breathing  over 
same  area ;  fine  rales  posteriorly  over  lower  part  of  left  side  of  chest ; 
pulse  100,  respiration  68,  temperature  101-f  °."  April  20th,  is  feeble  and 
takes  nutriment  with  difficulty;  tongue  thickly  coated;  pulse  160,  res- 
piration 68,  temperature  101f°.  April  26th,  condition  about  the  same 
as  at  last  record,  but  he  is  evidently  weaker ;  the  lips  are  ulcerated  and 
fauces  still  swollen.  May  2d,  cannot  speak  distinctly ;  a  brownish,  foul- 
smell  ing  secretion  lodges  on  the  spoon  used  in  depressing  the  tongue; 
left  side  of  face  swollen.  On  the  following  night  eight  convulsions 
occurred,  attended  by  orthopuoea,  and  mucous  rales  in  the  chest  from 
pulmonary  oedema.  Diarrhoea  supervened  and  the  patient  died  about 
midnight.  Autopsy :  Body  moderately  wasted  and  very  white,  several 
dark-blue  spots  on  scalp  and  face  from  hemorrhages  underneath;  lips 
covered  with  dry  crusts ;  brain  of  normal  appearance ;  aperture  of  the 
larynx  narrowed  at  the  chink  by  infiltration  and  swelling  of  the  tissues; 
surface  of  the  vocal  cords  covered  by  a  thin  white  film,  apparently  a 
fibrinous  exudation;  tracheal  surface  hypersemic;  about  a  drachm  of 
straw-colored  fluid  in  each  pleural  cavity ;  right  lung  wholly  adherent 
by  recent  exudation  of  fibrin ;  left  lung  also  largely  adherent.  A  care- 
ful examination  showed  the  presence  of  broncho-pneumonia  in  each  lung, 
with  considerable  infiltration  of  the  walls  of  the  bronchi,  and  cylindrical 
dilatation  of  many  of  them ;  cavities  of  the  heart  dilated,  so  that  this 
organ  appears  much  enlarged,  and  its  shape  approaches  the  globular ;  its 
apex  is  rounded  or  obtuse ;  transverse  diameter  of  the  right  ventricle, 
when  its  walls  were  open  and  drawn  apart,  was  three  and  one-quarter 
inches ;  that  of  the  left  ventricle  three  and  a  half  inches.  Similar  meas- 
urements of  the  heart  of  another  child  of  about  the  same  age,  believed 
to  be  normal,  were  about  one  inch  less  in  each  direction.  All  the  cavi- 
ties contain  white  firm  clots  along  with  soft  dark  clots.  Liver  of  normal 
size,  pale ;  the  outer  surface  and  all  cut  surfaces  are  studded  with 
nodules  of  the  size  of  a  pin's  head,  of  a  dull,  opaque  white  color.  These 
white  spots,  examined  microscopically  by  Professor  Delafield,  are  found 
to  be  neither  tubercles  nor  gummy  tumors,  but  to  consist  of  polygonal 
cells,  lying  in  the  meshes  of  the  capillary  plexus  of  veins,  which  are  per- 
fectly preserved.  He  has  not  observed  a  similar  case.  The  walls  of  the 
gall-bladder  are  one  line  or  more  in  thickness,  and  the  gall-duct  is  pervi- 
ous. The  microscope  shows  general  hypertrophy  of  the  gall-bladder  and 
hypertrophy  of  its  papillae.  The  urine  removed  from  the  bladder  was 
found  to  contain  albumen  and  hyaline  casts,  and  a  microscopic  exami- 
nation showed  a  small  amount  of  parenchymatous  inflammation.  The 
spleen  was  somewhat  enlarged.  Punctate  congestion  of  small  areas  of 


COMPLICATIONS  AND  SEQUELAE.  525 

gastric  surface,  no  increase  of  mucus;  mesenteric  glands  uniformly 
enlarged ;  jejunum,  ileum,  and  colon  exhibited  a  slightly  increased  vas- 
cularity.  The  immediate  cause  of  death  appeared  to  be  imperfect  con- 
traction of  the  heart  and  the  formation  of  clots  in  its  cavities,  due, 
apparently  to  the  pleuro-pneumouia  as  much  as,  or  more  than,  to  the 
primary  disease,  scarlatina.1 

There  can  be  little  doubt  that  nephritis  in  its  milder  form  is  much 
more  common  than  was  formerly  supposed.  A  few  years  since  little 
attention  was  given  by  a  large  proportion  of  physicians  to  the  state 
of  the  kidneys,  and  the  urine  was  not  examined  till  dropsy  made  its 
appearance,  which  only  occurs  in  the  more  severe  forms  of  nephritis 
and  is  a  late  symptom.  It  is  now  known  that  catarrh  of  the  renal 
tubes  frequently  occurs  in  a  mild  form  early  in  scarlet  fever,  without 
causing  albuminuria,  dropsy,  or  any  notable  symptom.  It  may  pro- 
duce a  smoky  color  of  the  urine,  and  the  appearance  in  it  of  granular 
epithelial  cells,  with  an  increase  of  mucus,  but  no  albumen.  With  care- 
ful treatment  and  no  exposure  to  cold,  the  renal  catarrh  abates  with  the 
decline  of  the  scarlet  fever.  It  is  scarcely  severe  enough  to  merit  the 
name  desquamative,  tubal,  or  parenchymatous  nephritis,  though  it  is  a 
mild  form  of  the  same  pathological  state.  Steiner  states,  as  the  result  of 
many  careful  examinations  of  cases,  that  hypersemia  of  the  kidneys  was 
always  present  in  those  who  died  early  in  scarlet  fever,  and  that  in  a  cer- 
tain proportion  of  these  cases  catarrh  of  the  renal  tubules  was  present  in 
addition  to  the  congestion.  Even  in  some  who  died  on  the  second  or 
third  day  he  found  cloudiness  of  the  epithelium  in  the  renal  tubes, 
although  the  urine  had  not  indicated  such  a  change.  The  opinion  has 
even  been  expressed  that  catarrh  of  the  renal  tubes  is  as.  common  in  scarlet 
fever  as  that  of  the  bronchial  tubes  in  measles;  that  is,  that  it  is  a 
uniform  element  in  the  disease ;  but  this  appears  to  be  an  exaggerated 
statement,  for  others  have  failed  to  find  any  evidence  of  renal  catarrh  in 
certain  cases. 

The  nephritis  which  gives  rise  to  symptoms,  and  therefore  interests 
the  practitioner,  commonly  begins  in  the  declining  period  of  scarlet 
fever  or  during  the  desquamative  stage,  and  is  in  many  instances  plainly 
attributable  to  exposure  to  cold  or  to  currents  of  air.  It  originates  cither 
during  this  period,  or,  if  it  have  previously  existed  as  a  mild  renal 
catarrh,  it  now  becomes  aggravated.  Dropsy,  which  always  attracts  atten- 
tion, does  not  occur  till  the  nephritis  has  continued  for  some  time. 

Why  nephritis,  with  the  subsequent  dropsy,  so  frequently  occurs  after 
scarlet  fever  is  not  fully  understood.  Rilliet  and  Barthez  attribute  it  to 
disturbance  of  the  function  of  the  skin.  The  fact  has  long  been  observed 
that  the  kidneys  become  aifected  nearly  if  not  quite  as  frequently  after 
mild  as  after  severe  cases.  Indeed,  the  chief  danger  in  mild  cases,  when 
the  patients  are  but  a  short  time  in  bed  and  are  soon  allowed  to  go  about, 
is  from  the  nephritis.  Chilling  the  surface  and  checking  cutaneous  trans- 
piration appear  to  be  the  immediate  cause  of  this  inflammation  in  a 
considerable  proportion  of  cases.  Therefore,  severe  attacks  of  scarlet 
fever  with  abundant  rash  and  desquamation,  which  require  the  patient 
to  be  kept  in  bed  the  proper  time  and  in  a  warm  room  two  or  three 

1  Dr.  Goodhart  (Guy's  Hospital  Reports,  1879)  reports  several  interesting  cases  to  con- 
firm his  opinion  that  acute  dilatation  of  the  heart  is  a  not  infrequent  sequel  of  scarlatin- 
ous nephritis,  and  is  the  cause  of  death  in  some  apparently  inexplicable  cases. 


526  SCARLET  FEVER. 

weeks,  appaar  to  be  less  frequently  followed  by  this  renal  disease  than 
are  milder  eases  which  are  more  carelessly  treated. 

The  most  thorough  and  minute  microscopic  examination  of  the  state 
of  the  kidneys  in  scarlet  fever  which  have  come  to  my  notice  were 
those  by  E.  Klein,  published  in  the  Land.  Path.  »S'oc.  Trans.,  and  illus- 
trated by  microscopic  drawings.  It  appears  from  these  examinations 
that  the  changes  in  the  kidneys  are  complex,  among  which  we  recognize 
both  those  of  parenchymatous  or  desquamative  nephritis  and  interstitial 
nephritis ;  but  we  would  infer  that  the  interstitial  nephritis  is  mild  in 
degree  and  quite  subordinate,  or  else  confined  to  portions  of  the  organ, 
from  the  fact  that  so  many  permanently  and  fully  recover.  The  follow- 
ing is  a  resume"  of  Klein's  examinations  in  twenty-three  cases  :  We  con- 
elnde  from  these  microscopic  researches  that  the  anatomical  changes  of 
both  parenchymatous  and  interstitial  nephritis  are  commonly  present  in 
greater  or  less  degree  in  cases  of  scarlet  fever.  If  they  are  mild  or  con- 
ftned  to  portions  of  the  kidneys,  no  symptoms  occur;  but  if  they  are 
sufficient  in  extent  or  degree  to  impair  the  function  of  these  organs,  then 
symptoms,  as  albuminuria,  diminution  of  urine,  etc.,  appear. 

1.  Parenchymatous  Nephritis,  Proliferation  of  Nuclei,  Hyaline  Degen- 
eration of  Arterioles,  the  Glomerulo-Nephritis  of  Klebs. — Klein  found 
increase  of  nuclei  (probably  epithelial)  upon  the  glomeruli  and  hyaline 
degeneration  of  the  intima  of  minute  arteries,  especially  marked  in  the 
afferent  arterioles  of  the  Malpighian  bodies.  The  intima  of  these 
vessels  was  in  places  so  swollen  as  to  resemble  cylindrical  or  spindle- 
shaped  hyaline  masses,  and  cause  narrowing  of  the  lumina  of  the  vessels 
in  which  this  degeneration  occurred.  Klein  observed  in  some  specimens 
so  great  hyaline  degeneration  of  the  capillaries  of  the  Malpighian  bodies 
that  circulation  through  them  was  obstructed.  In  the  more  advanced  or 
protracted  cases  this  hyaline  substance  in  the  glomeruli  began  to  assume  a 
fibrous  appearance.  Bowman's  capsule  was  considerably  thickened.  This 
hyaline  degeneration  of  the  Malpighian  Ixxlies  Klein  discovered  in  the 
earliest  cases  which  fell  under  his  observation. 

Also  in  the  earliest  cases  the  multiplication  or  germination  of  the 
nuclei  of  the  muscular  coat  of  the  arterioles  was  observed,  with  a  corre- 
sponding increase  in  the  thickness  of  the  walls  of  these  vessels.  This 
change  in  the  muscular  element  was  observed  in  the  arterioles  in  different 
parts  of  the  kidney,  but  it  was  most  conspicuous  in  arterioles  at  their  point 
of  entrance  into  the  Malpighian  bodies ;  and  it  was  distinctly  observed  in 
other  arterioles,  both  in  the  cortex  and  in  the  base  of  the  pyramids. 

In  the  glandular  portion  of  the  kidneys  other  anatomical  alterations 
were  observed,  indicating  parenchymatous  nephritis.  There  were  swelling 
of  the  epithelial  lining  of  the  convoluted  tubes ;  multiplication  of  nuclei 
of  epithelial  cells,  especially  in  ascending  tubules,  which  lay  close  to  the 
afferent  arterioles  of  Malpighian  corpuscles ;  granular  matter,  and  even 
Mood,  in  the  cavity  of  Bowman's  capsule  and  in  the  convoluted  tubes; 
cloudy  swelling  and  granular  disintegration  of  epithelium  in  some 
parts  of  the  convoluted  tubes;  detachment  of  epithelium  from  the 
membrane  of  larger  ducts  of  the  pyramids  in  some  cases.  These 
parenchymatous  changes  are  already  known  to  the  profession  through 
the  ol>servations  and  writings  of  Dickinson,  Fenwick,  Johnson,  John 
Simon,  and  others. 


COMPLICATIONS  AND  SEQUELS.  527 

Klein,  in  commenting  on  the  hyaline  degeneration  which  he  observed, 
states  that  Neelsen  found  the  walls  of  the  capillaries  of  the  pia  mater 
thickened,  highly  refractive,  and  of  a  lardaceous  appearance  in  certain 
acute  infectious  maladies,  as  variola,  typhoid  fever,  measles,  and  in 
one  case  of  scarlet  fever. l  Usually,  only  a  small  portion  of  the 
capillaries  were  thus  affected,  most  frequently  at  the  point  of  divis- 
ion into  branch  lets.  In  a  few  instances  Neelseu  observed  degen- 
eration of  arteriolcs  extending  a  considerable  distance,  with  fusion 
of  the  intima,  media  and  adventitia,  and  chemical  examination  showed 
that  the  substance  produced  by  this  degeneration  had  similar  properties 
to  elastic  tissue.  Although  the  examinations  by  Xeelseu  relate  to  the 
pia  mater,  two  of  his  observations  are  especially  interesting — first,  that  the 
hyaline  change  affects  chiefly  vessels  near  their  point  of  branching;  and, 
secondly,  that  the  hyaline  substance  is  of  the  nature  of  elastic  tissue,  for 
in  the  kidney  in  scarlatinous  nephritis  the  arterioles  undergo  the  change 
in  question  chiefly  near  their  point  of  branching  into  the  capillaries  of 
the  glomerulus;  and  the  intima  being  the  part  which  undergoes  the 
hyaline  change,  it  is  probable,  in  the  opinion  of  Klein,  that  the  same 
substance  is  produced  by  the  degeneration  in  walls  of  the  vessels  of  the 
kidney  which  Neelsen  observed  in  the  pia  mater,  and  therefore  that  it  is 
of  the  nature  of  elastic  tissue. 

This  hyaline  degeneration  of  the  arterioles  is  also  very  marked  in  the 
spleen  in  scarlet  fever;  and  in  studying  the  minute  anatomy  of  the 
intestines  and  spleen  in  typhoid  fever  Klein  has  found  the  same  degener- 
ation of  the  intima  of  the  minute  vessels.  He  believes  that  this  hyaline 
change  and  the  proliferation  of  muscle-nuclei  which  thus  occur  at  an 
early  period  in  scarlet  fever  in  the  renal  vessels  when  the  kidneys  become 
affected  are  due  to  an  irritating  cause  acting  similarly  to  that  in  typhoid 
fever. 

Klein  calls  attention  to  the  interesting  examinations  of  the  scarlatinous 
kidney  made  by  Klebs,  who  attributed  the  diminished  urination  and  the 
ursemic  poisoning  in  certain  cases  in  which  the  kidneys  do  not  exhibit 
any  marked  change  to  the  naked  eye,  to  what  he  designates  glomerulo- 
nephritis.  Klebs  says :  "  In  the  post-mortem  examination  the  kidneys 
are  found  slightly  or  not  at  all  enlarged,  firm,  ....  the  parenchyma 
very  hyperaemic.  Only  the  glomeruli  appear,  on  close  inspection,  pale 
like  small  white  dots.  The  urinary  tubes  are  often  not  changed  at  all. 
Occasionally  the  convoluted  tubes  are  slightly  cloudy.  The  microscopic 
examination  shows  that  there  are  neither  interstitial  changes  nor  prolifer- 
ation of  epithelium,  the  so-called  renal  catarrh  generally  supposed  to  be 
present  in  these  conditions  on  account  of  the  absence  of  other  perceptible 
derangements  ;  and  there  seems,  therefore,  leaving  out  the  glomeruli,  the 
congestion  of  the  kidneys  alone  to  remain  to  account  for  the  symptoms 
during  life."  But  that  mere  congestion  is  insufficient  to  produce  the 
symptoms  appears  from  the  fact  that  it  does  not  produce  them  under 
other  circumstances.  Klebs  finds,  "  on  microscopic  examination  of  the 
glomerulus,  the  whole  space  of  the  capsule  filled  with  small  somewhat 
angular  nuclei,  imbedded  in  a  finely  granular  mass.  The  vessels  of  the 
glomerulus  are  almost  completely  covered  by  nuclear  masses." 

Klein,  commenting  on  these  examinations  by  Klebs,  states  that  in  all 
1  Archiv  der  Heilkunde,  1876. 


528  SCARLET  FEVER. 

early  cases  which  he  examined  he  observed  great  abundance  of  nuclei 
of  the  glomeruli,  but  a  condition  like  that  described  and  figured  by  Klebs1 
he  has  seen  in  only  a  few  glomeruli ;  for  a  general  state  of  these  bodies,  as 
described  by  this  observer,  and  such  an  excessive  proliferation  of  the  nuclei 
that  the  blood-vessels  are  completely  compressed,  was  not  seen  in  one  of 
the  twenty-three  cases.  Klein  therefore  questions  whether  the  diminished 
urination"  and  retention  of  urea  in  scarlet  fever,  when  the  kidneys  do 
not  exhibit  any  conspicuous  catarrhal  or  other  change,  is  due,  unless  in 
exceptional  instances,  to  compression  of  the  vessels  of  the  glomeruli  by 
nuclear  germination,  but  believes,  rather,  that  the  obstructed  circulation, 
and  consequent  diminished  urinary  excretion,  is  largely  due  to  the 
changed  state  of  the  arterioles.  Klein  adds  that  perhaps  undue  con- 
traction of  the  arterioles,  through  stimulation  by  the  blood-irritant,  may 
also  be  a  factor  in  causing  arrest  of  circulation  in  the  Malpighian  cor- 
puscles. As  regards  cases  that  perished  early,  he  found  the  parenchy- 
matous  change  slight,  so  that  a  careful  examination  was  required  in  order 
to  detect  cloudy  swelling  and  granular  degeneration. 

2.  Interstitial  Nephritis. — A  second  set  of  changes  Klein  observed 
in  cases  that  died  on  about  the  ninth  or  tenth  day.  In  such  cases  he 
found  changes  due  to  interstitial,  in  addition  to  those  produced  by  paren- 
chymatous,  nephritis.  Round  cells,  lymphoid  cells,  or  whatever  else  they 
should  be  called,  were  seen  in  the  connective  tissue  of  the  kidneys.  In  the 
kidneys  of  those  that  died  at  the  end  of  the  first  week  after  the  com- 
mencement of  nephritis,  infiltration  with  round  cells  was  observed  in  the 
connective  tissue  around  the  large  vascular  trunks.  At  a  later  stage  this 
infiltration  had  extended  into  the  bases  of  the  pyramids  and  into  the 
cortex.  The  gradual  increase  in  extent  and  intensity  of  this  infiltration 
was  so  decided  in  the  cases  which  Klein  observed  that  he  has  no  hesita- 
tion in  concluding  that  when  interstitial  nephritis  occurs  it  begins  about 
the  end  of  the  first  week,  in  the  manner  already  stated — to  wit,  as  a 
slight  infiltration  of  the  tissue  around  the  large  vascular  trunks,  and 
gradually  extends,  so  that  portions  of  the  cortex,  and  rarely  portions  of 
the  base  of  the  pyramids,  are  changed  into  firm,  pale,  round-cell  tissue, 
in  which  the  original  tubes  of  the  cortex  become  lost. 

The  infiltration  of  the  cortex  with  round  cells,  beginning  at  the  roots 
of  the  interlobular  vessels,  spreads  rapidly  toward  the  capsule  of  the 
kidney,  and  laterally  among  the  convoluted  tubes  around  the  Malpighian 
bodies In  the  course  of  this  process  considerable  parts  of  the  per- 
ipheral cortex,  occasionally  of  a  more  or  less  distinctly  cuneiform  shape,  with 
the  base  nearest  the  capsule  of  the  kidney,  become  changed  into  whitish, 
firm,  bloodless,  cellular  masses,  in  which  Malpighian  corpuscles  and 
urinary  tubes  are  only  imperfectly  recognized,  being  more  or  less  degen- 
erated. In  some  cases  attended  by  this  infiltration  of  the  cortex  Klein 
observed  a  more  or  less  dense  reticulation  of  fibres,  especially  around  the 
interlobular  arteries,  containing  in  its  meshes  lymph-cells,  chiefly  uni- 
nuclear. 

In  a  child  of  five  years  that  died  after  a  sickness  of  thirteen  days  Klein 
found  evidence  of  intense  interstitial  inflammation,  and  also  emboli,  consist- 
ing of  fibrin  with  a  few  cells,  in  the  arteries,  both  in  those  of  large  size 
and  in  the  arterioles,  chiefly  where  they  enter  the  Malpighian  corpuscles. 
1  Eandbuch  der  Paihol,  p.  646,  fig.  72. 


COMPLICATIONS  AND  SEQUEL JE.  529 

He  states  that  in  the  specimens  which  he  examined  the  more  intense  the 
degree  of  interstitial  change,  the  greater  was  the  enlargement  of  the 
kidneys,  and  the  more  distinct  also  were  the  evidences  of  parenchymatous 
nephritis  in  the  urinary  tubes,  which  either  contained  casts  or  were 
in  the  process  of  destruction.  By  being  crowded  with  inflammatory 
product?,  especially  cells,  the  Ma'lpighian  corpuscles  were  obliterated, 
undergoing  fibrous  degeneration.  A  very  curious  fact  observed  was  the 
deposit  of  lime  in  the  urinary  tubes,  first  of  the  cortex,  and  then  also  of 
the  pyramids,  at  an  early  stage  of  scarlet  fever,  when  the  kidneys  other- 
wise showed  only  slight  change.  Several  observers,  as  Biermer,  Coats, 
and  Wagner,  have  each  described  a  case  of  scarlet  fever  with  interstitial 
nephritis,  which  they  consider  unusual ;  but  Klein  has  apparently  dem- 
onstrated, as  we  have  seen,  by  a  large  number  of  microscopic  examina- 
tions, that  this  form  of  nephritis  is  common  after  the  ninth  or  tenth  day. 

Nephritis,  in  proportion  to  its  extent  and  gravity,  is  accompanied  by. 
languor,  febrile  movement,  thirst,  loss  of  appetite  and  strength.  At  first 
the  patient  experiences  but  slight  pain  in  the  head  or  elsewhere,  and  the 
quantity  of  urine  is  not  notably  diminished ;  but  as  the  disease  continues 
urination  becomes  less  frequent  and  the  urine  more  scanty.  Albuminuria 
occurs,  while  the  urea  is  only  partially  excreted,  and  therefore  accumulates 
in  the  blood.  If  the  nephritis  be  so  severe  or  protracted  that  this  princi- 
ple accumulates  to  a  certain  extent,  grave  symptoms  occur,  as  headache, 
vomiting,  apathy  or  restlessness,  and,  more  dangerous  than  all,  eclampsia, 
which  is  not  unusual  in  these  cases.  Microscopic  examination  of  the 
urine  shows  the  presence  in  this  liquid  of  blood-corpuscles,  granular  epithe- 
lial cells,  and  hyaline  or  granular  casts,  or  both.  The  specific  gravity 
of  the  urine  is  diminished.  But  a  large  quantity  of  albumen  in  the 
urine  may  render  the  specific  gravity  as  high  or  higher  than  in  health. 

The  altered  state  of  the  blood  soon  gives  rise  to  transudation  of  serum, 
first  observed  in  most  cases  as  an  anasarca  occurring  in  the  feet  and  ankles. 
The  oedema,  if  not  checked  by  treatment  or  through  mildness  of  the  dis- 
ease, extends  over  the  limbs,  scrotum,  and  sometimes  upon  the  trunk.  It 
is  well  if  the  dropsy  remain  limited  to  the  subcutaneous  connective  tissue, 
but,  unfortunately,  it  is  apt  to  occur,  if  the  nephritis  continue,  in  and 
around  the  internal  organs,  producing,  mentioned  in  the  order  of  fre- 
quency, pulmonary  oedema,  effusion  into  the  pleural  and  peritoneal  cavi- 
ties, the  pericardium,  the  encephalon,  and  lastly  into  the  connective  tissue 
of  the  larynx,  causing  that  very  fatal  complication,  oedema  of  the  glottis. 
Although  this  is  the  common  order  in  which  dropsies  occur,  exceptions 
are  not  infrequent.  Even  the  anasarca  may  not  be  the  first  to  appear, 
although  in  the  vast  majority  of  cases  it  has  the  precedence.  Thus, 
Rilliet  relates  the  case  of  a  boy  of  five  years  who  twenty  days  after  the 
occurrence  of  scarlet  fever,  and  six  hours  after  the  appearance  of  bloody 
and  albuminous  urine,  had  double  hydrothorax,  rapidly  developed.  As 
long  as  the  hydrothorax  continued  no  anasarca  was  observed,  but  as  it 
declined  anasarca  appeared.  Legendre  cites  a  case  in  which  oedema 
of  the  lungs  occurred  without  anasarca  or  other  dropsy.  Occasionally, 
the  anasarca  and  internal  dropsies  take  place  nearly  simultaneously.  The 
nephritis  and  consequent  serous  effusions  usually  appear  within  three 
weeks  after  scarlet  fever  ends,  but  cases  occur  in  which  the  effusions  are 
first  observed  as  late  as  the  fourth  and  fifth  weeks.  The  patient  may  be 

VOL.  I.— 34 


530  SCARLET  FEVEE. 

considered  to  possess  immunity  from  this  sequel  if  he  have  reached  the 
close  of  the  fifth  week  after  the  abatement  of  scarlet  fever  without  its 
occurrence. 

The  dropsy  is  usually  acute,  but  it  may  assume  the  chronic  form,  since 
the  nephritis  which  causes  it,  happily  curable  in  most  instances,  may,  if 
neglected,  become  chronic.  Whether  the  dropsy  in  itself  involve  danger 
depends  in  great  part  on  its  location.  Anasarca  and  ascites  may  exist  a 
long  time  with  little  suffering  or  danger,  but  a  small  amount  of  serum  in 
certain  other  localities  causes  alarming  symptoms  and  speedy  death. 
(Edema  of  the  lungs,  hydro-pericardium,  oedema  of  the  glottis,  and  intra- 
cranial  effusions  are  always  dangerous,  and  the  last  two  are  sometimes 
fatal  within  twenty-four  to  forty-eight  hours.  QEdema  of  the  lungs  has 
been  fatal  within  twelve  hours  from  the  occurrence  of  the  first  symptoms 
of  obstructed  respiration. 

Cerebral  symptoms  occurring  during  scarlatinous  nephritis  are  probably 
sometimes  due  to  the  irritating  effect  of  the  retained  urea  on  the  nervous 
centre.  In  other  cases  the  cause  appears  to  be  cerebral  oedema  or  com- 
pression of  the  brain  by  effusion  of  serum  within  the  ventricles  and  upon 
the  surface  of  the  brain.  Headache,  dull  or  severe,  dilatation  of  the 
pupils  or  their  oscillation  in  the  same  degree  of  light,  vomiting  with  little 
apparent  nausea,  are  common  symptoms  of  scarlatinous  nephritis  when  it 
has  continued  a  few  days,  and  the  excretion  of  urea  is  so  diminished  that 
this  substance  begins  to  exert  its  poisonous  effect  on  the  system.  Such 
symptoms  are  apt  to  be  followed  by  somnolence,  threatening  coma,  or  by 
eclampsia,  unless  the  patients  are  promptly  and  properly  treated.  In 
some  patients  that  die  of  scarlatinous  nephritis,  death  occurring  in  con- 
vulsions or  coma,  no  appreciable  lesions  are  observed  within  the  cranium, 
unless  more  or  less  congestion,  the  fatal  ending  being  attributable  to  the 
uraemia.  In  other  instances  we  find  an  effusion  of  serum  within  the  ven- 
tricles or  upon  the  surface  of  the  brain.  Although  the  symptoms  in  scar- 
latinous nephritis  and  uraemia  may  appear  very  unfavorable,  the  progno- 
sis is  usually  good  under  prompt  and  appropriate  treatment.  Thus  severe 
convulsions  and  a  degree  of  somnolence  that  bordered  on  coma  may  abate, 
and  convalescence  be  fully  established  within  a  few  days,  and  Rilliet  and 
Barthez  announce  ten  recoveries  in  thirteen  patients  affected  with  convul- 
sions due  to  this  renal  affection. 

ANATOMICAL  CHARACTERS. — Scarlet  fever  being,  as  we  have  seen,  a 
constitutional  febrile  disease  of  an  ataxic  nature,  and  accompanied  by 
certain  inflammations,  necessarily  affects  the  composition  of  the  blood ; 
but  since  this  disease  varies  so  greatly  in  type  or  severity,  the  state  and 
appearance  of  this  liquid  also  vary.  At  the  autopsies  of  the  more 
malignant  cases  we  find  the  blood  dark  and  fluid,  with  small,  soft,  and 
dark  clots  in  the  heart  and  large  vessels.  In  other  cases  the  clots  are 
large,  firm,  and  solid,  as  described  in  a  preceding  page.  In  malignant 
cases  that  end  fatally  Rilliet  and  Barthez  state  that  both  the  large  and 
small  vessels  of  the  cerebral  meninges  and  the  brain  are  found  hyper- 
semic,  but  in  a  variable  degree.  In  those  who  die  in  coma,  preceded  by 
delirium  or  convulsions,  during  the  eruptive  stage,  the  intracranial  con- 
gestion is  usually  marked,  with  perhaps  some  transudation  of  serum,  but 
without  inflammatory  lesions.  The  fibrin  in  scarlet  fever  remains  in 
about  normal  proportion,  except  as  it  is  increased  by  inflammatory  com- 


ANATOMICAL  CHARACTERS.  531 

plications.  Andral  found  an  increase  in  the  proportion  of  blood-cor- 
puscles from  127  to  136  parts  in  1000. 

The  respiratory  apparatus,  except  the  Schneiderian  membrane,  is  usually 
normal  when  no  complications  exist.  Samuel  Fenwick1  made  post-mortem 
examinations  in  sixteen  cases  of  scarlet  fever,  and  concludes  from  them  that 
inflammation  of  the  mucous  membrane  of  the  stomach  and  intestines  occurs 
like  that  of  the  skin,  followed  by  desquamation  of  the  epithelial  cells,  like 
that  of  the  epidermis.  I  have  had  the  opportunity  of  examining  the 
stomach  and  intestines  of  those  who  died  of  scarlet  fever  in  the  eruptive 
stage,  and  have  not  found  any  unusual  hypersemia  of  the  gastro-intes- 
tinal  surface,  except  when  gastro-intestinal  inflammation,  usually  indi- 
cated by  diarrhoea,  had  occurred  as  a  complication. 

In  some  cases  the  abdominal  organs  exhibit  changes  which  suggest  a 
resemblance  to  typhoid  fever.  The  spleen  is  enlarged  and  somewhat 
softened,  and  Peyer's  patches  and  the  solitary  glands  are  thickened  and 
prominent,  but  less  in  degree  than  in  typhoid  fever.  The  mesenteric 
glands  also  are  in  a  state  of  hyperplasia.  In  other  patients  these  parts 
appear  normal. 

Klein  made  microscopic  examination  of  the  liver  in  eight  cases,  and 
states  that  he  found  granular  opaque  swelling  of  liver-cells,  and  changes 
in  the  internal  and  middle  coats  of  certain  arteries  similar  to  those 
observed  in  the  kidneys,  which  have  been  described  above.  He  also 
found  evidences  of  interstitial  inflammation,  as  an  increase  of  round 
cells  and  connective  tissue  in  the  liver.  He  remarks  also  that  he 
observed  hyaline  degeneration  of  the  intima  of  arteries  in  the  spleen. 
Rilliet  and  Barthez  state  that  swelling  and  softening  of  the  spleen  are 
exceptional  in  scarlet  fever,  but  are  sufficiently  common  to  merit  atten- 
tion. In  post-mortem  examinations  which  I  have  witnessed  nothing 
noteworthy  has  appeared  to  the  naked  eye  in  the  state  of  the  liver,  nor 
ordinarily  in  that  of  the  spleen. 

The  efflorescence,  though  one  of  the  anatomical  characters,  has  per- 
haps been  sufficiently  described  in  the  foregoing  pages.  It  begins  over 
the  neck,  chest,  and  groins  as  numerous  reddish  points  not  larger  than 
a  pin's  head,  closely  crowded  together,  but  with  skin  of  normal  color 
between.  It  is  estimated  that  the  aggregate  efflorescence  and  aggregate 
normal  skin  over  a  given  area  are  about  equal.  If  the  cutaneous  circu- 
lation be  active  and  the  febrile  movement  be  considerable  these  spots 
extend  and  coalesce,  producing  an  efflorescence  like  erythema  or  like  the 
hue  of  a  boiled  lobster,  to  which  it  has  been  likened.  The  efflorescence, 
less  upon  the  face  than  upon  the  trunk,  contrasts  in  this  respect  with 
that  of  measles,  in  which  the  rash  is  full  in  the  face,  often  causing  some 
swelling  of  the  features.  It  is  also  less  upon  the  palmar  and  plantar 
surfaces  than  elsewhere.  It  scarcely  causes  any  perceptible  elevation 
of  the  skin,  but  in  certain  localities,  as  upon  the  backs  of  the  hands 
and  upon  the  fore-arms,  it  communicates  the  sensation  of  slight  rough- 
ness. The  seat  of  the  efflorescence  is  mainly  in  the  superficial  payers  of 
the  skin,  but  it  is  said  that  it  sometimes  has  occurred  upon  a  cicatrix,  as 
that  from  a  burn.  In  the  robust  and  in  favorable  cases  in  which  the 
circulation  is  active  the  rash  has  a  scarlet  hue,  and  when  the  cutaneous 
capillaries  are  emptied  and  the  skin  rendered  pale  by  pressure  with  the 
1  London  Lancet,  July  23,  1864. 


532  SCARLET  FEVER. 

fingers,  the  circulation  immediately  returns  when  the  pressure  is  removed. 
In°malignant  cases  the  color  is  not  scarlet,  but  dusky  red,  and  so  sluggish 
is  the  capillary  circulation  that  the  skin  when  pressed  upon  recovers  the 
blood  very  slowly.  In  grave  cases  also  extravasation  of  blood  in  minute 
points  or  transudation  of  its  coloring  matter  is  apt  to  occur  in  portions 
of  the  surface,  when  of  course  decolorization  is  not  fully  produced  by 
pressure.  In  cases  ending  fatally,  during  the  eruptive  stage  the  efflores- 
cence may  entirely  disappear  in  the  cadaver,  or  it  remains  upon  parts  of 
the  surface,  especially  depending  portions.  Desquamation  is  attributable 
to  the  exaggerated  proliferation  of  the  epidermis  and  the  loosening  of  its 
attachment  by  the  inflammation. 

DIAGNOSIS. — In  the  commencement  of  scarlet  fever,  prior  to  the 
eruption,  no  symptoms  or  appearances  exist  which  enable  us  to  make  a 
positive  diagnosis.  Positive  statement  in  reference  to  the  nature  of  the 
attack  should  be  deferred,  for  the  credit  of  the  physician.  Still,  if  a 
child  with  no  appreciable  local  disease  sufficient  to  cause  the  symptoms  a 
few  days  after  exposure  to  scarlet  fever,  or  during  an  epidemic  of  this 
malady,  be  suddenly  siezed  with  fever,  the  pulse  rising  to  110,  120,  or 
more,  and  the  temperature  to  102°,  103°,  or  105°,  scarlatina  should  be 
suspected.  The  diagnosis  is  rendered  more  certain  at  this  early  stage  if 
vomiting  occur,  and  especially  if  the  fauces  be  red,  for  hypersemia  of  the 
fauces,  due  to  commencing  pharyngitis,  is  one  of  the  earliest  and  most 
constant  of  the  local  manifestations  of  scarlatina. 

When  the  eruption  has  appeared  the  nature  of  the  malady  is  in  most 
instances  apparent.  The  punctate  character  of  the  eruption  before  it 
becomes  confluent,  its  occurrence  within  twenty-four  hours  after  the  fever 
begins  over  almost  the  entire  surface,  but  its  absence  or  scantiness  upon 
the  face,  and  especially  around  the  mouth,  serve  to  distinguish  it  from 
other  diseases. 

Scarlet  fever  and  measles  were  long  considered  identical  by  the  pro- 
fession, and,  though  the  ordinary  forms  of  these  maladies  can  be  readily 
distinguished  from  each  other,  cases  occur  in  which  the  differential  diag- 
nosis is  attended  by  some  difficulty.  But  there  are  differences  in  the 
symptoms  and  course  of  the  two  diseases  which  aid  in  discriminating  one 
from  the  other.  Measles  begins  with  marked  catarrhal  symptoms,  as  if 
from  a  severe  cold.  Mild  conjunctivitis,  causing  weak  and  watery  eyes, 
coryza,  and  mild  laryngo-bronchitis,  with  accompanying  cough,  precede 
the  eruption  three  or  four  days  and  continue  during  the  eruptive  stage. 
The  febrile  movement  in  the  prodromic  stage  of  measles  is  remittent,  the 
evening  temperature  being  two  or  three  degrees  higher  than  that  in  the 
morning.  Contrast  this  with  the  invasion  of  scarlet  fever,  in  which  the 
only  catarrh  is  that  of  the  buccal  and  faucial  surfaces,  and  there  is  con- 
sequently little  or  no  cough,  and  the  febrile  movement,  ordinarily  high 
in  the  beginning,  is  nearly  uniform  in  the  different  hours  of  the  day. 
The  scarlatinous  eruption  appears,  as  we  have  seen,  within  twelve  to 
twenty- four  hours  about  the  neck  and  upper  part  of  the  chest,  and 
spreads  over  the  body  in  a  shorter  time  than  that  of  measles,  which 
appears  on  the  third  day.  The  rash  of  measles  begins  to  fade  at  the 
close  of  the  third  or  in  the  fourth  day  after  its  appearance,  that  of 
scarlet  fever  not  till  from  the  sixth  to  the  eighth  day.  In  nearly  all 
cases  of  measles,  even  when  the  rash  is  confluent  upon  the  face  and  a 


PROGNOSIS.  533 

considerable  part  of  the  trunk,  in  consequence  of  the  high  febrile  move- 
ment and  vigorous  cutaneous  circulation,  we  observe  the  characteristic 
rubeolar  eruption  upon  certain  parts  of  the  surface,  as  the  extremities, 
which,  in  connection  with  the  history,  renders  diagnosis  certain. 

Erythema  resembles  the  scarlatinous  eruption,  but  its  duration  is  com- 
monly shorter.  It  is  limited  to  a  part  of  the  surface,  and  it  is  accompa- 
nied by  much  less  febrile  movement.  The  temperature  in  erythema  does 
not  usually  rise  above  100°,  unless  for  a  few  hours,  whereas  in  scarlet  fever 
it  continues  considerably  above  100°  for  several  days.  The  scarlatinous 
efflorescence  has  also  a  brighter  red  or  more  scarlet  hue  than  that  of 
erythema,  except  in  the  more  malignant  cases,  in  which  the  severity  of 
the  symptoms  renders  the  diagnosis  clear.  But  an  important  aid  in 
differentiating  the  one  from  the  other  of  these  diseases  is  the  fact  that 
in  erythema  there  is,  with  few  exceptions,  no  faucial  inflammation,  and 
in  the  few  instances  in  which  it  is  present  it  is  slight  and  transient,  fading 
within  a  day  or  two. 

Scarlet  fever  is  readily  diagnosticated  from  diphtheria,  although  the 
affinity  is  close  between  these  two  maladies.  The  early  appearance  of 
the  pseudo-membrane  upon  the  fauces  in  diphtheria,  its  absence  in  scarlet 
fever,  and  the  absence  of  any  appearance  resembling  it  until  the  fever  has 
continued  some  days,  and  the  characteristic  efflorescence  upon  the  skin  in 
scarlet  fever,  render  diagnosis  easy.  If  scarlet  fever  have  continued 
some  days  when  first  seen  by  the  physician,  the  diphtheritic  pseudo- 
membrane  may  be  present  as  a  complication,  or  the  fauces  may  present 
an  appearance  like  diphtheria  from  ulceration  or  sloughing  and  the 
presence  of  foul  and  offensive  secretions,  which  produce  a  dark-grayish 
and  fetid  mass  over  the  faucial  surface.  Under  such  circumstances  the 
character  of  the  disease  is  ascertained  by  the  history  of  the  case,  and 
especially  by  the  occurrence  of  the  scarlatinous  eruption.  An  erythema 
t  nmsient  and  limited  to  a  part  of  the  surface  sometimes  appears  in  the  com- 
mencement of  diphtheria,  and  at  a  later  period,  as  a  result  of  the  toxaemia, 
points  of  a  roseoloid  appearance  and  irregular  patches,  often  located  upon 
the  extremities.  Both  kinds  of  rash  can  be  readily  diagnosticated  from 
that  of  scarlet  fever,  for  the  erythema,  as  has  been  stated,  is  transient  and 
partial,  and  does  not  exhibit  minute  points  of  deeper  injection,  while  the 
toxremic  rash  differs  in  form  and  aspect  from  that  of  scarlet  fever,  and 
appears  at  a  stage  of  the  case  when  the  scarlatinous  efflorescence  would 
have  laded  or  begun  to  fade. 

The  efflorescence  of  rothelu  sometimes  closely  resembles  that  of  scarlet 
fever,  though  it  is  usually  more  like  that  of  measles  ;  but  it  is  ordinarily 
accompanied  by  symptoms  which  are  much  milder  than  those  of  scarlet 
fever,  and  it  begins  to  abate  as  early  as  the  third,  and  disappears  on  the 
fourth,  day.  The  eyes  have  a  suffused  appearance,  the  temperature  may 
reach  102°  or  103°,  and  the  efflorescence  may  be  as  general  over  the  body 
as  that  of  scarlet  fever,  but  there  is  not  the  aspect  of  serious  indisposition, 
and  the  speedy  abatement  of  the  symptoms  shows  that  the  disease  is  not 
scarlet  fever. 

PROGNOSIS. — The  prognosis  depends  on  the  form  of  scarlet  fever, 
whether  mild  or  severe,  the  strength  of  the  patient,  and  the  presence  or 
absence  of  complications  or  sequela;.  The  type  of  this  disease  is  some- 
times so  mild  throughout  an  epidemic  or  during  a  series  of  years  that 


534 


SCARLET  FEVER. 


death  seldom  occurs,  whatever  the  mode  of  treatment ;  but  afterward  the 
type  changes,  and  the  percentage  of  deaths  increases  and  remains  high 
till  another  mitigation  in  the  type  occurs. 

Sydenham  in  the  middle  of  the  seventeenth  century  stated  that  scarlet 
fever,  as  he  saw  it  in  London,  was  so  mild  that  it  scarcely  deserved  the 
name  of  disease :  "  Vix  nomen  morbi  merebatur."  Morton  some  years 
later,  and  Huxham  in  the  following  century,  had  abundant  reason  to 
regret  the  change  of  type,  and  now  throughout  Great  Britain  scarlet  fever 
is  one  of  the  most  fatal  and  most  dreaded  of  the  diseases  of  childhood. 
In  Dublin  during  the  present  century,  prior  to  1834,  scarlet  fever  was 
uniformly  mild,  so  that  on  one  occasion  of  eighty  patients  in  an  institu- 
tion all  recovered.  In  1834  the  type  of  the  disease  totally  changed  and 
epidemics  of  unusual  virulence  occurred.  The  type  frequently  changes 
from  mild  to  severe  or  severe  to  mild,  not  only  in  consecutive  years,  but 
in  consecutive  months.  A  few  years  since  a  distinguished  physician  of 
New  York  treated  about  fifty  cases  of  scarlet  fever  in  one  of  the  institu- 
tions without  a  single  death,  but  a  few  months  later  the  type  of  the 
malady  changed,  and  his  own  son  was  among  those  who  perished  from  it. 
The  prevailing  type  of  the  disease  should  therefore  be  considered  in  giv- 
ing the  prognosis  when  in  the  commencement  of  a  case  we  are  asked  the 
probability  as  regards  the  termination. 

Extensive  statistics,  including  those  collected  by  Murchison  from 
various  sources,  show  that  in  different  epidemics  the  mortality  may 
vary  as  much  as  from  3  per  cent.  (Eulenberg  of  Coblentz)  to  19.3  per 
cent,  (cases  seen  by  myself  in  New  York  City  in  1881-82,  many  of 
wJiich  were  complicated  by  diphtheria),  or  even  to  34  per  cent,  (epidemic 
in  the  Palatinate  in  1868-89).  The  hospital  statistics  of  Rilliet  and 
Barthez  gave  46  deaths  in  87  cases,  or  about  53  per  cent. 

Observations  have  thus  far  failed  to  establish  any  connection  in  the 
atmospheric  conditions  of  temperature  or  moisture  and  the  type  of  scarlet 
fever.  Grave  as  well  as  mild  epidemics  have  occurred  in  all  climates  and 
seasons. 

The  mortality  is  nearly  equal  in  the  two  sexes,  but  age  bears  a  marked 
influence  on  the  percentage  of  deaths.  Comparatively  few  contract  scar- 
let fever  under  the  age  of  one  year,  and  the  period  of  its  greatest  mortal- 
ity, since  it  is  of  its  greatest  frequency,  is  between  the  ages  of  one  and 
six  years.  The  following  are  statistics  bearing  on  the  relation  of  the  age 
to  the  percentage  of  deaths : 


Under  1  year. 


Fleishman,    Cases 

Deaths 


Kraus, 


Voit, 


Koset, 


Cases........  13 

Deaths 4 


Cases 

Deaths 


Cases 43 

Deaths 16 


From  the  close 
of  1st  till  close 
of  5th  year. 

204 


1st  to  close  of 
6th  year. 

113 
29 

166 
24 

From  1st  to  close 
of  5th  year. 

156 
31 


From  the  5th  to 
the  12th  year. 

260 
51 

6th  to  12th  year. 

106 
10 

7th  to  16th  year. 

109 

10 

Over  5  years. 

88 
3 


From  the  12th 
to  20th  year. 

40 
2 


PROGNOSIS.  535 

Under  5  years.          5th  to  10th  year.          10th  to  15th  year.          Over  15  years. 

Kusigger,       Cases 101  126  47  27 

Deaths 21  20  3  0 

These  statistics,  which  I  believe  correspond  with  the  observations  of 
others,  show  that  although  few  cases  occur  in  the  first  year,  the  percentage 
of  deaths  is  large,  and  that  a  majority  of  the  deaths  occur  under  the  age 
of  six  years.  After  the  sixth  year  the  greater  the  age  the  less  the  propor- 
tionate number  of  deaths. 

Scarlet  fever  is  liable  to  so  many  complications  and  sequelae  that  a  phy- 
sician should  not  predict  a  certain  favorable  termination  in  the  beginning, 
however  mild  and  regular  the  symptoms  may  be.  But  a  favorable  result 
may  be  expected  if  the  attack  be  mild,  the  efflorescence  appear  at  the 
proper  time  and  extend  over  the  entire  surface,  the  angina  be  moderate 
and  accompanied  by  little  or  no  cellulitis  or  adenitis,  with  pulse  under 
140,  temperature  not  above  103°,  and  no  marked  nervous  symptoms. 

Whether  the  complications  or  sequelae  be  dangerous  depends  upon  their 
character.  Rheumatism  has  never  in  my  practice  been  dangerous,  nor 
has  it  materially  retarded  convalescence,  except  when  it  affected  the 
heart,  causing  pericarditis  or  endocarditis,  when  it  involves  great  danger. 
Nephritis,  if  it  be  moderate,  attended  by  little  albuminuria  and  serous 
effusion,  and  by  the  occurrence  of  few  renal  casts  in  the  urine,  commonly 
ends  favorably  under  judicious  treatment,  as  we  have  already  stated;  but 
severe  nephritis,  with  abundant  albuminuria  and  casts  and  serous  effu- 
sions, soon  gives  rise  to  alarming  symptoms,  and  is  the  cause  of  death  in 
a  considerable  number  of  instances.  A  similar  remark  is  applicable  to 
the  angina,  which  occurs  in  all  grades  of  severity.  If  it  be  attended  by 
much  cellulitis,  with  considerable  ulceration  or  necrosis,  the  state  is  one 
of  danger,  in  consequence  of  the  difficulty  in  administering  sufficient 
nutriment,  of  the  diminished  assimilation  and  of  the  loss  of  strength 
from  the  prolonged  inflammatory  fever,  the  septic  poisoning,  and  the 
occasional  hemorrhages.  Complication  by  pharyiigeal  or  nasal  diphthe- 
ria, now  so  common  where  diphtheria  is  endemic,  also  greatly  increases 
the  danger. 

Many  cases,  even  when  their  course  is  normal  and  without  complica- 
tions, involve  danger,  and  some  are  necessarily  fatal,  from  the  direct  effect 
of  the  scarlatinous  blood-poisoning.  Such  are  grave  or  malignant  forms 
of  the  disease  which  the  experienced  eye  recognizes  at  a  glance.  ^  Death 
often  occurs  rapidly  from  the  toxaemia.  Such  cases  are  characterized  by 
high  temperature  (105°  or  106°),  rapid  pulse,  a  dusky-red  hue  of  the 
surface  from  languid  capillary  circulation,  pungent  heat,  frequent  vomit- 
ing, diarrhceal  stools,  a  dry-brown  tongue,  and  marked  nervous  symptoms, 
such  as  delirium,  great  restlessness,  or  stupor.  Not  a  few  in  this  form  of 
scarlet  fever  take  eclampsia,  which  is  apt  to  be  severe  and  repeated,  and 
to  end  in  fatal  coma. 

Other  inflammatory  complications  and  sequelae,  which  have  been 
described  in  the  preceding  pages,  retard  convalescence  and  jeopardize  the 
life  of  the  patient,  such  as  empyema,  endocarditis,  pericarditis,  and  pueu- 
monia.  Otitis  media  is  seldom  immediately  dangerous,  although  it^may 
be  painful  and  involve  serious  consequences,  even  a  fatal  meningitis,  as 
has  been  stated  above,  after  months  or  years  of  otorrhoea.  Anomalous 
cases  are  believed  to  be,  as  a  rule,  more  dangerous  than  such  as  are 


536  SCARLET  FEVER. 

attended  by  au  early  and  full  efflorescence  and  have  the  usual  symp 
toms. 

TREATMENT. — PROPHYLAXIS.  Since  the  discovery  by  Jenuer  of  the 
prophylactic  power  of  vaccination  as  regards  small-pox,  the  attention  of 
the  profession  has  been  frequently  directed  to  the  prevention  of  scarlet 
fever.  Belladonna  has  been  employed  for  this  purpose  by  a  class  of 
practitioners  who  believe  in  the  theory  that  an  agent  which  produces 
symptoms  similar  to  those  of  a  disease  is  antagonistic  to  that  disease,  and 
therefore  tends  to  prevent  it,  or,  if  it  be  present,  to  render  it  milder ;  and 
since  this  herb  causes  an  efflorescence  upon  the  skin  and  redness  of  the 
fauces,  it  was  selected  as  the  proper  preventive  and  remedial  agent  for 
scarlet  fever.  Its  use,  however,  for  this  purpose  has  been  fruitless,  and 
it  is  now  nearly  or  quite  discarded. 

It  is  probable,  from  a  considerable  number  of  observations,  that  scarlet 
fever  occasionally  occurs  in  the  domestic  animals  during  epidemics  of  the 
disease  in  children.  It  is  stated  that  Spinola  observed  it  in  the  horse ; 
that  Heim  saw  a  dog  that  occupied  the  same  bed  with  a  scarlatinous 
patient  sicken  with  fever,  which  was  followed  by  desquamation ;  that 
Letheby  saw  scarlatina  in  swine,  and  Kraus  in  young  cattle.  Prominent 
veterinary  surgeons,  as  Williams  of  Great  Britain,  admit  the  occurrence 
of  scarlatina  in  animals,  and  the  hope  has  arisen  that  since  small-pox  is 
modified  in  cattle  so  as  to  afford  us  the  vaccine  virus,  perhaps  scarlet  fever 
may  also  be  modified  by  passing  through  one  of  the  lower  animals,  so 
that  a  milder  and  less  fatal  form  of  the  disease  might  be  produced  in  man 
by  inoculation  from  the  animal.  This  theory,  though  it  deserves  investi- 
gation, is  far  from  being  established.  It  has  not  yet,  so  far  as  I  am 
aware,  been  shown  that  scarlet  fever  is  milder  in  any  animal  than  in  man, 
nor,  if  we  admit  that  it  is  modified  in  the  animal,  is  it  certain  that  the 
disease  could  be  returned  to  man  in  the  modified  form.  In  the  N.  Y. 
Medical  Record  for  March  24,  1883,  some  experiments  are  detailed  by  S. 
W.  Strickler  of  Orange,  New  Jersey.  He  cites  the  experiments  of  Gaze 
and  Feltz,  who  injected  scarlatinal  blood  under  the  skin  of  sixty-six  rab- 
bits, and  of  these  sixty-two  died  within  eighteen  hours  to  fourteen  days, 
which  indicated  a  highly  poisonous  state  of  the  blood  employed,  either 
septic  or  scarlatinous,  and  certainly  no  mitigation  of  the  virulence  of  the 
scarlet  fever.  Strickler  obtained  from  Williams  of  Edinburgh  nasal 
mucus  from  a  horse  supposed  to  have  scarlatina,  and  with  it  inocu- 
lated twelve  children,  all  of  whom  had  sores  at  the  point  of  inoculation, 
with  redness  of  the  skin  around  the  sores,  and  in  some  instances  swelling 
of  the  adjacent  lymphatic  glands.  It  is  stated  that  the  children  thus 
inoculated  did  not  contract  scarlet  fever  subsequeutly  when  they  were 
exposed  to  scarlatina.  Obviously,  there  is  a  serious  objection  to  such 
experiments  upon  children,  so  that  they  may  not  be  repeated,  but  a  move- 
ment has  been  made  in  one  of  the  New  York  medical  societies  look- 
ing to  the  appointment  of  a  competent  committee  to  investigate  them. 
Some  of  the  prominent  veterinary  surgeons  of  this  city  do  not  attach 
much  importance  to  the  experiments  thus  far  made,  as  they  are  in  doubt 
whether  the  virus  employed  was  that  of  the  genuine  disease. 

It  is  a  matter  of  great  interest  and  importance,  and  one  not  yet  eluci- 
dated, whether  or  to  what  extent  disinfectant  and  antiseptic  remedies 
administered  internally  prevent  the  occurrence  of  the  infectious  maladies 


TEE  A  TMENT.—PR  OPHYLAXIS.  537 

in  those  who  have  been  exposed,  and  aid  in  curing  those  who  are  sick 
with  them.  Sodium  sulpho-carbolate,  from  which,  by  decomposition  in 
the  system,  carbolic  acid  is  supposed  to  be  set  free,  has  been  used  for 
this  purpose.  It  is  administered  to  adults  in  doses  of  ten  to  thirty 
grains,  and  to  children  in  doses  proportionate  to  their  age.  Declat 
has  prepared  a  syrup  of  phenic  (carbolic)  acid  as  a  preventive  and  cura- 
tive agent  in  the  infectious  diseases.  It  is  now  employed  by  several  of 
the  New  York  physicians,  but  thus  far  the  statistics  of  its  use  are  not 
sufficient  to  determine  its  efficacy.  It  is  a  question  whether  the  so-called 
antiseptics  can,  on  account  of  their  toxic  properties,  be  used  with  safety 
in  doses  sufficiently  large  to  be  antidotal  to  the  specific  principle  of  any 
of  the  infectious  maladies. 

It  is  not  my  intention  to  recommend  in  this  treatise  any  remedial 
agent  that  has  not  been  fully  tried  and  its  efficacy  determined;  but 
from  observations  made  by  myself  in  nearly  twenty  families  in  which 
scarlet  fever  was  prevailing,  I  am  convinced  that  boracic  acid  (acidum 
boricum),  an  antiseptic  recently  introduced  into  our  Pharmacopoeia, 
deserves  trial  as  a  preventive  and  antidote  of  scarlet  fever  as  well  as 
diphtheria.  The  good  result  in  my  practice  from  the  use  of  this  agent, 
which  only  extends  over  about  six  months,  may  be  due  to  the  present 
type  of  scarlet  fever,  but  I  have  been  surprised  at  the  favorable  progress 
of  the  cases  which  appeared  very  grave  in  the  beginning,  at  the  small 
mortality,  and  at  the  large  proportion  of  well  children  exposed  to  scarlat- 
inous cases  that  escaped  infection,  to  whom  this  medicine  was  regularly 
administered.  Boric  (boracic)  acid  has  been  recently  used  by  aurists  with 
remarkable  success  in  suppurating  and  granulating  otitis  media,  and  by 
occulists  as  an  eye-wash.  E.  R.  Squibbs  says  of  it  (Ephemeris,  May, 
1883) :  "A  solution  saturated  at  ordinary  temperatures  contains  between 

4  and  5  per  cent It  is  a  very  bland  and  soothing  application, 

whether  applied  in  powder  or  solution,  relieving  irritation  and  reducing 

suppuration It  has  been  administered  internally  in  large  doses  without 

any  disturbing  effects."  The  preparation  which  I  have  employed  is  one 
found  in  the  shops,  with  the  name  listerine,  prepared  by  a  Western  phar- 
maceutical firm.  It  contains,  according  to  the  manufacturers,  the  "essen- 
tial antiseptic  constituents  of  thyme,  eucalyptus,  baptisia,  gaultheria,  and 
mentha  arvensis,"  and  also  two  grains  of  benzo-boracic  acid  in  each  drachm. 
The  dose  of  listeriue  which  I  have  employed  for  an  adult  is  one  teaspoon- 
ful,  considerably  diluted  with  cold  water.  A  child  of  five  years  can 
take  ten  to  fifteen  drops  every  two  to  four  hours.  I  call  the  attention 
of  the  profession  to  the  use  of  boracic  acid  as  an  antidote  to  the  scarlat- 
inous poison,  without  sufficient  experience  to  enable  me  to  speak  posi- 
tively of  its  efficacy,  but  with  the  hope  and  expectation,  from  observing 
its  apparent  effects  in  seventeen  families  afflicted  with  scarlet  fever,  that  it 
will  be  found  a  useful  addition  to  our  means  of  controlling  this  much- 
dreaded  and  fatal  malady. 

In  the  present  state  of  our  knowledge  the  most  reliable  and  certain 
prophylaxis  is  the  isolation  of  patient  and  nurses,  and  the  thorough  and 
judicious  employment  of  disinfectants  upon  their  persons  and  in  the 
apartments.  All  furniture  and  articles  not  absolutely  required  should  be 
removed  from  the  sick  room,  and  no  one  should  be  allowed  to  enter  it 
except  the  medical  attendant  and  nurses.  Constant  ventilation  should  be 


538  SCARLET  FEVER. 

insisted  on  by  lowering  the  upper  and  raising  the  lower  sash  of  the 
window  two  or  three  inches  in  mild  weather.  Even  in  stormy  weather 
sufficient  ventilation  can  be  obtained  in  this  way  without  exposing  the 
patient  to  currents  of  air,  which  should  be  avoided. 

Since  the  exhalations  from  the  body,  the  various  excretions,  and  the 
epidermic  cells  shed  so  abundantly  in  the  desquamative  period  contain 
the  scarlatinous  poison,  measures  should  be  employed  to  disinfect  them, 
in  so  far  as  the  comfort  and  well-being  of  the  patient  will  allow.  Vessels 
which  receive  the  excretions  should  contain  carbolic  acid,  chloride  of  lime 
or  other  disinfectant,  and  they  should  be  immediately  emptied  and 
cleaned  after  use.  By  the  frequent  application  of  disinfecting  washes 
to  the  nostrils  and  fauces  the  secretions  from  these  surfaces  are  to  a 
great  extent  deprived  of  their  contagiousness.  If  otorrhoea  occur, 
boracic  acid,  so  serviceable  in  its  treatment,  acts  as  a  disinfectant,  but 
in  addition  the  ear  should  be  syringed  with  warm  carbolized  water,  one 
drachm  of  carbolic  acid  to  the  pint  of  water,  and  this  should  be  continued 
during  convalescence,  for  cases  occur  which  show  that  the  discharge  from 
the  ear  is  probably  the  vehicle  by  which  the  virus  is  communicated. 
Even  as  late  as  the  fourth  week  after  the  disappearance  of  the  rash  children 
in  scarlet  fever  experience  relief  from  inunction  of  the  surface,  and  if 
carbolic  acid  be  added  to  the  substance  which  is  employed  for  this  purpose, 
and  the  inunction  be  made  twice  daily  over  the  entire  surface,  contamina- 
tion of  the  air  through  the  exfoliations  and  exhalations  from  the  skin  is 
in  great  part  prevented.  The  late  William  Budd  of  Bristol,  England, 
was  in  the  habit  of  recommending  inunction  of  the  surface  twice  daily 
with  sweet  oil,  which  answered  the  purpose  of  preventing  dissemination 
of  epidermic  particles  through  the  air ;  and  we  will  presently  see  how 
successful  were  his  precautionary  measures. 

A  convalescent  child  should  not  be  allowed  to  mingle  with  other  chil- 
dren till  three  or  four  weeks  have  elapsed  and  desquamatiou  has  ceased  ; 
and  all  who  are  liable  to  take  the  malady  should  be  excluded  from  the 
room  in  which  a  case  has  occurred  for  a  longer  period,  and  until  it  has 
been  thoroughly  disinfected  by  burning  sulphur  or  other  methods. 

The  New  York  Board  of  Health  enforces  the  following  excellent  regu- 
lations to  prevent  the  spread  of  scarlet  fever  as  well  as  other  acute  infec- 
tious maladies : 

"  Care  of  Patients. — The  patient  should  be  placed  in  a  separate  room, 
and  no  person  except  the  physician,  nurse,  or  mother  allowed  to  enter  the 
room  or  to  touch  the  bedding  or  clothing  used  in  the  sick-room  until  they 
have  been  thoroughly  disinfected. 

"  Infected  Articles. — All  clothing,  bedding,  or  other  articles  not  abso- 
lutely necessary  for  the  use  of  the  patient  should  be  removed  from  the 
sick  room.  Articles  used  about  the  patients,  such  as  sheets,  pillow-cases, 
blankets,  or  clothes,  must  not  be  removed  from  the  sick  room  until  they 
have  been  disinfected  by  placing  them  in  a  tub  with  the  following  disin- 
fecting fluid;  eight  ounces  of  sulphate  of  zinc,  one  ounce  of  carbolic 
acid,  three  gallons  of  water.  They  should  be  soaked  in  this  fluid  for  at 
least  an  hour,  and  then  placed  in  boiling  water  for  washing. 

"A  piece  of  muslin  one  foot  square  should  be  dipped  in  the  same  solu- 
tion and  suspended  in  the  sick  room  constantly,  and  the  same  should  be 
done  in  the  hallway  adjoining  the  sick  room. 


HYGIENIC  TREATMENT.— THERAPEUTIC  TREATMENT.      539 

"  All  vessels  used  for  receiving  the  discharges  of  patients  should  have 
some  of  the  same  disinfecting  fluid  constantly  therein,  and  immediate!} 
after  being  used  by  the  patient  should  be  emptied  and  cleansed  with  boil- 
ing water.  Water-closets  and  privies  should  also  be  disinfected  daily 
with  the  same  fluid  or  a  solution  of  chloride  of  iron,  one  pound  to  a 
gallon  of  water,  adding  one  or  two  ounces  of  carbolic  acid. 

"  All  straw  beds  should  be  burned. 

"  It  is  advised  not  to  use  handkerchiefs  about  the  patients,  but  rather 
soft  rags,  for  cleansing  the  nostrils  and  mouth,  which  should  be  immedi- 
ately thereafter  burned. 

"  The  ceilings  and  side-walls  of  a  sick-room  after  removal  of  the 
patient  should  be  thoroughly  cleaned  and  lime-washed,  and  the  wood- 
work and  floor  thoroughly  scrubbed  with  soap  and  water." 

By  such  measures  of  prevention  there  can  be  no  doubt  that  the  number 
of  cases  of  scarlet  fever  would  be  greatly  reduced. 

Budd  for  years  recommended  similar  precautions  in  the  families 
which  he  attended,  and  the  following  is  his  testimony  in  regard  to  the 
result :  "  The  success  of  this  method  in  my  own  hands  has  been  very 
remarkable.  For  a  period  of  nearly  twenty  years,  during  which  I  have 
employed  it  in  a  very  wide  field,  I  have  never  known  the  disease  to  spread 
beyond  the  sick-room  in  a  single  instance,  and  in  very  few  instances 
within  it.  Time  after  time  I  have  treated  this  fever  in  houses  crowded 
from  attic  to  basement  with  children  and  others,  who  have  nevertheless 
escaped  infection.  The  two  elements  in  the  method  are  separation  on 
the  one  hand,  and  disinfection  on  the  other." ' 

HYGIENIC  TREATMENT. — The  room  occupied  by  a  scarlatinous  patient 
should  be  commodious  and  sufficiently  ventilated.  Its  temperature  should 
be  uniform  at  about  70°  during  the  course  of  the  fever.  When  the  fever 
begins  to  abate  and  desquamation  commences,  a  temperature  of  72°  to  75° 
is  preferable,  so  that  there  is  less  danger  that  the  surface  may  be  chilled 
during  unguarded  moments,  as  at  night,  when  the  body  may  be  accident- 
ally uncovered,  since  sudden  cooling  of  the  surface  at  this  time  may 
cause  nephritis  or  some  other  dangerous  inflammation.  Henoch  does 
not  believe  in  the  theory  that  the  nephritis  is  commonly  produced  by 
catching  cold,  but  many  observations  show  that  those  who  are  carefully 
protected  from  vicissitudes  of  temperature,  who  remain  during  conva- 
lescence in  a  warm  room,  and  are  protected  by  abundant  clothing,  more 
frequently  escape  this  complication  than  such  as  are  under  no  restraint 
of  this  kind  and  are  carelessly  exposed  in  times  of  changeable  weather. 
Nevertheless,  it  is  true  that  a  certain  proportion  suffer  from  nephritis 
however  judicious  the  after-treatment  may  be.  The  best  hygienic  man- 
agement does  not  always  prevent  its  occurrence.  The  patient  should 
not,  therefore,  leave  the  house  until  four  weeks  after  the  beginning  of  the 
fever,  and  in  inclement  weather  not  till  a  longer  time  has  elapsed.  So 
long  as  desquamation  is  going  on  and  the  skin  has  not  regained  its  normal 
function  the  patient  should  remain  indoor,  and  when  finally  he  is  allowed 
to  leave  the  house  he  should  be  warmly  clothed. 

THERAPEUTIC  TREATMENT. — In  order  to  treat  scarlet  fever  success- 
fully it  is  necessary  to  bear  in  mind  that  it  is  a  self-limited  disease,  run- 
ning for  a  certain  time  and  through  certain  stages,  and  that  it  is  not 
1  British  Medical  Journal,  Jan.  9,  1869. 


540  SCARLET  FEVER. 

abbreviated  by  any  known  treatment.  Therapeutic  measures  can  only 
moderate  its  symptoms  and  render  it  milder.  The  seventy  of  the  disease 
is  indicated  by  its  symptoms,  and  the  symptoms  are  to  a  certain  extent 
under  our  control. 

MILD  CASES. — A  patient  with  a  temperature  under  103°,  and  with 
only  a  moderate  angina,  does  not  require  active  treatment,  but,  however 
light  the  disease,  he  should  always  be  in  bed  and  in  a  room  of  uniform 
temperature,  as  stated  above.  Instances  have  come  to  my  notice  in  the 
poor  families  of  New  York  in  which  scarlet  fever  was  not  diagnosticated, 
and  the  patients  were  allowed  to  go  about  the  house,  and  even  in  the  open 
air,  in  the  eruptive  stage,  till  some  severe  complication  or  an  aggravation 
of  the  type  created  alarm  and  medical  advice  was  sought,  when  it 
appeared  that  a  grave  and  dangerous  condition  had,  through  carelessness 
and  ignorance,  resulted  from  a  mild  and  favorable  form  of  the  malady. 
The  physician,  when  summoned  to  a  case  however  mild,  should  never  fail 
to  take  the  temperature,  note  the  pulse,  inspect  the  fauces,  and  inquire  in 
reference  to  the  fecal  and  urinary  evacuations,  that  he  may  detect  early 
any  unfavorable  changes  which  may  occur. 

Since  in  all  cases  angina  and  more  or  less  blood-deterioration  are 
present,  the  following  prescription  will  be  found  useful  in  mild  as  well  as 
severe  scarlet  fever : 

!fy.  Potass.  Chlorat.      o\ i ; 
Tr.  Ferri  Chloridi  f^ii ; 
Syrupi  fsiv.     M. 

S.  Half  a  teaspoonful  every  hour  to  two  hours  to  a  child  of  three  years ; 
a  teaspoouful  to  a  child  of  six  years. 

Small  doses  of  this  medicine  frequently  administered  act  beneficially 
on  the  surface  of  the  throat  and  tend  to  prevent  the  anaemia  which  is 
so  common  after  scarlet  fever.  If  the  medicine  be  given  gradually 
diluted  with  only  a  moderate  amount  of  water,  the  effect  is  better 
on  the  inflamed  fauces.  Potassium  chlorate  is  known  to  be  an  irritant 
to  the  kidneys  in  large  doses,  causing  intense  hypenemia  of  these  organs, 
with  bloody  urine  or  suppression  of  urine.  The  melancholy  fate  of 
Fouutaine,  who  died  from  the  effects  of  one  ounce  of  this  medicine, 
is  known  to  the  profession.  I  have  seen  a  similar  instance  in  a 
child.  But  doses  of  one  to  four  grains,  according  to  the  age,  can 
be  administered  with  safety  to  children,  so  that  half  a  drachm  to  a 
drachm  and  a  half  are  taken  in  twenty-four  hours.  A  quantity  much 
exceeding  this  amount  involves  risk.  In  mild  cases  it  is  not  necessary  to 
treat  the  throat  by  topical  measures,  the  above  prescription  producing 
sufficient  local  effect,  but  camphorated  oil  may  be  used  externally.  I 
ordinarily  prescribe  quinine  in  small  doses  for  this  form  of  scarlatina,  as 
in  the  following  formula  : 

ty.  Quiuise  Sulphat.  gr.  xvi ; 

Ext.  Glycyrrhizse  Bss ; 

Syr.  Pruni  Virginianse   f.$ii.     M. 

S.  One  teaspoonful  every  fourth  hour  to  a  child  of  three  to  five  years, 
the  potassium  chlorate  and  iron  mixture  being  administered  twice 
between. 

The  treatment  of  scarlatina  by  antiseptic  remedies  will  be  considered 
hereafter. 


ORDINARY  CASES  AND  CASES  OF  SEVERE  TYPE.         541 

The  itching  and  dry  ness  of  the  surface,  which  increase  the  discomfort 
of  the  patient  in  mild  as  well  as  severe  scarlatina,  are  relieved  by  fre- 
quently anointing  the  whole  body  with  vaseline,  cold  cream,  or  butter  of 
cocoa.  Carbolic  acid  is  an  efficient  remedy  for  pruritus,  while  it  is  also  a 
disinfectant.  It  may  be  used  in  the  following  formula : 
3^.  Acidi  Carbolici  31 ; 

Vaseline  5iv.     M. 

S.  To  be  applied  over  the  entire  surface. 

In  New  York  leaf  lard  has  long  been  employed  as  an  unguent  over 
the  entire  surface  in  scarlet  fever,  and  patients  experience  benefit  from  it. 
Alcohol  and  water  or  vinegar  and  water  are  sometimes  employed  for  the 
same  purpose.  The  linen  should  be  changed  every  day  and  the  bed 
thoroughly  aired. 

ORDINARY  CASES  AND  CASES  OF  SEVERE  TYPE. — A  safe  tempera- 
ture in  scarlet  fever  may  be  considered  at  or  below  103°.  If  it  rise  above 
this,  measures  designed  to  abstract  heat  are  very  important — more 
important  even  in  many  cases  than  the  medicinal  agents  which  are  com- 
monly used  to  combat  this  disease.  Since  a  high  temperature  retards 
assimilation,  promotes  deleterious  tissue-change,  and  causes  rapid  emacia- 
tion and  loss  of  strength,  measures  designed  to  reduce  it  are  urgently 
needed.  "  The  production  of  heat  depends  chiefly  on  oxidation  of  the 
constituents  of  the  body"  (Billroth).  Therefore  fever  indicates  an 
increase  of  the  oxidation  and  a  molecular  disintegration  above  the  healthy 
standard.  Hence  the  augmentation  of  urea  in  the  urine  and  the  pro- 
gressive emaciation  and  loss  of  weight  which  characterize  the  febrile  state. 
Fever  also  diminishes  the  secretions  by  which  food  is  digested  and 
destroys  the  appetite,  so  that  •  repair  of  the  waste  is  insufficient.  More- 
over, a  high  temperature  continuing  for  a  time  tends  to  produce  degener- 
ative changes,  albuminous  and  fatty,  in  the  tissues,  the  more  rapidly  the 
higher  the  temperature,  so  that  the  functions  of  organs  are  seriously 
impaired.  Among  the  most  dangerous  of  the  tissue-changes  is  granulo- 
fatty  degeneration  of  the  muscular  fibres  of  the  heart.  In  dogs  and 
rabbits  that  have  perished  from  a  high  temperature  artificially  produced 
by  experimenters  granular  clouding  of  the  elementary  tissues  has  been 
found  after  death.1  A  high  temperature,  therefore,  in  itself  involves 
danger,  and  if  it  occur  in  an  ataxic  disease  like  scarlet  fever,  and  be 
protracted,  it  greatly  diminishes  the  chances  of  a  favorable  issue. 

The  temperature  can  be  reduced  without  shock  or  injury  to  the  child 
by  the  judicious  use  of  cold  water  externally.  The  cold-water  treatment 
is  not  necessary  if  the  temperature  be  under  103°,  though  useful  if 
judiciously  employed  by  sponging  when  the  temperature  is  at  102°  or 
103° ;  but  if  it  rise  above  103°  it  is  required,  and  the  more  urgently^the 
higher  the  temperature.  The  external  use  of  cold  water  as  an  antipy- 
retic in  the  febrile  diseases  is  now  almost  universally  recommended  by 
physicians,  but  it  still  meets  with  opposition  on  the  part  of  families, 
especially  in  the  treatment  of  the  exanthematic  fevers,  and  the  directions 
for  its  employment  are  therefore  not  apt  to  be  fully  carried  out  during 
the  absence  of  the  medical  attendant.  The  old  theory  that  the  fevers 
require  warmth  and  sweating  has  such  a  firm  hold  on  the  popular  mind 
that  some  years  longer  will  be  required  for  its  removal. 

1  See  experiments  by  Mr.  J.  "VV.  Legg,  Lond.  Path.  Soc.  Trans.,  vol.  xxiv.,  and  others. 


542  SCARLET  FEVER. 

The  modes  of  applying  cold  water  recommended  by  cautious  and 
experienced  physicians  are  various.  Von  Ziemssen  recommended  that 
the  patient  be  "immersed  in  water  at  a  temperature  of  90°,  and  cool 
water  be  gradually  added  till  the  temperature  fall  to  77°.  In  a  few 
minutes  the  patient  is  returned  to  his  bed,  his  surface  dried,  and  he  is 
covered  by  the  proper  bed-clothes,  when  his  temperature  will  probably 
be  found  reduced  two  or  two  and  a  half  degrees.  If  the  patient  com- 
plain of  chillness  or  his  pulse  be  feeble,  he  should  be  immediately  removed 
from  the  bath  and  stimulants  administered,  either  whiskey  or  brandy,  for 
if  the  extremities  remain  cool  and  the  capillary  circulation  sluggish,  the 
effect  may  be  injurious,  since  some  internal  inflammation  may  arise  to 
complicate  the  fever.  Under  such  circumstances  increased  alcoholic  stim- 
ulation is  required. 

The  cold  pack  is  also  effectual  for  reducing  the  temperature.  The 
patient  is  placed  upon  a  mattrass  protected  by  oil-cloth,  and  is  covered 
by  a  sheet  wrung  out  of  water  at  a  temperature  of  70°.  This  is  covered 
by  one  or  two  blankets.  In  half  an  hour  he  is  returned  to  bed,  and  will 
be  found  to  have  a  temperature  two  or  three  degrees  less  than  that  before 
the  bath.  Another  method  is  to  apply  the  sheet  wrung  out  of  water  at 
90°,  and  then  reduce  the  temperature  by  adding  water  at  a  lower  degree 
from  a  sprinkler.  In  most  cases,  however,  I  prefer  to  reduce  the  tem- 
perature by  the  constant  application  to  the  head  of  an  india-rubber  bag 
containing  ice.  The  bag  should  be  about  one-third  filled,  so  that  it 
should  fit  over  the  head  like  a  cap.  At  the  same  time,  as  a  potent  means 
of  abstracting  heat,  at  least  when  the  temperature  is  at  or  above  104°,  a 
similar  application  should  be  made  by  an  elongated  rubber  bag  lying  over 
the  neck  and  extending  from  ear  to  ear.  Cold  applied  over  the  great 
vessels  of  the  neck  promptly  abstracts  heat  from  the  blood,  while  it 
diminishes  the  pharyngitis,  adenitis,  and  cellulitis ;  which  is  an  import- 
ant gain.  At  the  same  time,  it  is  proper  to  sponge  frequently  the  hands 
and  arms  with  cool  water.  If  the  temperature  with  this  treatment  be 
not  sufficiently  reduced,  one  or  two  thicknesses  of  muslin  frequently 
wrung  out  of  ice-water  should  be  placed  along  the  arms  and  upon  either 
side  of  the  face.  By  such  local  measures,  which  are  agreeable  to  the 
patient  and  without  any  shock  or  perturbing  effect  on  the  system,  we 
can  reduce  the  temperature  two  or  three  degrees.  By  adding  alcohol  or 
one  of  the  alcoholic  compounds  to  the  water  the  popular  objection  to  the 
use  of  cold  is  overcome. 

Trousseau,  in  the  treatment  of  sthenic  cases  attended  by  a  high  tem- 
perature, was  in  the  habit  of  placing  the  patient  naked  in  a  bath-tub  and 
directing  three  or  four  pailsful  of  water  to  be  thrown  over  him  in  a 
space  of  time  varying  from  one  quarter  of  a  minute  to  one  minute,  after 
which  he  was  returned  to  bed  and  covered  by  the  bed-clothes  without 
being  dried.  Reaction  immediately  occurred,  often  with  more  or  less 
perspiration.  This  treatment  was  repeated  once  or  twice  daily,  according 
to  the  gravity  of  the  symptoms.  Trousseau,  alluding  to  this  treatment, 
says :  "  I  have  never  administered  it  without  deriving  some  benefit." 
But  the  application  of  cold  water  in  a  manner  that  does  not  excite 
or  frighten  the  patient  seems  preferable.  Henoch,  having  a  large 
experience^  gives  the  following  advice  in  reference  to  the  water  treat- 
ment :  "If  the  fever  continue  high  and  the  apparently  malignant  symp- 


ORDINARY  CASES  AND  CASES  OF  SEVERE  TYPE.          543 

toms  described  above  develop,  the  head  should  be  covered  with  an 
ice-bag,  ....  and  the  child  placed  in  a  lukewarm  bath,  not  under  25°  R. 
(88.25°  F.).  I  decidedly  oppose  cooler  baths,  because  in  scarlatina,  which 
presents  a  tendency  to  heart-failure,  cold  may  produce  an  unexpected 
rapid  collapse  more  than  in  any  other  affection.  But  I  strongly 
recommend  washing  the  entire  body  every  three  hours  with  a  sponge 
dipped  in  cool  water  and  vinegar."1  In  grave  cases  with  a  high 
temperature  the  application  of  cold  should  be  sufficient  to  produce  a 
decided  reduction  of  heat,  otherwise  the  full  benefit  from  its  use  is  not 
obtained.  "With  proper  stimulation  and  proper  precautions  prostration 
does  not  occur  from  the  ice-bags  to  the  head  and  neck  and  cool  sponging 
of  other  parts,  so  long  as  the  temperature  does  not  fall  below  102°  or 
103°.  The  danger  alluded  to  by  Heuoch  can  only  occur  from  the  use 
of  the  pack  or  general  bath,  and  the  water  treatment  can  be  efficiently 
carried  out  and  the  temperature  sufficiently  reduced  without  resorting 
to  these.  Even  Currie  of  Edinburgh,  who  first  drew  attention  to  the 
benefit  from  the  cold-water  treatment  of  scarlet  fever  in  an  age  when  the 
sweating  treatment,  and  even  the  exclusion  of  cool  and  fresh  air  from  the 
apartment,  were  deemed  necessary,  recommended  cold  affusion  only  in 
sthenic  cases  with  full  and  strong  pulse,  and  he  mentions  as  a  warning 
two  cases  with  quick  and  feeble  pulse  and  cool  extremities  in  which 
death  occurred  immediately  after  the  use  of  the  water. 

Sodium  salicylate  is  in  some  instances  a  useful  remedy  for  the  reduc- 
tion of  heat  in  the  infectious  diseases.  It  seems  to  be  more  decidedly 
antipyretic  than  quinine  in  the  febrile  and  inflammatory  diseases,  though 
somewhat  depressing  to  the  heart's  action.  James  Couldrey  writes 
to  the  London  Lancet  (Dec.,  1882,  p.  1064)  that  he  has  derived  great 
benefit  from  its  use  in  seven  cases  of  scarlet  fever.  He  administered  it 
every  two  hours  till  ringing  in  the  ears  was  produced,  and  afterward 
every  four  hours,  prescribing  one  grain  for  each  year  in  the  age  of  the 
patient.  It  is,  in  my  opinion,  a  proper  remedy  when  the  pulse  is  full 
and  strong  and  the  temperature  is  not  sufficiently  reduced  by  the  cold- 
water  treatment. 

Aconite  and  veratrum  viride  reduce  fever,  but  they  are  too  depressing 
to  be  safely  employed  in  grave  scarlet  fever,  and  their  antipyretic  effect  is 
less  than  that  of  water.  The  use  of  digitalis  might  be  suggested  by  the 
quick  and  feeble  pulse  in  certain  cases  that  are  attended  by  high  temper- 
ature, but  the  judgment  of  the  profession  is  for  the  most  part  against  its 
use  in  such  cases.  What  Stille  and  Maisch  state  of  its  employment  in 
typhoid  fever  appears  equally  applicable  to  scarlet  fever:  "Even  its 
advocates  have  not  shown  that  it  abridges  the  disease  or  lessens ^  its 
mortality,  while  it  is  abundantly  demonstrated  to  impair  the  digestion, 
reduce  the  strength,  and  even  to  occasion  sudden  death.  The  use  of 
digitalis  in  other  forms  of  fever  is  equally  unsatisfactory,  and  justifies 
the  judgment  of  Traube,  that  the  true  field  of  action  for  digitalis  is  not 
fever." 

Quinine  is  the  medicine  which  above  all  others  has  been  heretofore 
most  used,  by  almost  common  consent  of  the  profession,  to  reduce  the 
temperature  in  malignant  scarlet  fever,  but  its  use  for  this  purpose  is, 
according  to  my  observations,  far  from  satisfactory.  To  obtain  its  anti- 

lDiseases  of  Children. 


544  SCARLET  FEVER. 

pyretic  action  it  must  be  administered  in  large  doses,  and  if  any  of  the 
quinine  salts  in  ordinary  use  be  administered  by  the  mouth  in  sufficient 
quantity,  they  are  apt  to  be  vomited.  To  a  child  of  five  years  five  grains 
should* be  administered  twice  daily  by  the  mouth,  or  ten  grains  of  a 
soluble  salt,  as  the  bisulphate,  may  be  given  per  rectum,  dissolved  in  a 
little  warm  water.  Administered  per  rectum,  it  is  frequently  not 
retained  unless  held  for  a  time  by  a  napkin.  A  considerable  proportion 
of  the  malignant  cases  are  attended  by  not  only  irritability  of  the 
stomach,  already  alluded  to,  but  by  diarrhoea,  so  that  quinine,  if  admin- 
istered at  all,  should  be  employed  hypodermically.  The  double  salt  of 
quinia  and  urea  answers  for  this  purpose,  as  it  is  very  soluble  in  water 
and  does  not  produce  inflammation  of  the  connective  tissue.  When  the 
antipyretic  doses  of  quinine  are  discontinued,  this  agent  may  be  pre- 
scribed as  a  tonic  in  the  doses  recommended  for  the  treatment  of  mild 
scarlet  fever. 

In  severe  cases  with  frequent  and  rapid  pulse,  in  which  ante-mortem 
heart-clots  are  apt  to  occur,  the  ammonium  carbonate  is  often  useful.  It 
should  be  dissolved  in  water  and  given  in  milk,  in  as  large  doses  as  five 
grains  every  hour  or  second  hour  to  a  child  of  five  years.  It  aids  in 
producing  stronger  contraction  of  the  cardiac  muscular  fibres,  and  thus 
diminishes  the  danger  of  the  formation  of  thrombi.  Ten-drop  doses  of 
the  aromatic  spirits  of  ammonia  may  be  employed  instead  of  the  car- 
bonate, given  in  sweetened  water.  It  is  especially  useful  if  the  stomach 
be  irritable. 

In  severe  cases  attended  by  considerable  angina  and  foul  and  offensive 
secretions  upon  the  faucial  surface  an  antiseptic,  as  boracic  acid  in  small 
quantity,  should  be  added  to  the  potash  and  iron  mixture  recommended 
above.  If  no  drink  be  allowed  for  a  few  minutes  after  the  dose,  so  as 
not  to  wash  it  too  soon  from  the  fauces,  the  antiseptic  effect  is  more  cer- 
tainly produced.  Those  old  enough  should  be  directed  to  hold  the  medi- 
cine for  a  moment  like  a  gargle  in  the  throat  before  swallowing  it.  I 
employ  boracic  acid  by  preference,  as  in  the  following  formula : 
fy.  Acid.  Boracic.  3ss  ; 

Potass.  Chlorat.  3ii  ; 
Tr.  Ferri  Chloridi  f  sii ; 
Glycerinse, 

Syrupi  da.  f  si ; 

Aquae  fsii.     M. 

S.  Give  one  tablespoonful  every  two  hours  to  a  child  of  five  years. 

More  minute  directions  will  presently  be  given  for  the  treatment  of 
the  pharyngitis  when  we  speak  of  the  complications. 

Alcohol,  whether  administered  in  one  of  the  stronger  wines,  as  sherry, 
or  in  whisky  or  brandy,  is  a  most  useful  remedy  in  scarlet  fever,  and  is 
indeed  indispensable  in  all  grave  cases  which  are  attended  by  feeble  capil- 
lary circulation  and  evidences  of  prostration.  Milk  is  also  the  best 
vehicle  for  this  agent.  The  wine-whey  or  milk-punch  should  be  given 
every  hour  or  second  hour.  In  scarlet  fever,  as  well  as  diphtheria,  com- 
paratively large  doses  are  required,  as  a  teaspoonful  of  the  stimulant 
every  hour  or  second  hour  for  a  child  of  five  years. 

During  convalescence  the  hygienic  treatment  already  described  is 
important.  Nutritious  diet  and  a  moderate  amount  of  alcoholic  stimu- 


TREATMENT  OF  COMPLICATIONS  AND  SEQUELS.  545 

ix  are  required,  while  the  patient  is  kept  indoors  and  protected  from 
currents  of  air  as  long  as  desquamation  is  occurring.  More  or  less 
anaemia,  is  present  in  most  convalescent  patients,  so  that  a  mild  tonic 
containing  iron  will  aid  in  restoring  the  health.  Elixir  of  calisaya-bark 
and  iron ;  preparations  of  beef,  iron,  and  wine,  or  the  following  prescrip- 
tion, will  be  found  useful  under  such  circumstances  : 
1$!.  Ferri  et  Ammon.  Citrat., 

Ammon.  Carbonat.  da.  gr.xxiv; 

Syrupi  f  gi ; 

Aquae  fgii.     M. 

S.  Dose,  one  or  two  teaspoonsful,  according  to  the  age,  every  third  hour. 
ANTISEPTIC  TREATMENT. — It  is  still  to  be  determined  whether  or  to 
what  extent  antiseptics,  administered  internally,  antagonize  and  control 
the  scarlatinous  poison,  and  are  therefore  curative  of  scarlet  fever.  The 
most  important  agent  of  this  class,  carbolic  acid,  can  only  be  employed  in 
small  doses,  for  a  dose  much  exceeding  a  drop  for  a  child,  or  even  exceed- 
ing a  fractional  part  of  a  drop  for  a  young  child,  might  produce  poisonous 
symptoms.  Carbolic  acid  is  a  cardiac  and  arterial  sedative,  and  it  appears 
to  reduce  temperature.  Intra-uterine  injections  of  carbolized  water  in  the 
treatment  of  puerperal  fever  are  known  to  reduce  temperature,  even  when 
there  is  no  septic  matter  in  the  uterus  to  be  disinfected  and  washed  away, 
as  in  a  case  related  to  me  in  which  the  fever  proved  to  be  due  to  measles. 
It  is  not  improbable  that  the  antipyretic  action  in  patients  of  this  class  who 
have  no  septic  substance  within  the  uterus  is  due  largely,  if  not  mainly, 
to  the  absorption  of  carbolic  acid  from  the  uterine  surface  and  its  sedative 
action  on  the  vascular  system.  Whether  this  agent,  so  highly  extolled  by 
Declat,  and  to  which  I  have  alluded  in  a  preceding  page,  can  be  safely 
employed  in  doses  large  enough  to  be  efficient  and  curative  will  be  deter- 
mined by  future  observations.  The  same  remark  is  applicable  to  the 
sulpliocarbolate  of  sodium,  whose  antiseptic  action  is  supposed  to  be  due, 
as  already  stated,  to  the  liberation  of  carbolic  acid  in  the  system.  Since 
boracic  acid  does  not  seem  to  have  any  deleterious  action,  this  agent  has 
been  administered  to  most  of  my  scarlatinous  patients  during  the  last 
year,  in  addition  to  the  older  and  better  known  remedies,  and  with  a  very 
small  percentage  of  deaths.  What  may  be  the  result  in  a  more  severe 
type  of  the  disease  remains  to  be  seen. 

TREATMENT  OF  COMPLICATIONS  AND  SEQUELS. — Local  measures 
designed  to  diminish  or  cure  the  pharyngitis  are  important  in  all 
but  the  mildest  cases.  They  are  more  especially  required  in  the 
anginose  variety  and  in  those  not  infrequent  cases  in  which  diphtheria 
complicates  scarlatina.  Formerly  it  was  necessary,  in  making  applica- 
tions to  the  fauces,  to  employ  the  brush  or  probang  for  those  too  young 
to  use  the  gargle,  but  hand-atomizers,  as  Eichardson's  or  Delano's,  which 
are  now  in  common  use,  aiford  a  quick  and  easy  method  for  making  such 
applications.  Six  or  eight  compressions  of  the  bulb  of  a  good  atomizer 
are  sufficient  to  cover  the  fauces  with  the  spray.  Those  hand-atomizers 
in  the  shops  which  have  slender  metallic  points  are  apt  to  prick  the 
buccal  surface  and  cause  bleeding  if  the  child  resist  and  toss  the  head. 
To  prevent  this,  I  am  in  the  habit  of  directing  india-rubber  tubing  to  be 
drawn  over  the  point  in  such  a  way  as  not  to  obstruct  its  action.  The  fol- 
lowing will  be  found  useful  mixtures  for  the  atomizer  :  For  ordinary  cases, 

VOL.  I.— 35 


546  SCARLET  FEVER. 

~Bp.  Acidi  Carbolici    3ss,  vel.  Acid.  Boracic.  gii ; 
Potass.  Chlorat.  3ii ; 
Glycerinae  f  511 ; 

Aquae  flvi.     M. 

If  the  surface  of  the  throat  be  covered  by  foul  secretions, 
~Bp.  Acidi  Carbolici     3ss ; 
Potass.  Chlorat.    sii ; 
Glycerinae  f  3J ; 

Aquae  Calcis       f 3vii.     M. 
Or  else 

!fy.  Tine.  Ferri  Chloridi  f  |ss ; 
Acidi  Sulphurosi  foii ; 
Potass.  Chlorat.  oii ; 

Glycerinae  f  si ; 

Aquae  q.  s.  ad.  f svi.     M. 

If  diphtheritic  exudation  complicate  the  scarlatinous  angina,  or  the  sur- 
face of  the  throat  in  consequence  of  ulceration  or  necrosis  present  an 
appearance  like  that  in  diphtheria  when  the  exudation  begins  to  soften, 
being  foul,  jagged,  of  a  dirty  brown  appearance  from  dead  matter  and 
fetid  secretions,  the  following  should  be  prescribed  for  use  in  the 
atomizer : 

]$!.  Acidi  Carbolici       31,  vel.  Acidi  Boraci  £iii ; 
Liq.  Potassae         f&i ; 
Potass.  Chlorat.      3ii ; 
Glycerinae  f  |ii ; 

Aquae  Calcis          f  o"viii.     M. 

Liquor  potassae,  although  a  very  efficient  solvent  of  pseudo-membranes,  is 
too  irritating  for  use  in  the  atomizer  unless  largely  diluted.  One  part  to 
eighty,  as  in  the  above  mixture,  will  not  be  found  too  concentrated.  The 
following  powder,  used  every  third  hour  through  the  insufflator,  is  also 
useful  in  cases  of  diphtheritic  exudation  : 

Ify.  Acidi  Salicylici  3ii ; 

Bismuth.  Subnitrat.  3*ii.     M. 

To  be  used  every  third  hour.  It  is  the  favorite  remedy  of  some  of  the 
prominent  New  York  physicians  in  the  local  treatment  of  diphtheria. 

The  following  mixture  is  also  beneficial  for  local  treatment  when  the 
faucial  surface  is  foul  and  offensive  from  the  exudations  and  secretions. 
It  should  be  applied  by  a  large  camel's-hair  pencil  every  three  to  six 
hours : 

fy.  Acidi  Carbolici  gtt.  x ; 

Liq.  Ferri  Subsulphatis  f  5'n  • 
Glycerinse  f§i.     M. 

In  all  cases  of  scarlatinous  pharyngitis  sufficiently  severe  to  require 
special  treatment,  cool  applications  should  be  made  over  the  neck  from  ear 
to  ear,  as  by  two  thicknesses  of  muslin  frequently  squeezed  out  of  cold 
water,  or  by  the  elongated  india-rubber  bag  already  recommended  in  our 
remarks  relating  to  methods  to  reduce  temperature. 

In  the  first  days  of  scarlet  fever  the  coryza  is  slight,  and  no  dis- 
charge from  the  nostrils  occurs,  so  that  no  local  treatment  is  required ; 
but  before  the  termination  of  the  malady,  in  cases  of  ordinary  gravity,  a 
nasal  discharge  usually  supervenes,  producing  more  or  less  redness  and 


TREATMENT  OF  COMPLICATIONS  AND  SEQUELS.  547 

excoriating  the  upper  lip.  Moreover,  in  localities  where  diphtheria 
occurs,  if  this  malady  complicate  scarlet  fever,  it  is  apt  to  affect  the  nos- 
trils at  the  same  time  that  the  fauces  are  invaded.  These  conditions 
require  local  treatment  of  the  nares.  It  should  be  remembered  that  the 
Schueiderian  membrane  is  midway  in  sensitiveness,  as  it  is  in  location, 
between  the  conjunctival  and  buccal  surfaces,  and  is  readily  irritated  by 
strong  applications.  Medicinal  applications  made  to  it  must  be  much 
milder  than  those  which  the  fauces  tolerate.  They  should  always  be  applied 
warm,  and  a  teaspoonful  of  any  mixture  properly  employed  is  sufficient 
for  each  nostril  at  one  sitting.  The  applications  should  usually  be  made 
every  two  or  four  hours,  according  to  the  gravity  of  the  case  and  the 
amount  of  discharge.  The  best  instrument  for  this  purpose  is  a  small 
syringe  of  glass  or  brass  with  curved  neck  and  bulbous  tip.  The  child's 
head  should  be  thrown  back  and  the  piston  depressed  rapidly,  so  as  to 
thoroughly  wash  out  the  nasal  cavity.  The  application  can  also  be  made 
through  an  atomizer  with  a  rounded  tip  or  a  tip  covered  by  rubber  tubing. 
The  following  is  a  useful  prescription  : 

fy.  Acidi  Carbolici  3ss; 
Sodii  Chloridi  gii ; 
Aqua?  Oj. 

The  substitution  of  2  or  3  drachms  of  boracic  acid  in  place  of  the  carbolic 
acid  makes  a  nicer  preparation.  If  the  diphtheritic  pseudo-membrane 
appear  in  the  nares,  the  officinal  lime-water,  injected  every  hour  or  second 
hour,  is  beneficial  in  consequence  of  its  solvent  action  on  pseudo-mem- 
branes. 

It  is  evident,  from  what  has  been  stated  above,  that  the  condition 
of  the  ear  should  be  closely  observed  in  and  after  scarlet  fever.  If  the 
patient  have  earache,  considerable  relief  may  be  obtained  in  the  com- 
mencement by  dropping  a  few  drops  of  laudanum  and  sweet  oil  into 
the  ear  and  covering  it  by  some  hot  application,  either  dry  or  moist, 
which  will  retain  the  heat.  A  light  bag  containing  common  table-salt, 
heated,  or  dry  and  hot  chamomile  flowers  will  also  answer  the  purpose. 
Water  as  hot  as  can  be  well  tolerated  dropped  into  the  ear  or  allowed 
to  trickle  from  a  fountain  syringe,  so  as  to  fill  the  ear,  is  also  very  bene- 
ficial in  allaying  the  pain.  If  a  few  drops  of  laudanum  be  added  it 
is  more  useful.  If  the  pain  be  not  quickly  relieved,  a  leech  should  be 
applied  at  the  base  of  the  tragus.  O.  D.  Pomeroy,  an  experienced 
aurist  of  New  York,  says :  "  Leeching  employed  at  the  right  time  rarely 
fails  to  subdue  the  pain  and  inflammation.  The  posterior  face  of  the  tra- 
gus is  ordinarily  the  best  place  for  applying  the  leech,  but  it  may  be 
applied  in  front  of  the  ear  or  behind,  wherever  the  tenderness  on  pressure 
is  greatest.  In  my  opinion,  paracentesis  may  frequently  be  rendered 
unnecessary  by  the  timely  use  of  one  or  two  leeches  applied  to  the 
nieatus." 

If  the  otitis  continue,  as  shown  by  pain  in  the  ear,  of  which  chil- 
dren old  enough  to  speak  bitterly  complain,  and  which  causes  those  too 
young  to  speak  to  press  their  fingers  into  or  against  their  ears,  this  inflam- 
mation should  not  be  neglected,  as  it  may  involve  serious  consequences. 
Multitudes  of  children  have  had  permanent  impairment  or  even  loss  of 
hearing,  with  caries  or  necrosis  of  the  walls  of  the  middle  ear  and  of  the 
mastoid  cells,  which  might  have  been  prevented  by  prompt  and  skilful 


548  SCARLET  FEVER. 

management  of  the  ear  in  the  early  stage  of  the  inflammation.  If,  there- 
fore, the  otitis  continue  without  mitigation  of  pain  after  the  alxwe 
measures  have  been  employed,  paracentesis  of  the  drumhead  is  probably 
required.  The  following  directions-  for  performing  this  operation,  which 
will  be  useful  to  country  practitioners  who  may  not  be  able  to  obtain 
the  assistance  of  a  specialist,  are  from  the  pen  of  Pomeroy :  "  The  fore- 
head mirror  should  be  worn,  in  order  to  leave  the  hands  free  to  operate 
by  either  artificial  or  day  light.  A  good-sized  speculum  is  introduced 
into  the  meatus.  Then  an  ordinary  broad  needle,  about  one  line  in  diam- 
eter, with  a  shank  of  about  two  inches,  such  as  oculists  use  for  punctur- 
ing the  cornea,  should  be  held  between  the  thumb  and  fingers,  lightly 
pressed,  so  as  not  to  dull  delicate  tactile  sensibility.  The  part  being  well 
under  light,  the  most  bulging  portion  of  the  membrane  should  be  lightly 
and  quickly  punctured  with  a  very  slight  amount  of  force.  The  poste- 
rior and  superior  portion  of  the  membrane  is  most  likely  to  bulge.  The 
chordae  tympani  nerve  ordinarily  lies  too  high  up  to  be  wounded.  The 
ossicles  are  avoided  by  selecting  a  posterior  portion  of  the  membrane. 
After  puncture  the  ear  should  be  inflated  by  an  ear-bag  whose  nozzle  is 
inserted  into  a  nostril,  both  nostrils  being  closed,  so  as  to  force  the  fluid 
from  the  tympanum.  The  puncture  may  need  to  be  repeated  at  intervals 
of  a  day  or  two,  provided  that  the  pain  and  bulging  return." 

Albert  H.  Buck  of  New  York,  in  a  highly  instructive  paper  read 
before  the  International  Medical  Congress  in  1876,  writes  as  follows  of 
paracentesis  of  the  membrana  tympani  in  scarlatinous  otitis :  "  In  this 
one  slight  operation,  which  in  itself  is  neither  dangerous  nor  very  pain- 
ful, lies  the  power  to  prevent  the  whole  train  of  disagreeable  and  danger- 
ous symptoms."  Buck  relates  an  instructive  example :  The  age  of 
the  patient  was  three  years,  and  the  earache  had  been  complained  of  only 
about  twenty-four  hours.  "  Toward  morning,"  says  he,  "  I  was  sent  for, 

as  the  pain  had  become  constant An  examination  with  the 

speculum  and  reflected  light  showed  an  cedematous  and  bulging  mem- 
brana tympaui  (posterior  half),  the  neighboring  parts  being  very  red, 
though  as  yet  but  little  swollen.  In  the  most  prominent  portion  of  the 
membrane  I  made  an  incision  scarcely  three  millimetres  (one-tenth  inch) 
in  length,  and  involving  simply  the  different  layers  of  the  membrana 
tympani.  This  was  almost  immediately  followed  by  a  watery  discharge 
(without  the  aid  of  inflation),  which  ran  down  over  the  child's  cheek.  At 
the  end  of  three  or  four  minutes  the  child  had  ceased  crying,  and  in  less 
than  a  quarter  of  an  hour  she  was  fast  asleep.  At  first,  the  discharge 
was  very  abundant  and  mainly  watery  in  character,  but  it  steadily  dimin- 
ished in  quantity  and  became  thicker,  till  finally,  on  the  fourth  day,  it 
ceased  altogether.  On  the  tenth  day  the  most  careful  examination  of  the 
ear  could  not  detect  any  trace  of  either  the  inflammation  or  the  artificial 
opening."  The  ear  had  probably  been  saved  from  nlceration  of  the  drum 
membrane,  long-continued  suppurative  otitis,  and  perhaps  from  perma- 
nent impairment  of  hearing. 

When  an  opening  has  been  made  in  the  membrana  tympani  either  by 
incision  or  ulceration,  it  is  advisable  in  some  instances  to  inflate  the  tym- 
panum by  Politzer's  method,  which  has  been  alluded  to  above.  The 
nozzle  of  an  india-rubber  bag,  with  a  flexible  tube  attached,  is  introduced 
into  the  nostril  on  the  affected  side,  and  both  nostrils  are  compressed 


TREATMENT  OF  COMPLICATIONS  AND  SEQUELS  549 

against  it.  The  patient  fills  his  mouth  with  water,  which  he  swallows  at 
a  given  signal,  as  after  the  words  one,  two,  three,  spoken  by  the  operator. 
During  the  act  of  swallowing,  which  opens  the  Eustachian  tube,  the 
rubber  bag  is  forcibly  compressed,  which  forces  the  air  along  the  tube 
into  the  middle  car  and  facilitates  the  escape  of  the  pent-up  secretions  in 
the  tympanic  cavity. 

If  the  otitis  have  continued  unchecked  by  treatment  until  the  secre- 
tions within  it,  after  days  and  nights  of  suffering,  have  escaped  by  ulcer- 
tion  through  the  drumhead,  the  opportunity  for  prompt  and  certain  cure 
is  passed.  Still,  the  patient  under  these  circumstances  may  quickly 
recover,  or  there  may  be  the  other  alternative  described  above,  in  which 
the  ear  is  badly  damaged  and  chronic  inflammation  established  in  the 
walls  of  the  tympanum,  giving  rise  to  an  offensive  otorrhoea.  In  this 
state  of  the  ear  internal  remedies  are  indicated,  such  as  surgeons  employ 
in  suppurative  inflammations  of  bone  occurring  in  other  parts  of  the 
system.  Cod-liver  oil  and  iodide  of  iron  are  required,  especially  by 
patients  of  struinous  diathesis,  the  object  being  to  promote  a  more 
healthy  state  of  system,  so  as  to  prevent  extension  of  the  inflamma- 
tion and  facilitate  the  healing  process.  Carbolized  solutions,  as  the  fol- 
lowing, syringed  warm  into  the  ear  in  which  otorrhcea  is  occurring,  are 
useful  in  promoting  cleanliness  and  increasing  the  comfort  of  the  patient : 
ty.  Acidi  Carbolici  3ss ; 

Glycerinae          f  3*ii ; 

Aquae  fsiv.     M. 

But  recently  a  much  more  effectual  curative  agent  for  local  treatment  lias 
been  discovered  in  boracic  acid,  by  the  use  of  which  the  discharge  more 
quickly  diminishes  and  the  condition  of  the  ear  more  certainly  and 
rapidly  improves  than  by  the  use  of  the  carboli/ed  mixtures.  When 
the  inflammation  is  recent  and  the  ear  sensitive  and  painful,  the  follow- 
ing prescription  should  be  used  : 

~Bf.  Acidi  Boracici  oiiss; 

Morphise  Sulphat.     gr.  i ; 
Glyceriuse, 

Aquae  da.  f  oi.     M. 

S.  Drop  one  to  three  drops  into  the  ear  three  times  daily. 

If  the  acute  stage  of  the  otitis  have  passed,  with  fever  and  pain,  and 
no  tenderness  be  present  on  pressure,  the  following  prescription,  which 
causes  too  much  pain  in  the  acute  stage,  will  be  found  useful  to  check  the 
inflammation  and  otorrhcea  and  restore  a  healthy  state  to  the  granulating 
surface: 

~fy.  Acidi  Boracici  siiss ; 

Alcohol. 

Aquae  cia.  f  si. 

S.  Drop  one  to  three  drops  into  the  ear  three  times  daily.  ^ 

The  beneficial  effects  observed  from  the  use  of  boracic  acid  in  aural  sur- 
gery have  given  it  nearly  the  same  position  as  a  curative  agent  to  diseases 
of  the  ear  which  atropine  holds  to  diseases  of  the  eye.  Recently,  aurists 
are  employing  finely-triturated  powder  of  boracic  acid  dusted  into  the 
ear.  The  patient  lies  Upon  the  side  with  the  affected  ear  uppermost. 
The  ear  is  thoroughly  cleaned  by  syringing  with  tepid  water,  and  by 
means  of  a  little  scoop  made  of  stiff  paper  or  pasteboard  or  the  segment 


550  SCARLET  FEVER. 

of  quill  as  much  of  the  powder  is  introduced  into  the  ear  as  would  cover 
a  five-cent  silver  piece.  By  working  the  ear  it  descends  to  the  drum- 
head. I  can  bear  witness  to  its  efficacy  in  the  otorrhrea  of  children  when 
it  is  used  in  this  manner  three  times  daily. 

The  following  astringent  has  also  been  employed  with  good  results  for 
the  otorrhcea  resulting  from  scarlet  fever  as  well  as  from  other  causes  : 
1^.  Zinci  Sulphatis, 

Aluminis  da.  gr.  v ; 

AquaB  f  3i.     M. 

A  few  drops  of  this  should  be  dropped  into  the  ear,  or,  if  the  ear  be  sen- 
sitive and  painful,  five  drops  should  be  added  to  a  teaspoonful  of  warm 
water  and  dropped  or  syringed  into  the  ear. 

But  in  recent  times  aurists  have  discovered  a  remedy  superior  to  the 
above  in  iodoform,  the  action  of  which  is  safe  and  efficient  for  protracted 
otorrhoea  with  granulations,  and  it  is  superseding  to  a  great  extent  the 
agents  heretofore  used  in  the  treatment  of  this  disease.  The  ear  should 
first  be  thoroughly  cleaned  by  syringing  with  warm  water  and  dried,  and 
iodoform,  to  which  a  little  balsam  of  Peru  is  added  to  cover  the  dis- 
agreeable odor,  should  be  pressed  down  to  the  bottom  of  the  auditory 
canal  by  any  convenient  instrument.  It  is  anodyne,  astringent,  and  dis- 
infectant, and  should  be  employed  in  a  dry  state  in  considerable  quantity. 

The  sequelpe  of  otitis  media,  such  as  granulations  sprouting  out  from 
the  drumhead,  some  of  which  may  be  of  large  size  and  are  known  as 
polypi,  may  require  treatment  by  the  aurist.  A  polypus  may  sometimes 
be  removal  by  the  forceps  or  better  by  the  snare.  Polypi  not  large  and 
favorably  located  can  sometimes  be  cured  by  an  astringent  powder,  as 
iodoform,  sulphate  of  zinc,  or  alum,  or  by  applying  the  liquid  subsul- 
phate  of  iron.  The  otitis  externa  produced  by  the  irritating  discharge 
which  flows  from  the  middle  ear  soon  disappears  when  the  flow  ceases. 

The  renal  affection,  which,  as  we  have  seen,  so  often  commences 
in  the  declining  period  of  scarlet  fever  or  during  convalescence  in 
mild  as  well  as  severe  cases,  is  frequently  more  dangerous  than  the 
primary  disease.  It  largely  increases  the  percentage  of  deaths.  A 
clear  appreciation  of  its  therapeutic  requirements  is  important,  since  by 
judicious  treatment  many  recover  who  would  inevitably  be  sacrificed 
by  improper  measures.  The  family  should  be  informed  that  the  danger 
from  scarlet  fever  does  not  cease  with  the  decline  of  the  eruption,  and 
that  the  kidneys  may  become  seriously  aifected  by  too  early  exposure  of 
the  patient  to  currents  of  air  or  sudden  changes  of  temperature,  by  which 
cutaneous  transpiration  is  checked.  He  should  therefore  be  kept  indoors 
in  a  comfortable  and  uniform  temperature  three  or  four  weeks  after  the 
termination  of  the  fever,  until  desquamation  has  entirely  ceased  and  the 
new  epidcrm  is  sufficiently  thick  and  firm  to  protect  the  surface. 
During  the  changeable  temperature  of  the  autumnal,  winter,  and  spring 
months  even  longer  confinement  at  home  may  be  advisable. 

The  nephritis  and  consequent  albuminuria  antedate  by  some  days  the 
occurrence  of  dropsy,  and  a  physician  should  never  discharge  a  scarlatin- 
ous patient  without  one  or  more  examinations  of  his  urine.  When  his 
visits  cease  the  nurse  should  be  instructed  to  make  the  examinations  by 
heat  and  nitric  acid  during  the  ensuing  month,  and  if  any  evidence,  how- 
ever alight,  appear  that  the  kidneys  are  involved,  he  should  be  notified, 


TREATMENT  OF  COMPLICATIONS  AND  SEQUELM  551 

in  order  that  appropriate  treatment  may  be  immediately  commenced. 
Early  and  correct  treatment  of  the  nephritis  is  attended  by  much  better 
results  than  delayed  treatment,  and  many  more  patients  are  doubtless  now 
saved  than  in  former  times,  when  little  attention  was  given  to  the  state 
of  the  kidneys  until  dropsy  or  other  prominent  symptoms  appeared.  I 
have  found  no  mother  or  nurse  so  ignorant  that  she  could  not  properly 
employ  the  test  of  nitric  acid  and  heat,  and,  if  she  be  solicitous  for  the 
welfare  of  the  child,  she  will  not  hesitate  to  carry  out  the  directions  and 
immediately  notify  the  physician  if  the  tests  employed  produce  the  least 
cloudiness  or  turbidity  of  the  urine. 

The  patient  as  soon  as  nephritis  commences,  as  shown  by  the  state  of 
the  urine,  should  be  put  to  bed  in  a  room'of  warm  and  equable  tempera- 
ture (72°  to  75°  F.).  His  diet  should  be  liquid,  consisting  of  milk,  fari- 
naceous food,  and  a  moderate  quantity  of  animal  broths.  He  may  drink 
liquids  freely,  especially  water  not  too  cool,  to  which  spiritus  aetheris  nitrosi 
is  added.  If  he  be  prostrated  by  the  primary  disease,  alcoholic  stimulants 
should  be  allowed. 

The  indications  are  to  relieve  the  hyperaemic  kidneys  by  diaphoresis 
and  purgation.  To  produce  the  former  the  patient  should  be  immersed 
in  a  warm  bath  at  about  the  temperature  of  the  body  (98°  to  100°),  in 
which,  if  he  be  quiet  and  comfortable,  he  should  remain  from  fifteen  to 
twenty  minutes,  but  if  restless  and  frightened  by  the  water  a  less  time, 
after  which  he  should  be  placed  in  a  warm  bed  and  well  covered  by 
blankets.  If  perspiration  result,  the  bath  has  been  useful,  and  it  may  be 
employed  in  grave  cases  two  or  three  times  daily.  If  perspiration  do  not 
result,  it  may  be  produced  by  surrounding  the  body  either  by  hot  dry  or 
moist  air.  Hot  dry  air  may  be  produced  by  burning  alcohol  in  a  thin 
layer  upon  a  plate  under  a  chair  upon  which  the  patient  sits  while  he  is 
surrounded  by  a  blanket,  or  he  may  be  covered  in  bed  and  the  hot  air 
introduced  under  the  bed-clothes.  In  New  York  a  convenient  apparatus 
is  used  for  this  purpose,  consisting  of  a  small  sheet-iron  pipe  enclosed  in 
a  small  box  of  the  same  material.  The  box  is  in  the  form  of  a  trunk, 
with  a  handle  for  convenience  in  carrying,  and  the  lower  end  of  the  pipe, 
which  extends  nearly  to  the  floor,  contains  an  alcohol  lamp.  Hot  moist 
air  may  be  produced  by  placing  against  the  patient  bottles  of  hot  water 
surrounded  by  towels  wrung  out  of  water.  The  steam  arising  from  them 
and  enveloping  the  body  and  limbs  produces  a  prompt  sudorific  effect. 
There  is  in  use  in  this  city,  in  the  treatment  of  these  and  similar  cases 
requiring  diaphoresis,  a  convenient  apparatus  for  generating  steam.  It 
consists  of  a  cylinder  pierced  with  holes  for  the  admission  of  air  and  con- 
taining a  spirit  lamp,  over  which  is  a  pan  or  pail  holding  a  little  water. 
The  patient,  nearly  naked,  is  placed  in  a  chair  with  the  apparatus 
underneath,  and  is  covered  by  a  blanket,  so  that  the  steam  surrounds  the 
body.  This  gives  rise  to  free  perspiration,  which  continues  after  the 
patient  is  placed  in  bed.  This  treatment  should  be  repeated  one  or  more 
times  daily,  according  to  the  gravity  of  the  case. 

The  sudorific  effect  of  the  treatment  by  external  warmth  described 
above  should  be  aided  by  employing  diaphoretics.  Those  which  have 
been  most  used  are  the  acetates  of  ammonium  and  potassium,  the  bitar- 
trate  and  citrate  of  potassium,  and  spiritus  aetheris  nitrosi.  If  employed 
when  the  surface  is  cool,  they  act  rather  as  diuretics  than  diaphoretics. 


552  SCARLET  FEVER. 

These  agents,  being  simple  in  their  action  and  without  deleterious  effects, 
may  be  given  frequently  and  in  large  proportionate  doses  for  the  age. 

But  lately  a  diaphoretic  which  far  surpasses  these  in  efficiency  has  been 
discovered  in  pilocarpine,  the  active  principle  of  jaborandi.  Being  soluble 
in  water  and  tasteless,  it  is  easily  administered,  and  is  retained  when,  on 
account  of  the  ursemic  poisoning  present  in  scarlatinous  nephritis,  the 
stomach  is  irritable  and  other  medicines,  as  digitalis,  are  rejected.  Ether 
may  be  employed  with  it,  or  the  amount  of  alcoholic  stimulant  may  be 
increased  at  the  time  of  its  exhibition  in  order  to  guard  against  any 
depressing  effect.  To  a  child  of  two  years  one-fortieth  to  one-twentieth 
of  a  grain  may  be  given  every  six  hours  by  the  mouth.  It  may  also  be 
employed  hypodermically,  as  one-twentieth  of  a  grain  to  a  child  of  five 
years.  It  has  both  a  diaphoretic  and  diuretic  action,  while  it  stimulates 
both  the  salivary  and  mucous  secretions.  According  to  one  observer,  an 
adult  when  fully  under  the  influence  of  pilocarpiue  secretes  from  one  pint 
to  one  quart  of  saliva  within  two  hours,  and  Leyden  reports  a  case  of 
diphtheritic  nephritis  in  which  the  quantity  of  urine  rose  from  half  a  pint 
to  five  pints  daily.  But  its  most  prompt  and  certain  action  is  upon  the 
sweat-glands.  Hirschfelder  speaks  of  its  beneficial  action  in  relieving 
various  forms  of  dropsy,  and  adds:  "In  one  morbid  condition  of  the 
kidney,  however,  jaboraudi  is  the  remedy  par  excellence,  and  that  is  the 

acute  parenchymatous  nephritis  which  frequently  follows  scarlatina 

This  disease  heals  spontaneously  if  the  danger  that  threatens  life  from 
reduction  of  the  urine  and  from  the  effusions  of  fluid  into  the  cavities  of 
the  body  be  averted.  In  this  disease  jaborandi  works  wonders."  I  have 
also  found  it  an  invaluable  agent  when  the  older  remedies  failed  and 
death  seemed  imminent.  The  following  cases,  in  which  the  beneficial 
action  of  this  agent  was  apparent,  occurred  in  my  practice : 

Case  8. — G ,  male,  aged  five  years  and  six  months,  sickened  with 

scarlet  fever  on  June  2,  1882.  It  began  with  vomiting,  and  was  attended 
by  a  degree  of  febrile  movement  which  indicated  an  attack  of  rather 
more  than  the  average  gravity.  The  fauces  at  one  time  exhibited 
a  slight  exudation  like  that  of  diphtheria.  In  the  declining  stage  of 
the  malady  rheumatic  pain  and  tenderness  occurred  in  the  wrist  and  fin- 
ger-joints, but  not  in  those  of  the  lower  extremities.  The  case,  however, 
progressed  favorably,  and  during  the  convalescence  my  attendance  ceased. 
On  June  24th  my  attention  was  again  called  to  the  child,  when  the  urine 
was  found  to  be  scanty  and  very  albuminous.  External  measures,  such 
as  are  described  in  the  foregoing  pages,  were  employed,  and  the  infusion 
of  digitalis  with  potassium  acetate  ordered  to  be  given  every  three  hours, 
but  this  medicine  was  for  the  most  part  vomited.  The  bowels  were  kept 
open  by  jalap  and  the  potassium  bitartrate.  The  urine,  however,  con- 
tinued scanty,  and  on  June  28th  severe  convulsions  occurred.  At  this 
time  the  quantity  of  urine  was  only  f'sij  in  twenty-four  hours.  The 
pulse  in  the  convulsions  was  quick  and  feeble,  the  skin  very  hot,  and  the 
axillary  temperature  103°.  The  eclampsia  continued  one  hour,  and  were 
controlled  by  large  and  repeated  doses  of  bromide  of  potassium,  aided  b^ 
clysters  of  five  grains  of  hydrate  of  chloral  in  water.  Muriate  of  pilo- 
earpine  -\vas  now  directed  to  be  given  in  doses  of  one-thirty-second  of  a 
grain  every  three  hours,  dissolved  in  cold  water.  This  agent  was  not 
vomited,  and  it  must  have  been  given  by  the  parents  in  their  fright  and 


TREATMENT  OF  COMPLICATIONS  AND  SEQUEL  J£.  553 

anxiety  in  larger  or  more  frequent  doses  than  were  directed,  for  on  July 
1st  the  bottle  containing  one  grain  was  empty.  Free  diaphoresis  resulted 
from  the  pilocarpine,  and  the  quantity  of  urine  was  increased.  The 
mother  stated  that  the  child  had  taken  only  two  doses,  or  one-sixteenth 
of  a  grain,  of  pilocarpiue  when  the  diuretic  effect  was  apparent  and  free 
diaphoresis  also  occurred.  She  also  stated  subsequently  that  the  quantity 
of  urine  was  larger  when  the  pilocarpine  was  administered  every  third 
hour  than  when  given  at  a  longer  interval.  A  flaxseed  poultice  on  which 
mustard  was  dusted  was  also  applied  over  the  kidneys.  On  June  29th 
the  pulse  was  96,  temperature  100.5° ;  occasional  convulsive  attacks 
occurred,  which  were  readily  controlled  by  euemata  of  hydrate  of 
chloral.  On  June  30th  the  symptoms  were  all  better ;  uo  more  attacks 
of  eclampsia  had  occurred,  and  the  urine  Avas  more  abundant  and  less 
albuminous.  The  mother  remarked  that  the  new  medicine  (pilocarpine) 
had  settled  the  stomach  and  increased  the  urine.  The  patient  continued 
to  improve,  and  on  July  4th  the  record  states:  "Now  takes  the  pilocar- 
piue, gr.  -gJg-,  every  six  hours;  passes  urine  freely  since  yesterday;  has  not 
vomited  since  he  began  to  take  the  pilocarpiue;  pulse  106,  axillary  tem- 
perature 99° ;  is  playful  and  takes  milk  freely,  nearly  three  quarts  in 
twenty-four  hours,  with  some  farinaceous  food.  Digitalis  with  potas- 
sium acetate  is  also  given  in  occasional  doses."  July  6th,  pulse  92,  tem- 
perature 99°;  perspires  much,  and  urine  nearly  normal  in  quantity  and 
character. 

Case  9, — Mary  S ,  aged  five  years,  on  Dec.  22,  1882,  presented 

the  symptoms  of  severe  nephritis.  Her  brother  had  scarlet  fever  two 
weeks  previously,  and  she  had  sore  throat  at  about  the  same  time,  but 
without  efflorescence ;  pulse  98,  temperature  98.5°;  her  urine  highly 
albuminous,  and  reduced  to  f  |iv  in  twenty-four  hours ;  bowels  consti- 
pated. Ordered  a  single  dose  of 

1^.  Hydrarg.  Chlor.  Mitis  gr.  iii ; 

Resin.  Podophylli          gr.  fa     M. 

The  muriate  of  pilocarpine  was  also  ordered,  gr.  ^  but  the  patient 
vomited  soon  after  taking  it.  Another  dose  was  retained,  and  was 
followed  by  considerable  perspiration.  Dec.  23d,  had  one  stool  from 
the  powder  of  yesterday.  Has  taken  five  doses  of  pilocarpine,  but 
vomited  after  three  of  them.  The  last  dose  was  administered  at  10 
P.  M.,  and  the  mother  says  she  "sweat  fearfully"  during  the  night.  The 
patient  was  kept  warm  in  bed;  stimulating  poultices  of  mustard  and 
fiaxseed,  one  to  sixteen,  were  constantly  in  use  over  the  kidneys,  and  the 
pilocarpine  was  administered  three  or  four  times  a  day.  The  record  for 
Dec.  26  states  :  "  Took  the  pilocarpiue  four  times  since  yesterday  morn- 
ing, and  each  dose  is  followed  by  perspiration  lasting  from  one  to  one 
and  a  half  hours  ;  quantity  of  urine,  from  f  5vj  to  f  sviij  daily ;  vomited 
twice  yesterday,  not  to-day  ;  pulse  104,  temperature  97.75°;  complains 
of  frontal  headache;  bowels  regular;  has  considerable  salivation.  The 
patient  is  warm  in  bed,  and  the  flaxseed  and  mustard  poultice  over  the 
kidneys  is  continued.  Dec.  28th,  specific  gravity  of  urine  1019  ;  urine 
still  quite  albuminous,  and  containing  blood-corpuscles  and  granular  casts, 
also  crystals  of  oxalate  of  lime.  Dec.  30th,  takes  gr.^  pilocarpine 
twice  daily,  and  occasional  doses  of  infusion  of  digitalis;  urine  more 
abundant ;  its  specific  gravity  1014,  slightly  albuminous,  and  containing 


554  SCARLET  FEVER. 

very  few  granular  casts  and  blood-corpuscles ;  has  lost  its  smoky  appear- 
ance ;  reaction  alkaline  ;  perspiration  slight ;  patient  convalescent. 

In  another  instance,  a  child  of  five  years,  from  three  to  four  weeks  after 
scarlet  fever  was  noticed  to  have  anasarca  of  the  face  and  extremities, 
with  scanty  and  albuminous  urine.  Oue-thirty-second  of  a  grain  of 
muriate  of  pilocarpiue  was  administered  every  six  hours  without  the 
desired  sudorific  effect.  It  was  then  administered  every  four  hours,  with 
an  increase  of  perspiration  and  urination,  so  that  the  nephritic  symptoms 
were  relieved  and  the  patient  apparently  out  of  danger  within  three  or 
four  days. 

In  a  fourth  patient,  a  girl  of  three  years,  having  scarlatinous  nephritis, 
with  symptoms  very  similar  to  those  in  the  last  case,  the  administration 
of  one-twentieth  grain  doses  of  pilocarpine  in  conjunction  with  the  hot- 
air  bath,  was  followed  by  increased  perspiration  and  urination,  and  pro- 
gressive and  rather  rapid  convalescence.  This  child  had  been  taking 
bichloride  of  mercury  in  one-fiftieth  grain  doses,  prescribed  by  a  homceo- 
pathic  physician,  without  appreciable  benefit.  It  had  been  for  the  most 
part  vomited. 

Given,  as  in  the  above  cases,  in  moderate  doses  and  with  sufficient 
interval,  pilocarpine  has  never  in  my  practice  had  any  deleterious  effect, 
and  I  regard  it  as  a  very  important  addition  to  the  remedies  for  the 
relief  of  scarlatinous  nephritis.  It  is  apparently  the  most  useful  and 
important  diaphoretic  for  this  disease  which  we  possess. 

Cathartics,  especially  those  of  a  hydragogue  nature,  are  also  very 
beneficial.  Their  action  is  more  certain  than  that  of  most  diaphoretics 
and  diuretics,  and  their  employment  is  imperatively  required  in  severe  or 
dangerous  cases  in  which  it  is  necessary  to  remove  as  soon  as  possible  the 
serum  or  urea  which  endangers  life.  Young  children  or  those  with 
delicate  stomach,  and  those  much  enfeebled  by  the  primary  disease,  may 
take  magnesia,  either  the  citrate  or  the  calcined.  A  good  cathartic  for 
ordinary  cases  is  a  mixture  of  jalap  and  potassium  bitartrate,  the  pulvis 
jalapae  compositus,  consisting  of  one  part  of  jalap  and  two  of  cream  of 
tartar.  Ten  grains  of  the  mixture  may  be  given  to  a  child  of  five  years, 
and  repeated  according  to  circumstances.  Its  effect  is  increased  by  dis- 
solving a  teaspoonful  of  potassium  bitartrate  in  a  gobletful  of  water,  and 
allowing  the  patient  to  drink  from  it.  The  following  is  a  good  cathartic 
in  some  instances,  especially  if  the  stomach  be  irritable,  so  that  the  more 
bulky  and  nauseating  cathartics  are  rejected.  Care  should  be  taken  to 
obtain  a  good  article,  as  some  of  the  podophyllin  of  the  shops  Ls  not 
reliable : 

I$*.  Resinse  Podophylli    gr.  j  ; 
Sacchari  9j.     M. 

Ft.  in  chart.         No.  v.-x. 
S.  Give  one  powder,  and  repeat  according  to  circumstances. 

In  the  treatment  of  one  of  the  cases  reported  above  it  will  be  recol- 
lected that  the  mild  chloride  of  mercury  mite  was  given  with  the  podo- 
phyllin, with  a  good  result. 

After  the  use  of  laxative  agents  the  kidneys,  being  less  congested  on 
account  of  the  diversion  that  has  occurred,  often  begin  to  excrete  urine 
more  freely.  But  if  the  patient  be  anremic  or  enfeebled  and  the  symp- 
toms are  not  urgent,  it  is  frequently  better  to  avoid  active  catharsis,  which 


TREATMENT  OF  COMPLICATIONS  AND  SEQUELAE.  555 

more  or  less  reduces  the  strength,  and  employ  remedies  of  a  sustaining 
character,  as  in  the  following  case,  which  occurred  in  my  practice :  A 
little  boy,  pallid  and  scrofulous,  began  to  have  anasarca  after  scarlet  fever, 
chiefly  in  the  scrotum,  accompanied  by  a  moderate  degree  of  ascites.  The 
urine,  which  was  passed  in  nearly  the  normal  quantity,  contained  albu- 
men, but  not  in  large  amount.  This  patient  gradually  and  fully  recov- 
ered, with  no  treatment  except  the  use  of  an  oil-silk  jacket  over  the 
kidneys  and  abdomen  to  promote  diaphoresis,  and  the  use  of  iron.  Such 
a  patient,  treated  by  the  powerful  eliminatives  which  we  employ  for  the 
more  urgent  and  robust  cases,  would  probably  have  been  injured  rather 
than  benefited.  No  treatment  can  therefore  be  recommended  in  a  trea- 
tise on  scarlatinous  nephritis  which  will  be  strictly  applicable  for  all  cases. 
Variations  are  demanded  according  to  the  state  of  the  patient  and  the 
form  and  gravity  of  the  disease. 

Diuretics  which  do  not  stimulate  the  kidneys  are  proper  at  an  early 
as  well  as  late  period  of  the  renal  malady,  and  digitalis  is  the  one  usually 
prescribed.  I  do  not  hesitate  to  order  it  from  the  first  day  in  combina- 
tion with  the  acetate  of  potassium.  One  teaspoonful  of  the  infusion  may 
be  given  every  third  hour  to  a  child  of  five  years.  The  following  formula 
is  for  one  of  this  age  in  good  general  condition : 
1^.  Potass  Acetatis  ESS  ; 

Infus.  Digitalis  fsvi.     M. 

The  following  formulae  are  recommended  by  Meigs  and  Pepper  : 
^*.  Potass.  Bitart.  31 ; 

Spt.  Junip.  Comp.      f^ii ; 
Spt.  JEther.  Nitros.  f 31  j 
Tr.  Digitalis,  ^xv; 

Syrupi  f£v ; 

Aquae  fgii.     M. 

Dose  one  teaspoonful  every  two  hours  to  a  child  of  two  to  four  years. 
1^.  Potass.  Acetat.   31 ; 
Tr.  Digitalis 
Syr.  Scillae, 
Syr.  Zingib. 
Aquae  q.  s.  ad   fsiii.     M. 

Dose,  a  teaspoonful  every  two  or  three  hours  to  children  two  or  three 
years  old. 

Local  treatment  is  important.  L.  Thomas,  Romberg,  and  others  recom- 
mend the  application  of  leeches,  three  or  more,  over  the  kidneys. 
Thomas  says :  "  In  many  cases  the  abstraction  of  blood  causes  immediate 
and  permanent  relief;  the  fever  and  the  pain  in  the  region  of  the  kidneys 
cease,  the  secretion  of  urine  becomes  augmented,  the  albuminuria  lessens 
from  day  to  day,  and  the  moderate  degree  of  dropsy  that  has  been 
developed  disappears."  It  is  only  in  the  more  robust  children,  who  have 
been  but  little  reduced  by  the  primary  disease,  that  leeching ^  is,  in  my 
opinion,  admissible.  In  the  majority  of  cases  instead  of  depletion  a  poul- 
tice slightly  irritating,  so  as  to  cause  redness  of  the  skin,  should  be 
applied  over  the  kidneys,  or  for  older  children,  not  likely  to  be  frightened 
by  the  process,  the  dry' cups  may  be  applied  daily.  In  subacute  cases,  not 
attended  by  any  alarming  symptoms,  sufficient  redness  may  be  produced 
by  one  of  the  irritating  plasters  which  the  shops  contain,  constantly  worn. 


556  SCARLET  FEVER. 

Eclampsia,  described  in  the  preceding  pages,  is  produced,  as  we 
have  seen,  during  the  course  of  scarlet  fever  by  the  irritating  effect 
of  the  scarlatinous  poison  upon  the  nervous  centres,  but,  occurring 
after  the  decline  of  scarlet  fever,  it  is  ordinarily  produced  by  the 
retained  urea.  The  same  remedies  are  required  to  control  the  convul- 
sive movements  as  when  they  occur  under  other  circumstances.  The 
bromide  of  potassium  should  be  immediately  administered  in  large  and 
frequent  doses  whenever  eclamptic  symptoms  arise.  During  eclampsia  a 
child  of  three  years  should  take  five  grains  of  this  agent  every  five  to  tcu 
minutes  till  the  attack  ceases,  and  then  at  longer  intervals.  The  hydrate 
of  chloral  is  a  more  powerful  agent,  and  if  the  eclampsia  be  not  quickly 
controlled,  I  commonly  employ  it  per  rectum,  dissolved  in  one  or  two 
teaspoonsfuls  of  water.  For  a  child  of  three  to  -five  years  five  grains 
should  be  thrown  into  the  rectum  by  a  small  glass  or  gutta-percha  syringe, 
and  retained  by  pressure.  Properly  administered  and  retained,  it  rarely 
fails  to  control  the  eclampsia  within  ten  or  fifteen  minutes.  Subsequently, 
occasional  doses  of  the  bromide  should  be  given  to  prevent  the  occurrence 
of  eclampsia  while  the  measures  described  above  are  being  employed  to 
relieve  the  uraemic  condition. 

Rheumatism,  endocarditis,  and  pericarditis,  arising  as  complications 
or  sequela?,  require  the  treatment  which  is  appropriate  when  they  occur 
under  other  circumstances,  but  the  remedies  should  not  be  depressing,  as 
the  system  is  already  enfeebled  by  the  primary  disease.  The  rheumatism, 
if  mild,  usually  abates  in  a  few  days  without  medication,  and  the  affected 
joints  require  only  some  soothing  lotion  and  support  by  a  bandage.  The 
following  liniment  may  be  applied  upon  muslin  and  covered  by  cotton 
wadding : 

ty.  Acid.  Carbolici  f^i ; 
Tine.  Belladonna  f  si ; 
Ol.  Camphorati  f  3ii ; 

If  the  rheumatism  be  severe  and  affect  several  joints,  the  sodium  salicy- 
late  should  be  prescribed,  as  in  the  idiopathic  disease,  with  an  occasional 
opiate  to  procure  rest. 

Endocarditis  and  pericarditis  require  rest  in  the  horizontal  position, 
avoidance  of  all  excitement,  the  use  of  the  tincture  or  infusion  of  digi- 
talis or  of  the  fluid  extract  of  convalaria  to  procure  a  slow  and  steady 
action  of  the  heart.  Three  drops  of  the  tincture  of  digitalis  or  five 
minims  of  the  fluid  extract  of  convalaria  may  be  given  every  four  hours 
to  a  child  of  five  years.  The  same  external  measures  should  be  employed 
as  in  acute  pleuritis.  I  prefer  the  application  of  a  thin  poultice  of  flax- 
seed  containing  one-sixteenth  part  of  mustard  and  covered  with  oiled  silk. 
The  cardiac  inflammations,  as  well  as  rheumatism,  require  opiates  in  suf- 
ficient doses  to  procure  rest  and  sleep. 

Pleuritis,  which  we  have  stated  is  apt  to  be  suppurative,  demands  the 
same  treatment  as  the  idiopathic  disease  when  it  occurs  in  cachectic 
patients. 


RUBEOLA.1 

BY  W.  A.  HARDAWAY,  M.  D. 


SYNONYMS. — Rubeola,  Morbilli,  Measles,  Maseru,  Flecken,  Rougeole. 

DEFINITION. — Measles  is  an  acute  infectious  disease  involving  the  skin 
and  mucous  membranes,  characterized  by  successive  stages  and  a  maculo- 
papular  eruption,  which  terminates  in  a  fine  branny  desquamation.  In 
normal  cases  it  runs  a  definite  course,  which  from  the  date  of  invasion  to 
the  end  of  desquamation  occupies  about  fourteen  days.  It  is  highly  con- 
tagious, and  occurs,  as  a  rule,  but  once  in  the  same  person. 

HISTORY. — The  word  rubeola  is  probably  of  Spanish  origin  and  was 
formerly  written  rubiola  or  rubiolo.  The  designation  morbilli  is  the 
diminutive  of  the  Italian  il  morbo,  the  plague.  Although  it  is  doubtful, 
as  claimed  by  Willan,  that  the  Greek  and  Roman  physicians  were 
acquainted  with  measles,  there  is  no  question  that  Rhazes  was  one  of  the 
first  to  describe  the  affection  correctly.  Rubeola  is  said  to  have  been  dis- 
tinguished from  variola  by  the  Arabians  in  the  twelfth  century ;  but, 
nevertheless,  as  late  as  the  middle  of  the  seventeenth  century  we  find 
Sennertus  discussing  the  question  "why  the  disease  in  some  constitutions 
assumed  the  form  of  small-pox,  and  in  others  that  of  measles ;"  and  in  a 
posthumous  work  of  Diemerbroeck,  published  in  1687,  it  is  asserted  that 
small-pox  and  measles  are  only  different  degrees  of  the  same  affection.2 
According  to  Mayr,  the  merit  of  having  shown  measles  to  be  a  distinct 
malady  from  scarlatina  must  be  ascribed  to  Forestus  and  Sydenham.  It 
is  not  clear,  however,  that  the  two  diseases  were  accurately  differentiated 
till  the  close  of  the  last  century,  and  notably  by  Withering  in  1792. 

ETIOLOGY. — The  exact  nature  of  the  measles  contagium  has  never 
been  satisfactorily  established,  although  we  are  in  possession  of  numerous 
researches  in  that  direction,  which,  however,  are  to  a  great  extent  contra- 
dictory. A  brief  examination  of  these  .  various  observations  will  not 
prove  uninteresting.  Hallier  found  in  the  blood  and  sputa  numbers  of 
free  cocci,  which  fructified  upon  various  substrata,  but  was  invariably  the 
same  fungus — mucor  mucedo  verus,  Fres.  In  1862,  Salisbury3  published 

1  In  the  preparation  of  this  article  the '  writer  has  consulted   the  following  works : 
Thomas,   in  Ziemssen's   Cyclop.  Pract.  Med.,   vol.  ii.,  N.  Y.,  1875,  Am.  edit. ;   Bohn,  in 
Gerhardfs   Handbuch  der   Kinderkrankh.,   Zweiter   Band,   Tubingen,    1877 ;   Squire,    in 
Quain's  Diet.  Med.,  N.  Y.,  1883;  Ringer,  in  Reynolds's  Syxlem  Med.,  vol.  i.,  Phila.,  1879; 
Meigs  and  Pepper,  Dis.  of  Children,   Phila.,   1882 ;   J.  Lewis  Smith,  Dis.  of  Children, 
Phila.,  1882 ;  Hebra,  Dis.  of  Skin,  London.  1866 ;    Vogel,  Dis.  of  Children,  N.  Y.,  1871 
Niemeyer,  Handbook  of  Pract.  Med.,  N.  Y.,  1869 ;  Trousseau,  Clinical  Med.,  Phila.,  1871. 
Other  references  will  be  found  in  the  foot-notes  to  the  text. 

2  Cyclop.  Pracl.  Med.,  London,  1834,  p.  625. 
*  Am.  Jour.  Med.  Sci.,  July  and  Oct.,  1862. 

657 


558  RUBEOLA. 

his  observations  on  the  relation  of  the  straw  fungus  to  measles.  He 
recorded  instances  of  inoculation  with  this  organism  that  resulted,  accord- 
ing to  him,  in  the  production  of  a  modified  form  of  rubeola,  and,  more- 
over, was  protective  against  further  attacks  of  the  same  disease.  In 
an  exhaustive  paper  bearing  on  this  question  H.  C.  Wood1  quotes 
certain  experimental  inoculations  made  by  William  Pepper,  which 
showed  conclusively  that  measles  was  not  propagated  in  this  way,  and 
that  where  any  symptoms  were  developed  they  were  not  those  of  true 
measles,  nor  did  they  protect  the  subjects  from  unquestioned  measles. 
Salisbury  also  claimed  that  measles  had  occurred  in  camps  where 
damp  and  mouldy  straw  had  been  employed  for  bedding.  J.  J.  Wood- 
ward in  his  work  on  Camp  Diseases  points  out  that  camp  measles  pre- 
vailed almost  exclusively  in  regiments  from  the  rural  districts,  while 
men  enlisted  in  towns  and  cities  were  more  or  less  completely  exempt. 
The  explanation  was,  that  those  from  the  country  had  hitherto  escaped 
the  disease,  while  townspeople  had  suffered  from  it  at  some  previous  time 
— a  condition  of  affairs  inconsistent  with  the  theory  of  the  straw  fungus. 
Coxe  and  Felz  found  numerous  bacteria  in  the  blood  of  measles  patients, 
especially  in  regions  where  the  eruption  was  most  pronounced.  The 
nasal  mucus  also  contained  similar  germs.  Inoculation  of  the  blood 
from  the  subjects  of  measles  upon  rabbits  did  not  produce  an  analogous 
affection  (Thomas).  Klebs2  obtained  micrococci  from  the  trachea  and 
from  blood  taken  from  the  hearts  of  infant  cadavers.  "In  the  latter, 
collected  in  flattened  capillary  tubes,  there  developed  balls  of  micrococci ; 
in  the  trachea  both  micrococci  and  bacteria  were  present  in  large  quanti- 
ties. Under  observation,  pale,  finely-granular  micrococcus  balls  developed 
and  changed  very  quickly  to  bacteria,  which  moved  about  very  actively. 
These  sought  the  periphery,  about  J  mm.  distant  from  the  centre  of 
development,  and  formed  a  zone,  comparable  with  a  hedge  or  fence  that 
is  composed  of  rods.  From  this  were  formed  new  masses  of  micrococci, 
but  further  no  regular  process  of  arrangement  or  development  could  be 
observed." 

Braidwood  and  Vacher,3  as  the  result  of  a  number  of  experiments, 
believed  that  they  had  sufficient  evidence  for  concluding  that  the  most 
active  mode  of  the  transmission  of  measles  was  through  the  breath,  and 
accordingly  instituted  a  series  of  experiments  by  carefully  examining  the 
breath  of  children  in  the  acute  stage  of  the  disease.4  With  this  object  in 
view  they  coated  over  with  glycerine  the  inside  of  several  clean  glass 
tubes  of  a  diameter  of  a  half  to  three-quarters  of  an  inch.  As  soon  as 
the  nature  of  the  eruption  was  manifest  the  patient  was  required  to 
breathe  through  one  or  more  of  the  tubes,  and  so  on  each  day  till  the 
eruption  had  faded.  Upon  examination  of  the  glycerine  with  an  one- 
eighth  objective  every  specimen  showed  numerous  sparkling  bodies,  some- 
thing like  those  found  in  vaccine,  but  larger.  Some  Avcre  spherical ;  others 
were  elongated,  with  sharpened  ends.  They  were  most  abundant  during 
the  first  and  second  days  of  the  eruption.  Healthy  children  and  patients 
suffering  from  typhoid  and  scarlet  fevers  were  made  to  imitate  these 

1  Ibid.,  Oct.,  1868,  p.  333. 

a  Wilrzbr.  Vrrh.,  N.  F.,  v.,  1874,  quoted  by  Forchheimer  in  Supplement  to  Ziemsxen's 
Cyclopedia,  W.  T.,  1881,  p.  102.  «  Brit.  Med.  Jour.,  Jan.  21,  1882. 

4  Several   years  ago  Ransnme  of  Manchester  obtained   particles  from  the  breath  of 
two  persons  suffering  from  measles  (Squire). 


ETIOLOGY.  559 

experiments,  but  no  such  bodies  were  to  be  seen  in  their  specimens. 
They  conclude  from  these  observations  that  the  small  spherical  elements 
discovered  in  the  breath  are  perhaps  the  active  agents  in  the  propagation 
of  measles.  Upon  post-mortem  of  patients  who  had  died  of  rubeola 
these  germs  were  found  in  the  lungs  and  liver,  and,  particularly,  close  to 
the  walls  of  the  capillaries.  They  believe  that  the  "lungs  are  the 
favorite  breeding-ground  of  the  contagium." 

That  inoculation  of  morbillous  blood  may  convey  the  disease  was  first 
demonstrated  by  Home  in  1757,  which  experiments  were  verified  by 
Speranza  in  1822  and  by  Katona  in  1842.  The  inoculations  of  the 
latter  are  especially  noteworthy,  as  they  numbered  more  than  a  thou- 
sand. No  person  inoculated  by  him  died,  and  only  7  per  cent,  of  the 
inoculations  failed.  On  the  other  hand,  inoculations  made  by  Mayr 
gave  negative  results.  It  is  stated  that  Monro  and  Locke  communicated 
measles  by  inoculating  with  the  tears  and  saliva.  Attempts  of  the  same 
kind  were  fruitlessly  made  in  Philadelphia  in  1801,  although  the  blood, 
the  tears,  the  nasal  and  bronchial  mucus,  and  the  exfoliated  lamellae  of 
the  epidermis  were  successively  employed  in  the  trials.1 

Mayr  has  shown  that  the  nasal  mucus  is  capable  upon  inoculation  of 
propagating  the  disease.  He  performed  the  experiment  upon  two  healthy 
children  living  at  a  distance  from  each  other,  at  a  time  when  the  disease 
had  ceased  to  be  epidemic.  Some  nasal  mucus  taken  from  the  patient 
during  the  stadium  flavitionis,  and  kept  fluid  in  a  glass  tube,  was  the 
same  day  placed  upon  the  mucous  membrane  of  each  of  these  children. 
In  one  of  them  the  first  symptom  of  sneezing  occurred  after  eight  days, 
in  the  other  at  the  expiration  of  nine  days.  Febrile  symptoms  set  in 
two  days  later.  In  each  child  the  rash  appeared  on  the  thirteenth  day 
after  infection.  The  inoculated  disease  was  mild  and  regular  in  its 
course. 

While  it  is  perhaps  true  that  the  contagion  of  measles  is  not  so  tena- 
cious as  that  of  small-pox  and  scarlatina,  it  is  a  matter  of  observation 
that  susceptible  persons  are  liable  to  contract  the  disease,  even  if  not 
directly  exposed  to  its  influence.  There  is  incontestable  evidence  that  it 
is  conveyed  by  fomites — a  fact  well  worth  bearing  in  mind. 

It  is  but  just  to  say  that  so  excellent  an  observer  as  Mayr  taught  that 
measles  could  not  be  conveyed  by  clothes,  linen,  etc.  unless  transferred 
immediately  from  one  individual  to  another.  Panum,  however,  showed 
that  contagion  could  be  carried  many  miles  by  an  unaffected  third  person 
without  losing  its  activity.  Aitkcn2  has  also  pointed  out  the  fact  that 
children's  clothes  sent  home  in  boxes  from  schools  where  the  disease  has 
raged  communicated  the  disease,  and  that  susceptible  children  who  had 
slept  in  the  same  beds,  in  the  same  rooms,  after  they  had  been  occupied 
by  persons  suffering  from  measles,  have  taken  the  malady.  Squire 
observes  that  the  contagium  of  measles,  except  in  the  catarrhal  stage,  is 
not  far  diffusible  in  the  air,  but  clings  to  surfaces,  and  may  be  thus 
carried  from  place  to  place;  on  the  other  hand,  children  have  been 
brought,  while  in  full  eruption,  into  a  house  among  others,  and  nursed 
in  a  room  apart,  without  any  extension  of  the  disease  to  the  most  sus- 
ceptible. 

1  Kayer,  Diseases  of  the  Skin,  Phila.,  1845. 
*  Science  and  Prac.l.  of  Med.,  Phila.,  1868. 


560  RUBEOLA. 

Various  circumstances  render  it  probable  that  measles  is  most  readily 
propagated  during  the  stage  of  efflorescence ;  but  that  it  is  also  highly 
infectious  during  the  prodromal  period  is  now  universally  acknowledged. 

According  to  Niemeyer,  the  probability  of  infection  during  the  prodro- 
mal stage  is  supported  by  the  wonderful  spread  of  measles  through 
schools;  for,  while  the  strictest  surveillance  is  established  over  children 
with  any  suspicious  eruptions,  and  those  known  to  have  had  the  disease 
are  not  allowed  to  return  till  long  past  the  stage  of  desquamation,  no  heed 
is  paid  to  those  exhibiting  the  premonitory  cough  and  coryza.  There  is 
no  reason  for  believing  that  measles  can  be  propagated  during  the  period 
of  incubation ;  on  the  other  hand,  there  is  no  satisfactory  argument  for  the 
denial  of  its  infectiousness  in  the  desquamative  stage.  Although  Pauum 
is  inclined  to  doubt  its  contagiousness  at  this  time — and  his  observations 
are  worthy  of  the  greatest  confidence — other  good  authorities  diifer  from 
him  materially,  and  extend  the  stage  of  personal  infection  to  a  period  of 
from  three  weeks  (Squire)  to  forty  days  (Hillairet). 

Reasoning  from  analogy,  we  would  naturally  expect  that  the  period  of 
incubation  in  measles  suffered  a  certain  amount  of  variation;  the  result 
of  numerous  observations  confirms  this  expectation.  It  is  manifestly  a 
difficult  matter  in  densely  populated  communities  to  establish  with  accu- 
racy the  date  of  a  given  infection,  but  from  a  study  of  more  or  less  care- 
fully noted  cases  it  will  be  found  that  the  period  of  incubation  may  vary 
from  three  to  thirty  days.  For  the  vast  majority  of  cases  the  average 
time  between  the  reception  of  the  measles  poison  and  the  appearance  of 
the  characteristic  eruption  will  be  about  from  thirteen  to  fourteen  days. 
Panum,  under  exceptionally  favorable  surroundings,  found  it  more  fre- 
quently fourteen  than  thirteen  days.  Therefore,  deducting  the  three  or 
four  days  occupied  by  the  invasion  stage,  we  shall  find  that  the  real  incu- 
bation period  is  from  nine  to  ten  days  from  the  date  of  exposure.  Mayr's 
two  cases  of  inoculation  with  nasal  mucus  showed  no  departure  from  this 
rule,  but  in  the  inoculations  made  by  Katona  with  blood  the  prodromic 
symptoms  made  their  appearance  in  seven  days,  the  cutaneous  lesions  devel- 
oping two,  and  at  the  most  three,  days  afterward. 

Minor  epidemics  of  measles  are  said  to  occur  every  three  to  five  years, 
more  extensive  and  severe  ones  every  seven  or  eight  years.  In  the  centres 
of  population  measles  may  be  said  to  be  endemic;  in  isolated  regions  the 
visitations  of  the  disease  may  be  widely  separated.  Measles  is  a  less  severe 
disease  in  warm  than  in  cold  climates,  and,  as  a  rule,  we  also  find  the 
affection  more  common  and  more  intense  in  the  fall,  winter,  and  spring 
than  in  the  summer  months.1  Epidemics  of  measles  are  usually  short, 
and  it  is  thought  that  there  is  a  definite  relation  between  the  severity  of 
their  onset  and  their  duration,  this  being  in  general  short  in  proportion  as 
the  given  epidemic  was  at  first  severe  (Mayr).  Intestinal  complications 
are  more  frequent  in  summer,  and  involvements  of  the  respiratory  organs 
more  common  in  winter.  The  varying  aspects  of  different  epidemics — 

1  Aitken  (op.  cit.,  p.  295)  declares  that  the  mortality  returns  from  England  and  Wales 
show  that  the  influence  of  season  is  most  trifling.  Occasionally  it  has  been  found  that  the 
deaths  in  summer  exceeded  those  in  winter,  hut  we  believe  that  the  statement  made  above 
is,  in  the  main,  correct.  For  instance,  Parson's  figures  for  Berlin  for  the  years  1863-67, 
inclusive,  are:  spring,  11.9  per  cent.;  summer,  13.3;  autumn,  33.4;  winter,  41.4.  Voit's 
statistics  in  an  average  of  thirty  years  at  the  Children's  Clinic  at  Wiirzburg  establish  the 
same  general  principles  (ThomasX 


ETIOLOGY.  561 

sthenic,  asthenic,  etc. — depend  on  changes  in  the  weather,  season  of  the 
year,  the  presence  of  complications,  and  other  agencies  not  very  clearly 
understood.  Epidemics  of  whooping  cough  may  precede,  accompany,  or 
follow  in  the  wake  of  measles,  and  it  has  therefore  been  suggested  that  it 
stands  in  some  peculiarly  close  connection  with  the  latter ;  but,  aside  from 
this  often-observed  coincidence,  we  are  not  justified  in  our  present  state 
of  knowledge  in  assuming  any  definite  relation  of  cause  and  effect  between 
the  two  diseases. 

There  would  seem  to  be  neither  geographical  nor  racial  bar  to  the 
propagation  of  measles,  for  it  has  been  observed  in  all  countries  and 
among  all  peoples.  As  in  the  case  of  other  zymotic  diseases,  a  tolerance 
is  established  for  measles  in  countries  where  the  disease  is  more  or  less 
constantly  prevalent ;  but  where  the  affection  becomes  epidemic  for  the 
first  time,  or  reappears  after  many  years,  it  rages  with  terrific  violence. 
This  fact  was  particularly  exemplified  in  the  epidemic  in  the  Faroe  Islands, 
and  more  especially  in  the  recent  (1877)  visitation  of  the  Fiji  Islands, 
where  one-fourth  of  the  population  succumbed  in  a  comparatively  short 
time. 

It  is  quite  probable,  as  asserted  by  Mayr,  that  children  affected  with 
scrofulous  complaints,  as  well  as  those  who  are  the  subjects  of  diseases 
of  the  respiratory  organs — pertussis,  bronchitis,  or  tuberculosis — are  emi- 
nently susceptible  of  measles ;  but  his  statement  that  sufferers  from  epi- 
lepsy, chorea,  and  paralysis  exhibit  an  unusual  power  of  resistance  cannot 
be  accepted  without  reservation.  Acute  diseases  often  appear  to  delay 
the  outbreak  of  measles,  so  that  the  latter  does  not  appear  till  convales- 
cence from  the  former  (Thomas).  The  development  of  vaccinia  is  occa- 
sionally interfered  with  by  an  attack  of  rubeola ;  on  the  other  hand,  the 
two  diseases  may  be  seen  running  their  courses  together.1  The  emphatic 
statement  made  by  Hebra,  that  measles  is  never  seen  to  occupy  a  patient 
simultaneously  with  another  acute  exanthem,  has  not  been  confirmed  by 
other  observers.  My  own  experience  furnishes  several  examples. 
Measles  may  also  occur  during  the  course  of  other  acute  or  chronic  mala- 
dies. From  a  study  of  the  literature  of  measles  complicating  pregnancy 
and  parturition  Underbill2  finds  it  to  be  quite  uncommon,  due  probably 
to  the  fact  that  most  adults  are  insusceptible  of  further  attacks  ;  but  when 
it  does  occur  in  pregnancy  he  regards  it  as  a  very  serious  and  frequently 
fatal  complication.  Underhill  believes  measles  to  be  most  fatal  when  it 
supervenes  soon  after  delivery,  while  those  who  are  confined  during  the 
course  of  the  malady  stand  a  better  chance  of  recovering  from  it.  That 
puerperal  women  are  not  always  unfavorably  affected  by  measles  is  well 
shown  in  two  remarkable  cases  reported  by  Nelson3  of  St.  Louis  and 
Chantier4  of  Geneva,  in  which  the  mothers  were  safely  delivered,  though 
suffering  from  measles  contracted  at  the  end  of  their  pregnancies. 

All  ages  are  susceptible  to  the  measles  poison,  and  the  apparent  exemp- 
tion enjoyed  by  adults  is  due  to  the  fact  that  most  grown-up  people  have* 
already  suffered  the  disease  in  childhood ;  but  in  Panum's  epidemic,  men- 
tioned above,  it  was  discovered  that  nearly  all  who  had  not  had  measlet) 

1  Hardaway,  Essentials  of  Vaccination,  p.  60. 

2  Obstel.  Jour.  Great  Britain  and  Ireland,  July,  1880. 

3  St.  Louis  Courier  of  Med.,  Sept.,  1879. 
*  Annales  de  Gynecologic,  May,  1879. 

VOL.  I.— 36 


562 


RUBEOLA. 


elsewhere,  or  were  not  old  enough  to  have  been  exposed  at  the  last  visita- 
tion, sixty-five  years  before,  acquired  the  affection  regardless  of  age.  It 
is  quite  probable,  however,  that  the  law  of  decrease  of  susceptibility  with 
age  holds  good  for  measles  as  well  as  for  variola,  etc.,  but  to  a  less  degree. 
It  will  therefore  be  seen  that  measles  is  not  essentially  a  disease  of  child- 
hood. Although  there  is  no  special  limit  to  the  susceptibility  of  rubeola 
at  one  extreme  of  life,  it  would  seem  to  be  quite  well  established  that  it 
is  much  modified  at  the  other — namely,  that  infants  under  six  months 
are  rarely  attacked.  This  latter  fact  is  conceded  by  individual  expe- 
rience, by  the  records  of  epidemics,  and  by  the  testimony  of  most 
observers.1 


Under  one  year   

England. 

London. 

Males. 

Females. 

Males. 

Females. 

3022 
6086 
3178 
1730 
.  980 

2530 
5825 
3255 
1851 
1028 

3571 

8630 
4683 
2594 
1358 

2987 
8050 
4757 
2620 
1466 

Two     "       "      three"    

Three"       "       four    "      

Four   "       "       five     "      

Five  and  under  ten  years       

255 
29 
9 

7 
5 
3 

278 
38 
13 
9 
8 
5 

301 
24 
9 
5 
5 
2 

316 
32 

11 
7 
7 
3 

Ten                      fifteen  years       

Fifteen    "           twenty     "             

Twenty   "           twenty-five  years  

Twentv-five  and  under  thirty-five  years  

Thirty-five         "            forty-five       "     

Even  sucklings  do  not  enjoy  a  complete  immunity  from  measles. 
Steiner2  states  that  he  has  met  with  it  in  children  only  four  or  five  weeks 
old.  Monti  has  recorded  ten  cases  of  rubeola  in  children  under  two 
months  of  age.  A  case  is  reported  by  Kunze  where  a  mother  in  the  stage 
of  efflorescence  gave  birth  to  a  child,  which  contracted  the  disease  five  days 
afterward.  Quite  a  number  of  cases  of  congenital  measles  have  been  put 
on  record  from  time  to  time ;  but  Thomas,  after  a  careful  investigation, 
says  that  he  has  been  able  to  discover  but  six  authentic  accounts  of  such 
occurrences.3  That  children  born  to  mothers  suffering  at  the  time  of  par- 
turition from  measles  may  yet  escape  it  themselves  is  proven  by  the 
cases  of  Nelson  and  Gautier  mentioned  above.  Whether  a  pregnant 
woman  attacked  by  measles  transmits  the  disease  to  the  foetus  in  utero, 
thereby  securing  immunity  from  it  in  after  life,  is  a  question  difficult  of 
decision,  especially  as  we  have  not  yet  been  able  to  decide  this  same 
inquiry,  with  infinitely  better  opportunities,  for  vaccinia.4 

There  is  no  good  reason  to  believe  that  sex  is  of  much  importance  in 
establishing  a  predisposition  to  measles,  although  the  statement  has  been 
^repeatedly  made  that  males  are  more  frequently  attacked  than  females. 

1  On  the  other  hand,  as  quoted   by  Forchheimer  (loe.  cit.},   H.  C.  Fox   publishes 
some  tables  which  show  that  for  England  and  London  a  much  larger  number  of  young 
children  are  attacked  by  measles  than  other  statistics  would  lead  us  to  believe: 

2  Compendium  of  Children's  .Diseases,  N.  Y.,  1875,  p.  396. 

3 1  believe  that,  under  certain  circumstances,  the  erythema  papulatum  of  the  new-born 
is  often  mistaken  for  measles. 

4  See  experiments  of  Burckhardt,  Rickett,  Gart,  and  others,  quoted  in  Hardaway's 
Essentials  of  Vaccination,  p.  38. 


SYMPTOMS  AND  COURSE.  563 

Fox's  statistics  show  a  slight  preponderance  in  favor  of  the  male  sex  ;  but 
a  careful  examination  of  accessible  statistics  proves,  as  would  be  expected, 
that  this  degree  of  susceptibility  varies  at  different  times  in  obedience  to 
circumstances  not  readily  understood. 

By  the  older  writers  (Willan,  Rosenstein,  Fuchs)  it  was  very  dogmati- 
cally asserted  that  one  attack  of  measles  completely  extinguished  all  future 
susceptibility  to  the  disease.  Of  late  years  this  dogma  has  met  with 
much  opposition,  and  numerous  observations  have  been  recorded  which, 
if  entirely  trustworthy,  would  lead  us  to  believe  that  rubeola  may  occur 
not  only  twice,  but  several  times,  in  the  same  individual.  While  from 
analogy  and  actual  experience  we  are  quite  sure  that  the  recurrence  of 
measles  is  not  so  uncommon  an  event  as  it  was  once  held  to  be,  a  closer 
examination  of  the  question  in  all  its  bearings  clearly  confirms  us  in  the 
belief  that  subsequent  attacks  are  much  more  infrequent  than  is  now 
thought  to  be  the  case  by  many,  and  that  other  diseases,  more  or  less 
resembling  true  measles,  are  largely  responsible  for  errors  of  diagnosis  in 
this  regard.  Panum  found  that  all  the  old  people  who  had  measles  dur- 
ing the  epidemic  on  the  Faroe  Islands  in  1781  escaped  it  in  1846.  Both 
Rosenstein  and  Willan  declared  that  they  had  never  witnessed  an  instance 
of  the  true  recurrence  of  measles.  Among  other  facts,  it  may  be  stated 
in  this  connection  that  Woodward  (loc.  cit.)  has  shown  that  during  our 
late  war,  while  members  of  regiments  recruited  from  the  rural  districts, 
who  had  never  before  had  measles,  largely  took  it  when  exposed  to  its 
influence,  regiments  from  the  cities,  who  had  presumably  acquired  the  dis- 
ease in  childhood,  remained  almost  entirely  exempt.1  Other  arguments  of 
a  similar  sort  could  be  readily  adduced.  There  is  no  question  that  mis- 
takes in  diagnosis  have  occurred  from  confounding  rotheln,  roseola,  etc., 
which  closely  simulate  measles,  with  that  disease.  Those  particularly 
engaged  in  the  treatment  of  cutaneous  affections  could  multiply  instances 
of  such  errors.  It  is  quite  significant  that  for  certain  analogous  infectious 
diseases — e.  g.  variola  and  scarlatina — the  same  frequency  of  recurrence  is 
not  claimed,  although  as  a  matter  of  fact  they  do  occur.  The  explanation 
would  seem  to  lie  in  the  fact  that  neither  small-pox  nor  scarlet  fever  is  so 
closely  counterfeited  by  other  skin  affections,  notably  by  rotheln,  as  is 
measles.  But  it  would  be  entirely  contrary  to  analogy  and  indubitable 
experience  to  go  to  the  extreme  of  the  older  writers  and  absolutely  deny 
the  possibility  of  second,  and  even  third,  attacks  of  rubeola.  The  fre- 
quency of  such  cases  is,  however,  as  Henoch2  truly  states,  much  over- 
estimated. 

Occupying  quite  a  different  position  from  the  measles  induced  by 
reinfection  from  without  are  the  so-called  relapses  of  rubeola.  These 
relapses,  which  may  occur  in  from  two  to  four  weeks  after  the  original 
invasion,  are  analogous  to  the  similar  occurrences  in  scarlatina  and 
typhoid  fever.  I  am  cognizant  of  but  a  single  case  of  this  sort,  but 
Steiner  and  other  accurate  observers  record  a  number  of  such  instances. 

SYMPTOMS  AND  COURSE. — It  is  generally  stated  that  the  stage  of  incu- 
bation exhibits  no  symptoms  whatever  ;  but  it  is  undoubtedly  true  that 
the  patient  will  sometimes  appear  dull  and  listless,  and,  on  occasion,  even 
give  evidence  of  some  slight  and  ephemeral  elevations  of  temperature. 

1  These  observations  of  Woodward  were  made  without  any  reference  to  the  question  at 
issue.  *  Lectures  on  Diseases  of  Children,  N.  Y.,  1882,  p.  282. 


564  RUBEOLA. 

As  a  rule,  however,  this  period  is  devoid  of  any  marked  indication  of 
the  presence  of  the  measles  poison  in  the  system.1 

The  prodromal  stage  is  usually  ushered  in  by  symptoms  of  general 
malaise,  fretfulness,  more  or  less  frontal  headache,  shiverings,  nausea, 
loss  of  appetite,  excited  sleep,  and  sometimes  delirium.  Vomiting  is  not 
so  common  in  measles  as  in  scarlatina,  and  may  occur  at  any  time  pre- 
vious to  the  appearance  of  the  rash.  The  tongue  is  apt  to  be  coated, 
although  it  may  remain  clean  ;  the  taste  is  bad,  and  pressure  over  the 
stomach  and  bowels  occasionally  elicits  considerable  pain ;  an  aching  pain 
over  the  sternum  is  also  noted.  As  a  general  thing,  at  this  time  patients 
are  drowsy  and  inclined  to  sleep  much.  Meigs  and  Pepper  found  this  a 
very  constant  symptom,  which  they  state  is  in  no  way  alarming  unless 
associated  with  other  more  serious  symptoms  of  local  or  general  dis- 
turbance. Constipation  is  present  in  some  cases,  or  the  bowels  may  be 
relaxed  or  remain  in  their  natural  state. 

The  prodromal  fever  of  measles  follows  a  peculiar  course,  it  is 
remarkably  remittent  in  character,  and  is  rarely  of  such  intensity  as  to 
threaten  life,  as  is  often  the  case  in  scarlet  fever.  The  temperature  will 
rise  on  the  first  day  to  102°-104°  F.,  and  the  height  of  the  fever  at  this 
time  will  measurably  foreshadow  the  character  of  the  subsequent  course. 
On  the  second  day  of  the  prodromal  stage  the  fever  suffers  a  marked 
remission,  or  may  even  entirely  disappear,  to  again  rise  in  the  evening. 
Smith  has  observed  two  exacerbations  in  the  day.  Again,  in  some 
instances,  after  the  high  initiatory  fever,  the  temperature  may  remain 
normal  till  just  before  the  rash  comes  out  (Bohn).  It  is  this  peculiar 
behavior  of  the  fever,  together  with  the  fact  that  the  child  may  regain  its 
usual  vivacity  in  the  fever-free  intervals,  which  so  often  misleads  the 
physician  into  the  diagnosis  of  malarial  poisoning. 

The  most  pronounced  feature  of  this  stage  of  the  disease  is,  beyond  all 
others,  the  catarrhal  affection  of  the  mucous  membranes.  The  mucous 
membranes  of  the  eyes,  nose,  mouth,  and  air-passages  are  all  more  or  less 
involved,  and  the  patient  suffers  in  varying  degrees  from  photophobia, 
coryza,  hoarseness,  cough,  and  pain  in  swallowing.  Sneezing  is  frequent 
and  annoying,  and  slight  epistaxis  is  not  uncommon.  The  cough  usually 
appears  on  the  first  day,  simultaneously  with  the  fever.  It  is  not  very 
troublesome  at  first,  but  by  the  fourth  day  it  becomes  more  frequent, 
assuming  a  hoarse,  barking,  paroxysmal  character.  Expectoration  is 
scanty,  and  auscultation  reveals  a  harsh  vesicular  murmur  or  else  sibilant 
rales.  Alarming  but  not  dangerous  attacks  of  false  croup  may  come  on 
during  the  night.  Many  observers  have  called  attention  to  the  red  spots 
(papules)  in  the  oral  cavity,  which  make  their  appearance  during  the 
period  of  invasion.  According  to  Bohn,  usually  on  the  second  or  third 
day  from  the  beginning  of  the  fever  there  appear  upon  the  slightly 
hypersemic  mucous  membrane  of  the  soft  palate,  palatal  arch,  and  uvula 
small  or  large,  dark,  red  spots  that  spread  to  the  mucous  membrane  of 
the  cheeks,  and  sometimes  to  the  hard  palate,  lips,  and  gums.  Soon  they 
become  more  defined,  and  are  to  be  distinguished  by  shape  and  coloring 

1  Some  writers  describe  a  much  more  marked  train  of  symptoms  as  prevailing  at  this 
time  than  seems  warranted  by  general  experience,  and  Rehn  has  gone  so  far  as  to  declare 
that  the  prodromal  period,  as  usually  understood,  properly  commences  in  the  stage  of 
incubation.  Bohn  is  inclined  to  a  similar  view.  The  prodromic  stage  of  authors  is,  then, 
to  be  looked  upon  as  the  "  period  of  the  mucous  membrane  exanthem." 


SYMPTOMS  AND   COURSE.  565 

from  the  membrane  upon  which  they  are  situated.  According  to  the 
same  authority,  they  also  afford  an  index  to  the  intensity  and  extent  of 
the  coming  cutaneous  eruption.  It  is  also  stated  that  if  the  latter  par- 
takes of  a  hemorrhagic  character,  the  spots  on  the  mucous  membrane 
may  also  become  livid.  This  same  punctate  reddening  has  been  demon- 
strated in  the  epiglottis,  larynx,  and  trachea  (Gerhardt),  and  upon  the 
bronchi  and  small  intestines  of  children  who  had  died  during  this 
stage  of  the  eruption.  It  is  also  to  be  noted  on  the  conjunctive. 
It  has  been  assumed  that  this  period  of  this  disease  is  not  to  be 
looked  upon  as  the  stadium  prodromorum,  but  as  the  period  of  the 
"  exauthem  of  the  mucous  membrane."  This  view  of  the.pathology  of 
measles  seems  to  me  most  reasonable  ;  but  in  whatever  way  we  may  look 
upon  the  question,  the  practical  importance  of  this  precutaneous  eruptive 
stage  is  to  be  insisted  upon  for  diagnostic  purposes,  just  as  is  the  analo- 
gous eruption  upon  the  mucous  membrane  in  small-pox. 

In  ordinary  cases  of  measles  we  do  not  find  such  profound  reaction  of 
the  nervous  system  as  in  scarlatina.  I  believe  that  convulsions  in  the 
prodromal  stage  are  much  more  common  than  available  statistics  would 
have  us  believe ;  at  least,  this  is  my  own  experience.  Meigs  and  Pepper 
met  with  convulsions  but  five  times  in  314  cases  at  the  beginning  of  the 
eruption,  while  Eilliet  and  Barthez  observed  but  one  convulsion  in  167 
cases.  Thomas  says  that  convulsions  are  almost  always  absent.  On  the 
other  hand,  Trousseau  and  Bohii  expressly  declare  that  they  are  very 
common,  the  former  stating  that  they  occur  with  greater  frequency  than 
in  scarlatina.  I  consider  that  convulsive  seizures  occurring  in  connection 
with  marked  catarrhal  affection  of  the  mucous  membranes  are  very 
important  aids  in  forecasting  a  probable  attack  of  rubeola.  Fortunately, 
convulsions  at  this  stage  are  not  very  serious  unless  repeated  or  injudi- 
ciously treated. 

The  duration  of  the  period  of  invasion  in  regular  cases  is  from  three 
to  five  days,  with  an  average  of  about  four,  but  in  perfectly  uncompli- 
cated attacks  this  period  may  be  extended  to  six  or  eight  days,  or  even 
longer.  But  that  the  duration  of  this  stage  may  be  much  shorter  than 
the  average  is  not  sufficiently  insisted  upon  by  writers.  Ringer,1  for 
instance,  says  that  he  had  an  opportunity  of  testing  the  earliest  appear- 
ance of  the  rash  in  an  epidemic  of  measles  in  a  large  public  school  for 
boys  under  twelve.  In  every  case  during  the  epidemic  the  rash  appeared 
on  the  first  day,  the  cases  being  severe,  though  of  short  duration,  the 
temperature  rising  to  103°  and  to  104°  F.  In  some  instances  the  rash 
preceded  (?)  the  fever.  Thus,  several  of  the  boys  feeling  poorly,  their 
temperature  was  carefully  taken  night  and  morning  under  the  tongue, 
and  in  several  cases  the  rash  appeared  in  the  morning  about  the  face  and 
collar-bone,  while  the  temperature  remained  normal,  and  did  not  rise  till 
the  evening,  when  it  ran  up  to  101°-103°  F.,  and  even  higher.  These 
cases  certainly  resemble  rothcln  more  than  measles.  In  two  cases,  which 
I  observed  under  very  favorable  conditions,  the  eruption  commenced  to 
appear  on  the  morning  of  the  second  day,  and  more  or  less  similar 
experiences  are  recorded  by  others. 

The  skin  eruption,  which  appears,  as  a  rule,  on  the  third,  fourth,  or 
fifth  day  of  the  attack,  is  ushered  in  with  an  increase  in  the  general  and 
1  Handbook  of  Therapeutics,  6th  ed.,  London,  1868 — note  to  p.  26. 


566  RUBEOLA. 

local  symptoms  of  the  disease.  It  is  particularly  to  be  remarked  that  the 
fever  does  not  subside  at  this  time,  as  is  the  case  in  variola.  The  erup- 
tion appears  first  upon  the  face,  about  the  cheeks  and  forehead,  then  on 
the  chin  and  neck,  and  thence  gradually  overspreads  the  trunk,  and 
finally  reaches  the  extremities.  When  the  eruption  is  intense  no  part  of 
the  body  is  free  from  it,  the  rash  being  found  upon  the  palms  and  soles 
and  upon  the  hairy  scalp.  The  cutaneous  lesions  proper  consist  at  first 
of  hypersemic  spots  of  about  a  line  in  diameter,  which  gradually  increase 
in  size,  until  at  their  full  development  they  may  attain  a  diameter  of 
from  one-twentieth  to  a  quarter  of  an  inch.  In  the  beginning  they  bear 
a  very  close  .resemblance  to  the  sub-papular  lesions  of  small-pox.  The 
maculo-papules,  when  fully  developed,  are  slightly  elevated  above  the 
level  of  the  skin,  the  elevation,  however,  being  more  appreciable  to  touch 
than  sight,  have  a  smooth  velvety  feel,  and  are  so  arranged  as  to  enclose 
areas  of  healthy  skin.  In  the  individual  spots  we  may  frequently 
observe  one  or  several  minute,  darker-colored  papules,  due  to  follicular 
congestion,  which  when  more  intense  constitutes  the  morbilli  papulari 
presently  to  be  described.  The  macula  are,  as  a  rule,  roundish,  or  they 
may  be  moon-shaped,  or  their  borders  may  present  an  indented  or  notched 
appearance.  Where  the  capillary  circulation  is  active — on  the  cheeks,  for 
example — or  upon  parts  subjected  to  pressure,  the  eruption  may  become 
confluent;  that  is  to  say,  the  usually  pale  intervening  skin  becomes 
injected  or  the  papules  coalesce,  and  in  this  way  produce  a  uniform  red- 
ness over  large  single  tracts  of  skin.  This  scarlatinoid  rash,  however, 
never  occupies  the  whole  surface  of  the  body,  but  only  limited  regions, 
and  in  other  situations  may  be  detected  the  characteristic  discrete  papules 
of  rubeola ;  the  color  is  not  uniform,  but  is  broken  here  and  there  by  the 
darker  streaks  and  spots  of  the  measly  eruption.  The  rash,  which  dis- 
appears upon  pressure  to  return  when  the  pressure  is  removed,  is  of  a 
more  or  less  rosy  red,  with  a  tendency  in  some  to  deep  red,  and  has  occa- 
sionally a  purplish  hue.  According  to  Mayr  and  Hebra,  it  is  of  the  pre- 
cise color  which  is  obtained  by  adding  a  little  yellow  or  brown  to  a  red 
pigment. 

According, to  the  researches  of  Thomas,  Squire,  and  Wunderlich,  as 
abstracted  by  Seguin,  the  fever  of  the  eruptive  period  is  divided  into  a 
moderately  febrile  stage  and  the  fastigium  or  acme.  The  moderately 
febrile  stage  averages  thirty-six  to  thirty-eight  hours,  and  is  made  up  of 
one  or  two  exacerbations  of  100.4°  to  i02.2°  F.,  but  not  quite  so  high 
as  the  initial  fever.  If  there  are  two  exacerbations,  the  second  one  is 
the  higher ;  the  intervening  remissions  are  not  so  low  as  those  of  the 
prodromal  stage,  yet  even  now  the  norm  may  be  noted  on  a  single  occa- 
sion. ^  The  fastigium  commences  early  in  the  day  or  in  the  evening  ;  if 
the  rise  should  occur  in  the  morning,  the  evening  temperature  rises  still 
higher,  with  or  without  a  slight  remission  the  following  morning,  and 
the  next  evening  attains  the  maximum.  If  the  acme  begins  in  the  even- 
ing, the  remission  on  the  next  morning  is  either  absent  or  very  slight. 
The  greatest  height  of  the  fever  in  normal  cases  corresponds  to  the 
greatest  intensity  and  development  of  the  eruption.  This  rule  is  not 
invariable,  however,  for  sometimes  the  fever  is  higher  soon  after  the 
eruption  appears,  and  has  fallen  when  the  exanthem  has  reached  its 
highest  point.  The  whole  fastigium  lasts  from  one  and  a  half  to  two 


SYMPTOMS  AND  COURSE.  567 

and  a  half  days,  so  that  the  complete  eruptive  fever  occupies  from  three 
to  four  and  one-half  days.1  The  pulse  in  general  preserves  a  propor- 
tionate correspondence  to  the  temperature,  and  never  attains  the  great 
frequency  to  be  observed  in  scarlatina. 

The  general  symptoms,  with  the  exception  of  the  fever,  do  not  greatly 
differ  from  those  common  to  the  prodromal  stage.  The  skin  is  hot  and  more 
or  less  swollen,  particularly  about  the  face ;  there  are  anorexia,  photopho- 
bia, lachrymation,  and  sometimes  epistaxis ;  the  cough  continues,  and  is 
generally  frequent  and  harassing,  and  attended  with  little  or  no  expecto- 
ration ;  the  voice  is  hoarse.  The  tongue  is  coated,  principally  in  the 
middle,  through  which  the  swollen  papillae  protrude,  while  the  tip  and 
sides  are  red.  The  blotchy  redness  of  the  oral  cavity  is  visible  for  some 
days,  and  finally  becomes  indistinguishable  from  the  surrounding  conges- 
tion. The  tonsils  sometimes  become  considerably  enlarged,  though  sup- 
puration must  be  rare.  Enlargement  of  the  glands  behind  the  jaw  and 
in  the  neck  and  groin  are  to  be  observed.  At  the  outset  of  the  eruption 
a  profuse  diarrhoea  supervenes  in  most  cases — a  symptom  which  Trous- 
seau rightly  insists  to  be  an  essential  feature  of  measles.  This  occur- 
rence is  interpreted  by  some  writers  as  an  evidence  of  the  implication  of 
the  mucous  membranes  in  the  specific  exanthem  of  the  disease.  This 
flux,  which  is  sometimes  accompanied  by  a  little  blood  and  tenesmus, 
rarely  continues  long,  and  may  be  succeeded  by  a  degree  of  constipation. 
The  respiration  is  generally  somewhat  accelerated,  mostly  in  correspond- 
ence to  the  amount  of  fever  present.  Some  degree  of  deafness  is  not 
uncommon,  owing  to  the  extension  of  inflammation  along  the  Eustachian 
tubes.  The  urine  is  scanty  and  high  colored  ;  there  is  sometimes  scald- 
ing in  urination  and  vesical  tenesmus,  and  at  the  acme  of  the  fever  traces 
of  albumen  may  be  detected. 

The  eruption,  in  fact,  generally  occupies  the  skin  an  average  of  four 
days,  and,  although  this  period  may  be  shortened  materially,  it  is  less  apt 
to  be  lengthened.  The  duration  of  the  eruption  at  its  maximum  of 
development  over  the  whole  surface  is  about  half  a  day,  more  or  less, 
and,  as  a  rule,  corresponds  with  the  greatest  elevation  of  the  temperature. 
The  retrocession  of  the  rash  takes  place  in  the  order  of  its  appearance — 
viz.  first  from  the  face,  then  from  the  trunk  and  upper  parts  of  the 
extremities,  and  last  from  about  the  feet  and  hands,  where,  indeed,  it 
may  remain  vivid,  or  even  progress  for  a  short  time  longer,  after  the 
eruption  has  begun  to  subside  in  other  situations.  Sometimes  _  the  almost 
faded  spots  will  be  temporarily  renewed  by  an  abnormal  rise  in  the  tem- 
perature. 

With  the  decline  of  the  eruption  the  other  symptoms  begin  to  subside. 
The  cough  loses  its  hacking,  paroxysmal  character,  and  becomes  less  and 
less  frequent,  and  gradually  disappears.  The  voice  regains  its  normal 
tone,  the  tongue  loses  its  fur,  cleaning  up  in  patches,  and  expectoration, 
which  was  absent  or  scanty  and  viscid  in  the  beginning,  increases  and  is 
free,  the  masses  coughed  up  being  coin-shaped  and  floating  _  in  a  clear 
watery  mucus — a  symptom  much  dwelt  upon  by  the  older  writers.  The 
behavior  of  the  temperature  at  this  period— the  stage  of  decline — is  quite 

1  According  to  Kinger,  the  highest  temperature  reached  in  normal  cases  is  103°  F. 
Thomas  places  it  as  high  as  104°  F.,  but  states  that  it  may  go  up  to  105  F.  without  the 
intervention  of  any  complication. 


568  RUBEOLA. 

characteristic.  The  fall  usually  begins  at  night,  and  generally  the  next 
morning  it  has  reached  the  norm  or  else  fallen  below  it.  On  the  other 
hand,  the  descent  may  be  less  precipitate,  and  the  fall  continues  less  rapidly 
all  through  the  day ;  or  there  may  be  a  slight  rise  again  in  the  evening, 
the  norm  being  reached  the  following  morning.  The  termination  by  lysis 
— that  is,  slight  elevations  in  the  evening  for  several  days — is  much  rarer, 
and  'while  it  may  occur  in  perfectly  regular  cases,  it  should  put  the  medi- 
cal attendant  on  his  guard  against  complications. 

The  comparatively  normal  course  of  measles  portrayed  in  the  preceding 
paragraphs  does  not  always  occur,  but,  on  the  contrary,  the  disease  may 
depart  from  the  more  usual  type  in  one  or  more  particulars,  either  in  espe- 
cial stages  of  its  progress  or  in  the  greater  or  less  intensity  of  the  malady 
as  a  whole. 

In  addition  to  those  cases  of  measles  where  the  eruptive  and  catarrhal 
symptoms  are  so  slight  as  to  almost  escape  observation,  except  for  the 
existence  of  other  cases  in  the  same  house  or  family,  there  are  to  be  recog- 
nized two  other  trivial  varieties  of  the  disease — namely,  measles  without 
the  catarrh,  and  measles  without  the  rash. 

That  the  eruption  of  measles  should  occur  upon  the  skin  without  impli- 
cation of  the  mucous  membranes  seems  to  be  much  more  doubtful  than 
that  the  catarrh  should  appear  without  the  eruption.  It  is  quite  probable, 
at  any  rate,  that  many  so-called  cases  of  rubeola  sine  catarrho  are  merely 
instances  of  rotheln,  which  we  know  may  occur  without  any  reference  to 
an  existing  epidemic  of  measles.  But  that  this  form  of  measles  does  exist 
is  admitted  by  trustworthy  observers,  although  its  diagnosis  under  any 
circumstances  must  be  a  matter  of  great  difficulty.  Measles  without  the 
eruption  (rubeola  sine  eruptione)  is  more  readily  recognized,  especially  and 
only,  however,  when  a  susceptible  person  is  exposed,  and  as  a  result 
acquires  the  characteristic  catarrhal  symptoms.  Since  in  recent  years 
more  attention  has  been  paid  to  the  eruption  on  the  mucous  membranes,  it 
may  be  that  its  discovery  in  these  situations  may  lend  positive  assistance 
to  the  diagnosis  in  such  cases.  It  is  hard  to  understand  how  this  variety 
of  measles,  which  presents  no  inflammatory  changes  in  the  skin,  should 
be  followed  by  desquamation ;  yet  this  observation  has  been  made.  The 
assertion  that  these  anomalous  forms  of  the  affection  afford  no  protection 
against  subsequent  attacks  seems  to  be  founded  in  error,  and  is  undoubt- 
edly due  to  the  confusion  existing  between  measles  and  rotheln  or  other 
exanthems. 

Continental  writers,  especially,  describe  a  form  of  measles  called  by 
them  inflammatory  or  synochal.  It  is  simply  an  exaggeration  of  the 
symptoms,  particularly  those  appertaining  to  the  mucous  membranes, 
found  in  ordinary  measles  (morbilli  vulgaris).  The  prodromal  stage  is 
much  more  violent,  the  nervous  symptoms  more  threatening,  the  implica- 
tion of  the  mucous  membranes  more  pronounced  and  persistent,  the  febrile 
movement  is  of  a  higher  inflammatory  character,  and  the  eruption,  which 
instantly  covers  the  whole  body  (Yogel),  is  made  up  of  dark-red  or  pur- 
plish spots  which  fade  slowly.  It  is  this  form  of  measles,  according  to 
Niemeyer,  ^  which  is  chiefly  attended  by  croupous  instead  of  catarrhal 
laryngitis,  in  which  the  inflammation  of  the  air-passages  often  extends  to 
the  alveoli  of  the  lungs,  and  in  which  the  gastric  and  intestinal  coats  are 
often  affected  with  catarrh. 


SYMPTOMS  AND   COURSE.  569 

Let  the  contagion  of  measles  be  a  grade  more  virulent,  or  perhaps  the 
resisting  power  of  the  patient  more  feeble,  and  the  case  will  assume  the 
features  of  the  septic,  typhous,  or  hemorrhagic  variety  (rubeola  uigra). 
It  is  said  that  the  hemorrhagic  measles  is  most  apt  to  occur  in  epidemics ; 
certain  it  is  that  the  dreaded  black  measles  of  former  times  is  very  infre- 
quent now-a-days,  due,  no  doubt,  to  a  more  rational  treatment  and  a 
better  hygiene.  Isolated  cases,  however,  are  occasionally  encountered. 
As  a  rule,  from  the  beginning  all  the  symptoms  evidence  an  overwhelm- 
ing of  the  system  by  the  virulence  of  the  poison — a  condition  of  things 
much  more  common  in  scarlatina.  The  pulse  becomes  weak,  thready, 
and  frequent ;  the  temperature  lacks  the  typical  remittent  character  of 
normal  measles ;  there  is  unusual  prostration ;  and  the  nervous  centres 
are  profoundly  concerned,  as  shown  by  delirium,  convulsions,  and  coma. 
The  eruption  lags,  and  finally  makes  its  appearance  in  an  imperfect  or 
irregular  manner.  The  spots  are  of  a  livid  hue,  interspersed  with  larger 
or  smaller  ecchymoses.  •  Hemorrhages  from  the  mucous  cavities  take 
place,  and  the  patient  dies  in  convulsions  or  sinks  into  fatal  coma.  It 
has  been  said  that  the  grave  constitutional  symptoms  do  not  generally 
make  their  appearance  till  the  eruptive  stage,  but  I  know  from  experi- 
ence that  the  patient  may  be  overwhelmed  quite  early,  as  in  purpura 
variolosa. 

Too  much  stress  should  not  be  laid  on  these  different  types  of  the 
disease,  whether  mild  or  grave,  since  they  depend  upon  a  common  cause, 
however  much  modified  in  one  way  or  another ;  but  they  may  be  allowed 
to  stand  for  the  sake  of  clinical  convenience. 

Measles  may  also  present  certain  irregularities  in  its  various  stages 
without  necessarily  departing  from  the  otherwise  benign  character  of  the 
disease. 

As  stated  elsewhere,  it  is  believed  by  some  writers  that  a  greater  part 
of  the  period  of  incubation  is  occupied  by  symptoms  which  already  indi- 
cate the  activity  of  the  measles  poison  in  the  system,  and  that,  therefore, 
this  stadium  in  reality  lasts  but  a  few  days.  This  opinion  does  not  seem 
to  be  generally  accepted ;  at  any  rate,  I  think  we  are  quite  safe  in  saying 
that  in  the  majority  of  cases  no  departure  from  the  usual  latency  is 
observed.  The  deviations  in  the  stage  of  invasion  have  been  considered 
above,  and  mostly  concern  its  duration  and  the  character  of  the  tempera- 
ture. Evanescent  rashes,  which  have  nothing  in  common  with  the  spe- 
cific exanthem,  are  sometimes  observed  at  this  period.  The  eruption  of 
measles  may  present  certain  peculiarities.  First,  as  to  localization. 
Instead  of  coming  out  on  the  face  first,  it  may  primarily  develop  on 
other  parts  of  the  body,  provoked  into  existence,  as  it  were,  by  local 
exciting  causes ;  thus,  where  ointments  or  plasters  have  been  applied  or 
upon  a  part  subjected  to  constant  pressure.  It  may  affect  only  one-half 
of  the  body,  or  entirely  spare  paralyzed  extremities  (Mayr).  In  some 
instances  the  papules  are  so  sparse,  indistinct,  and  short-lived  as  to  be 
scarcely  appreciable. 

Second,  as  to  the  physical  characters  of  the  eruption.  Hebra  and  Mayr 
recognize  the  following  modifications  : 

Morbilli  tavis.  The  efflorescence  is  smooth  and  flat,  and  the  individ- 
ual lesions  are  separated  from  each  other  by  normal  integument.  Thie 
is  the  common  form  of  measles. 


570  RUBEOLA. 

Morbilli  papulosi.  The  papules  are  dark  red  and  more  elevated,  are 
about  the  size  of  hempseeds,  and  situated  at  the  mouths  of  tiie  hair-fol- 
licles. 

Morbilli  vesiculosi.  In  this  variety  the  mouths  of  the  hair-follicles 
are  tilled  with  fluid  and  produce  delicate  transparent  vesicles. 

Morbilli  confluentes.  The  maculae  are  here  so  crowded  together  that 
no  healthy  skin  intervenes. 

Morbilli  hsemorrhagici.  The  efflorescence  consists  of  macula?  or  pap- 
ulae of  a  dark-red  color,  due  to  extravasations  of  blood,  and  do  not  fade 
on  pressure.  It  is  well  to  mention  in  this  connection  the  fact,  particu- 
larly noted  by  Meigs  and  Pepper  in  this  country,  that  hemorrhages  into 
the  skin  may  occur  in  cases  which  otherwise  run  a  benign  course.  They 
are  best  seen  after  the  eruption  has  faded.  In  some  cases  the  efflores- 
cence of  measles  may  remain  visible  for  a  week  or  ten  days. 

As  heretofore  observed,  there  may  be  a  relapse  of  the  measles  eruption 
after  some  weeks,  accompanied  by  fever.  It  is  said  that  the  spots  appear 
on  parts  of  the  skin  hitherto  normal  (Thomas).  So  far  as  I  know,  Hebra 
was  one  of  the  first  to  point  out  the  fact  that  the  so-called  stri king-in  of 
the  eruption  was  the  result,  and  not  the  cause,  of  some  complication  in 
the  disease  ;  for,  as  this  author  states,  before  the  rash  fades  or  disappears 
the  internal  disease  is  always  present.  It  is  well  known,  for  instance, 
that  syphilitic  eruptions  will  sometimes  disappear  upon  the  supervention 
of  some  acute  intercurrent  affection,  such  as  pneumonia,  acute  rheuma- 
tism, etc.;  but  no  one  will  suppose  for  a  moment  that  the  retrocession  of 
the  syphilides  was  the  cause  of  these  affections.1  The  pathological  expla- 
nation seems  obvious. 

COMPLICATIONS. — The  complications  of  measles  consist,  as  a  rule,  in 
the  exaggerated  morbid  action  of  organs  or  parts  that  are  essentially 
implicated  in  the  disease ;  therefore  we  are  most  apt  to  encounter  such 
affections  as  laryngitis,  bronchitis,  pneumonia,  etc.  Inflammation  of 
serous  membranes,  on  the  other  hand,  are  rare ;  thus,  pleurisy  is  infre- 
quent unless  in  connection  with  a  lobar  pneumonia. 

The  exact  causes  of  the  complications  are  not  always  obvious,  but  in 
many  instances  can  be  traced  to  the  previous  bad  health  of  the  patient, 
to  the  influence  of  insanitation,  or,  finally,  to  certain  ill-understood  fea- 
tures attendant  upon  some  epidemics. 

Simple  bleeding  from  the  nose,  not  associated  with  the  hemorrhagic 
diathesis,  is  not  an  uncommon  accompaniment  of  the  prodromal  stage, 
and  is  rarely  a  dangerous  symptom — rather  the  contrary.  It  may  also 
arise  after  the  development  of  the  rash,  and  occasionally  proves  a  compli- 
cation of  serious  import. 

The  aural  complications,  unlike  those  in  scarlatina,  are  generally  not 
.sufficiently  prominent  at  first  to  attract  attention.  The  symptoms,  par- 
ticularly pain  and  deafness,  are  apt  to  be  masked.  Purulent  processes 
and  consequent  perforation  may  occur  during  the  eruption,  but  are  more 
frequent  at  the  stage  of  desquamation  (Spencer).2 

Various  disorders  of  the  skin  have  been  observed  during  the  course  of 
measles — viz.  miliary  vesicles,  and  even  pustules,  as  already  described ; 
herpes  facialis,  zoster  femoralis  (Thomas),  and  erythematous  rashes,  which 

1  See  Bumstead  and  Taylor  on  Venereal  Disease*,  4th  edit.,  p.  513. 

2  Oral  communication. 


COMPLICATIONS.  571 

may  precede,  accompany,  or,  it  is  said,  follow  the  eruption.  Of  consider- 
ably more  importance  is  the  pemphigoid  eruption  mentioned  by  several 
observers.  In  Henoch's1  case,  a  girl  of  four  years,  the  usual  remission 
of  the  fever  on  the  evening  of  the  second  day  was  absent,  and  from  the 
third  day  there  appeared  over  nearly  the  whole  surface  blebs  filled  with  a 
limpid  fluid,  which  varied  in  size  from  a  hazel-nut  to  a  thaler,  and  even 
larger.  The  cheeks  and  the  backs  of  the  hands  were  each  covered  with 
a  single  bleb.  The  exanthem  was  of  a  hemorrhagic  character,  and  the 
intervening  skin  was  red  and  the  face  swollen.  The  bullse  appeared  not 
only  where  the  eruption  existed,  but  also  on  parts  of  the  body  free  from 
it.  The  fever  remained  at  the  same  height  till  the  fifth  day,  when,  upon 
the  cessation  of  the  bullous  eruption,  it  fell  to  100°  F.  A.  M.,  and  101°  F. 
p.  M.  The  child  died  on  the  eighth  day  of  a  pneumonia  which  developed 
between  the  sixth  and  seventh  days.  Other  cases  have  been  reported  by 
Steiner,  Kliippel,  and  Loschner.  Henoch  rejects  the  theory  that  the 
bullse  are  the  result  of  the  morbillous  dermatitis,  but  thinks  that  they 
are  merely  instances  of  the  coincidence  of  a  contagious  pemphigus. 

The  severe  aifections  of  the  eye  described  by  continental  writers — blen- 
norrhoaa,  keratitis,  iritis,  etc. — are  certainly  very  rare  in  this  country  as 
complications  of  measles.  Various  so-called  strumous  disorders  of  this 
organ,  as  will  be  seen  hereafter,  not  uncommonly,  however,  come  under 
the  care  of  the  ophthalmologist  as  sequelae  of  the  disease. 

The  tonsils  and  the  mucous  membrane  of  the  pharynx  may  become 
severely  inflamed.  The  tonsils  are  sometimes  very  much  enlarged,  but 
suppuration,  if  it  occur,  is  certainly  rare.  Slight  ulceration  of  the  gums 
close  to  the  teeth  is  occasionally  noted,  also  aphthous  ulcerations  on  the 
lips,  tongue,  and  gums  (Ringer). 

Some  degree  of  laryngitis  is  an  accompaniment  of  all  cases  of  measles. 
It  has  already  been  stated  that  catarrhal  or  false  croup  is  frequently 
observed  during  the  stage  of  invasion.  Inflammation  of  the  larynx  may 
be  present  in  all  grades  of  severity.  Rilliet  and  Barthez  found  ulcera- 
tions and  erosions,  especially  of  the  vocal  cords,  upon  post-mortem  exam- 
ination of  a  large  proportion  of  measles  subjects ;  and  Gerhardt,  both 
during  life  and  by  autopsy,  has  verified  these  observations.  Loeri2  states 
that  inflammatory  changes  are  more  marked  in  the  larynx  and  trachea 
than  in  the  pharynx.  According  to  his  examinations,  hemorrhages  or 
ecchymoses  seldom  occur,  but  more  frequently  superficial  or  even  deep 
catarrhal  ulcers,  especially  on  the  anterior  aspect  of  the  posterior  wall  of 
the  larynx  at  the  apices  of  the  cartilages  of  Santorini,  or  on  the  posterior 
portion  of  the  vocal  cords.  The  physical  condition  of  these  parts  readily 
accounts  for  the  frequent  and  harassing  cough  and  attacks  of  spasmodic 
laryngitis  which  are  such  frequent  complications  of  the  invasion  and 

1*7?  f  i 

eruptive  stages  of  measles. 

There  may  be  an  extension  of  the  tracheo-bronchitis  to  the  finer  bron- 
chial tubes,  thus  producing  capillary  bronchitis  (suffocative  catarrh).  It 
is  apt  to  prove  fatal  to  very  young  children.  It  occurs  more  generally 
during  or  after  the  eruption. 

Pneumonia  is  one  of  the  most  frequent  and,  directly  and  indirectly, 
most  dangerous  complications  of  measles.  Catarrhal  pneumonia  (bron- 
cho-pneumonia) is,  for  obvious  reasons,  more  common  than  the  lobar  or 

1  Berl.  klin.  Woch.,  No.  13,  1882.  *  Jahrbf.  Kinderhdlk,  xix.  B.,  1  H. 


572  RUBEOLA. 

croupous  variety.  Pneumonia  may  develop  at  almost  any  stage  of 
measles,  but  experience  does  not  confirm  the  statement  occasionally  made 
that  it  is  most  frequent  in  the  initial  stage.  Most  observers  will  agree  as 
to  its  greater  frequency  just  at  the  end  of  the  eruption  or  during  the 
desquamative  period.  The  occurrence  of  epileptoid  convulsions,  or  an 
untoward  increase  of  the  fever,  or  an  unexplained  continuance  of  the 
same,  should  direct  the  attention  of  the  attendant  to  the  chest,  if  his  anx- 
iety have  not  already  been  aroused  by  a  change  in  the  character  of  the 
respiration  or  other  symptoms.  It  may  be  mistaken  for  meningitis 
(Squire).  In  estimating  the  prognosis  it  should  be  remembered  that 
croupous  and  catarrhal  pneumonias  run  quite  different  courses.  The 
influence  of  inflammation  of  the  lungs  upon  the  rash  is  quite  decided. 
If  an  intense  pneumonia  should  develop  in  the  initial  stage,  the  eruption 
will  be  pale  and  sparse,  or  else  absent ;  if  the  eruption  is  already  out  at 
the  time  of  the  attack,  it  may  become  temporarily  more  vivid,  to  rapidly 
fade  later.1 

Chadbourne2  has  the  merit  of  calling  attention  to  the  occurrence  of 
heart-clot  and  subsequent  pulmonary  oedema  as  a  fatal  complication  of 
measles.  In  a  number  of  autopsies  he  found  that  in  each  case  the  heart 
contained  clear  gelatinous  clots  of  a  very  firm  consistence,  which  in  most 
instances  extended  to  the  pulmonary  arteries,  and  in  some  to  the  extent 
of  one  and  one-fourth  inches.  In  the  series  of  cases  observed  by  him 
pneumonic  consolidation  was  mostly  absent,  and  there  was  very  little 
evidence  of  collapse,  but  the  lungs  were  exceedingly  osdematous.  But 
Keating  has  also  found  heart-clot  to  be  the  cause  of  death  in  some  cases, 
and  believes,  as  the  result  of  his  investigations,  that  the  presence  of  large 
numbers  of  micrococci  in  the  blood  and  in  the  white  blood-corpuscles  is 
responsible  for  this  condition.3 

There  is  a  strong  tendency  in  measles  to  intestinal  catarrh.  As  already 
stated,  a  quite  sharp  diarrhoea  is  not  uncommon  at  the  beginning  of  the 
eruptive  stage ;  but,  unless  it  should  prove  "^ery  profuse  and  long-con- 
tinued, it  is  not  to  be  looked  upon  as  of  very  serious  import,  especially 
if  the  other  general  symptoms  of  the  disease  are  following  a  normal 
course.  In  other  instances  the  bowel  affection  may  be  much  more  severe, 
giving  rise  to  tenesmus,  bloody  stools,  and  the  other  phenomena  of  colitis. 
In  weakly  children  the  early  diarrhoea  may  persist  in  spite  of  treatment 
for  many  days  ;  indeed,  under  the  influence  of  high  temperatures  it  may 
take  on  a  true  choleraic  character.  Diarrhoea  is  a  very  frequent  and  grave 
complication  of  the  broncho-pneumonia  of  measles. 

Acute  miliary  tuberculosis  as  an  immediate  concomitant  of  measles  is 
rare.  According  to  Thomas,  the  disease  at  times  immediately  follows 
the  exanthem,  and  reaches  a  fatal  issue  in  a  few  days  or  weeks.  The 
tubercles  are  more  particularly  to  be  found  in  the  lungs  and  in  the 
membranes  of  the  brain. 

Among  the  more  common  disturbances  of  the  nervous  system  convul- 
sions play  an  important  rdle.  The  epileptoid  seizures  of  the  prodromal 
stage  generally  terminate  favorably,  but  in  some  cases  of  a  malignant 
character  the  onset  of  the  disease  may  be  ushered  in  with  fatal  convul- 

1  A  scanty  rash  by  no  means  indicates  an  unfavorable  course  of  the  disease  ;  this  symp- 
tom is  only  serious  when  evidently  due  to  some  complication. 
1  Am.  Jour.  Obstet.,  Oct.,  1880.  *  Pkila.  Med.  Times,  Aug.  12,  1882. 


SEQUELS. 

sions.  Convulsions  in  the  later  stages  are  apt  to  have  a  lethal  termina- 
tion, as  they  usually  occur  in  connection  with  some  grave  complication, 
particularly  of  the  thoracic  organs. 

Diphtheria  is  an  exceedingly  grave  complication  of  measles,  although 
not  necessarily  a  fatal  one.  It  is  of  less  frequent  occurrence  than  in 
scarlatina.  It  may  attack  any  of  the  usual  oral,  nasal,  or  laryngeal 
regions,  sometimes  extending  into  the  bronchi,  but  suffers  no  modi- 
fications in  its  symptoms  and  course  from  the  primary  disease.  It 
may  also  rarely  involve  other  parts — e.  g.  genitals,  eyelids,  etc.  There  is 
reason  to  believe  that  it  is  most  prone  to  attack  those  cases  in  which  the 
mucous  membranes  have  undergone  the  greatest  inflammatory  alterations.1 

Many  other  complications  of  measles  have  been  recorded  in  literature 
(see  Thomas,  op.  cit.*) ;  but  it  is  no  doubt  true/as  observed  by  Bohn,  that 
very  few  of  them  have  a  real  essential  connection  with  that  affection,  and 
might  as  readily  be  associated  with  any  other  malady,  especially  in  already 
vitiated  constitutions.  In  the  above  sketch  the  endeavor  has  been  made 
to  indicate  those  disorders  which  from  the  nature  of  measles  would  seem 
to  have  a  more  or  less  close  and  definite  relationship  to  it.  It  is  certain 
that  the  more  serious  complications  and  sequelae  of  measles  are  compara- 
tively infrequent  in  private  practice  in  America,  although  common  enough 
in  continental  Europe,  and  to  a  certain  extent  in  the  children's  asylum? 
and  foundling  hospitals  in  this  country. 

SEQUELAE. — It  is  a  difficult  matter  to  dissociate  the  complications  and 
sequelae  of  measles.  Properly  speaking,  the  sequelae  are  to  be  looked 
upon  as  the  complications  which  have  continued  in  existence  after  the 
subsidence  of  the  exanthem ;  but  it  is  also  customary  to  include  under 
this  head  certain  affections  that  are  the  result  of  the  derangement  of  the 
system  by  the  morbillous  process. 

As  would  be  expected,  among  the  most  frequent  sequelae  of  measles 
are  those  diseases  which  have  their  seat  in  the  mucous  membranes.  Thus, 
we  may  observe  various  grades  of  inflammation  and  ulceration  of  the 
larynx,  trachea,  and  bronchial  tubes.  According  to  Loeri,  follicular 
ulcers  of  the  larynx  always  give  a  bad  prognosis,  for  these  cases  usually 
succumb  to  tuberculosis.  It  is  not  uncommon  to  observe  a  bronchial 
catarrh,  apparently  simple  in  nature,  which  persists  with  frequent  exacer- 
bations for  many  mouths.  The  very  frequent  broncho-pneumonia,  which 
occurs  as  a  complication,  always  remains  as  a  sequel,  or  it  may  develop 
after  the  morbillous  process  has  come  to  an  end.  In  favorable  cases 
recovery  may  take  place  in  two  or  three  weeks,  or,  preceded  by  hectic  and 
progressive  emaciation,  the  disease  may  prove  fatal  after  a  number  of 
months.  But  even  here  it  is  not  impossible  for  affected  persons  to 
recover. 

Chronic  pulmonary  tuberculosis  is  one  of  the  most  formidable  and  fre- 
quent sequelae  of  measles.  It  is  a  not  uncommon  occurrence  that,  with 
the  exception  of  some  trivial  bronchitis,  a  patient  may  apparently  recover 
his  health  completely,  and  only  after  a  lapse  of  time  slight  daily  eleva- 
tions of  temperature,  accompanied  by  loss  of  appetite  and  emaciation, 

1  Loeri  (loe.  cit.)  says  that  diphtheria  may  appear  at  any  stage  of  measles,  and  com- 
mences generally  in  the  larynx,  and  sometimes  in  the  trachea  simultaneously ;  seldom 
in  the  pharynx,  as  in  primary  diphtheria  or  in  that  complicating  other  diseases  than 
measles. 


574  RUBEOLA. 

first  give  warning  of  the  impending  danger.  This  form  of  phthisis  may 
follow  either  croupous  or  catarrhal  pneumonia.  Granular  meningitis  or 
general  miliary  tuberculosis  also  frequently  follows  in  the  wake  of 
measles,  connected  in  many  cases  with  foci  of  caseous  degeneration  in  the 
involved  lymphatic  glands  or  unabsorbed  pneumonic  exudation. 

Various  gangrenous  affections,  particularly  of  the  oral  cavity  (noma) 
and  genitals,  but  also  of  the  skin,  subcutaneous  connective  tissue,  car- 
tilages of  the  nose,  ear,  etc.,  are  often  to  be  observed  after  an  attack  of 
measles.  Cancrum  oris  is  to  be  especially  noted. 

Albuminuria  is  not  an  essential  sequel  of  measles,  although  it  may 
occasionally  occur  as  the  result  of  great  exposure  and  neglect. 

A  large  group  of  chronic  affections  may  follow  in  the  track  of  measles, 
either  in  the  form  of  sequelae  to  the  complications  which  arise  during  the 
course  of  the  disease  or  in  the  nature  of  secondary  accidents.  Some  few, 
perhaps,  are  more  common  after  measles  than  after  any  other  complaint, 
but  the  majority  are  such  as  might  arise  in  weakly  children  subsequent 
to  any  specific  disturbance  of  the  health.  In  addition  to  those  already 
mentioned  we  may  especially  designate  chronic  intestinal  disease,  together 
with  ulceratious  and  strictures  of  the  bowel ;  chronic  coryza,  in  varying 
degrees  of  obstinacy  and  severity ;  chronic  ophthalmia,  under  which  title 
may  be  included  ciliary  blepharitis,  granulations,  trachoma,  phlyctenular 
conjunctivitis,  ulcers  of  the  cornea,  etc.  (Michel1);  aural  affections  in  the 
form  of  chronic  suppurative  inflammation,  and,  more  rarely,  chronic 
catarrh  of  the  middle  ear  (Spencer) ;  certain  cutaneous  diseases,  more 
especially  in  my  experience  furunculosis  and  pustular  eczema;  chronic 
bone  and  joint  disorders  (strumous),  which,  according  to  Gibney,2  may 
not  only  be  evoked  in  the  already  hereditarily  predisposed,  but  also 
induced  when  the  diathesis  has  not  heretofore  existed ;  and,  lastly, 
various  derangements  of  the  nervous  system. 

In  Thomas's  valuable  and  freely-quoted  monograph  on  measles  (pp.  tit.) 
it  is  stated  that  secondary  measles  can  exert  various  influences  upon  the 
primary  disturbance.  In  most  instances  when  measles  attacks  a  person 
already  the  subject  of  some  other  disease,  particulaily  when  the  latter 
belongs  to  the  common  complications  of  the  former,  it  usually  is 
aggravated.  This  is  a  matter  of  common  experience ;  but  this  author 
further  declares — and  supports  his  assertion  with  numerous  references — 
that,  on  the  other  hand,  should  measles  appear  during  the  existence  of  a 
disease  to  which  it  does  not  usually  give  rise,  it  may  favorably  influence 
the  course  of  the  latter.  In  spite  of  the  cases  quoted  in  support  of  this 
view,  such  results  would  appear  to  be  contrary  to  pathological  laws.3 

1  Oral  communication. 

2  See  valuable  statistical  article  in  N.  Y.  Med.  Record,  June  3,  1882. 

3  Thus,  while  Thomas  seems  to  be  without  personal  experience  in  the  matter,  he  quotes 
without  dissent  a  number  of  observations  in  support  of  his  assertion — viz. :  Behrend  saw 
a  chronic  eczema  of  the  scal|i  permanently  disappear  after  measles ;  Rilliet  found  that  a 
chronic  coxitis  improved  noticeably  after  measles;  various  chronic  skin  symptoms,  and 
also  chorea,  epilepsy,  incontinence  of  urine,  mania,  worms,  dropsy,  joint  diseases,  ophthal- 
mia, gonorrhoea,  etc..  have  been  known  to  recover  under  the  same  influence.     Gibney  (loc. 
cit.)  in  his  valuable  paper  states  that  he  can  readily  believe  that,  occasionally,  any  acute 
disease,  occurring  in  the  course  of  a  chronic  one,  will  prove  beneficial  to  tlie  other,  but 
that  he  is  far  from  considering  this  to  be  anything  more  than  an  exception  to  a  very 
general  rule  to  the  contrary.     Chronic  joint  disease,  he  continues,  is  especially  a  disease 
of  exacerbations,  and  any  one  not  familiar  with  their  natural  history  may  interpret  the 
post  hoc  as  a  propter  hoc.     Gibney  has  collected  24  cases  of  chronic  bone  disease  in  chil- 


DR  P.  S.  O'REILLY  &  STAFF 

MORBID  ANATOMY.— DIAGNOSIS.  575 

MORBID  ANATOMY. — The  normal  rash  of  measles  is  not  to  be  observed 
on  the  dead  body,  and  the  only  lesions  of  the  skin  to  be  noted  are  those 
resulting  from  extravasation  of  blood  into  that  tissue.  Examination  of 
the  skin  removed  during  life  from  a  patient  with  measles  reveals  the  fol- 
lowing anatomical  changes,  according  to  Morris.1  In  the  earliest  stages 
are  found  usually  slight  hypersemia  around  the  orifice  of  a  sebaceous  folli- 
cle, with  slight  swelling  from  effusion  of  plasma.  Occasionally  swelling 
alone  is  present,  and  more  rarely  hypersemia  only.  Round  the  small 
hypersernic  papule  thus  developed — often  pierced  by  a  hair — a  roseolar 
patch,  due  to  congestion  of  the  papillary  body,  soon  makes  its  appearance. 
Slight  exudation  of  plasma,  with  a  few  corpuscles,  usually  follows,  and 
produces  elevation  of  the  papule  itself.  As  most  of  the  deaths  in  measles 
are  due  to  the  presence  of  some  complication,  the  post-mortem  changes 
will  be  found  to  correspond  to  the  lesions  produced  by  these  diseases,  prin- 
cipally affections  of  the  respiratory  organs  and  intestinal  tract. 

DIAGNOSIS. — As  a  rule,  the  diagnosis  of  measles  offers  no  great  diffi- 
culties, especially  if  a  correct  clinical  picture  of  the  disease  has  been 
thoroughly  impressed  upon  the  mind.  The  salient  points  may  be  thus 
summarized  :  A  period  of  incubation  of  about  fourteen  days — i.  e.  from 
the  date  of  infection  to  the  commencement  of  the  eruption ;  a  prodromic 
stage  of  about  four  days,  ushered  in  with  fever  and  marked  implication 
of  the  mucous  tract,  notably  cough,  coryza,  epistaxis,  and  photophobia ; 
in  this  stage  may  also  be  noted  the  punctated  redness  of  the  conjunctivas 
and  of  the  palatal  mucous  membrane,  which  is  to  be  regarded  as  a  diag- 
nostic sign  of  great  value  and  importance ;  finally,  there  appears  at  the 
conclusion  of  the  stage  of  invasion,  simultaneously  with  increase  of  the 
febrile  movement,  a  characteristic  eruption  upon  the  cutaneous  surface, 
this  eruption  coming  out  first  upon  the  face,  and  composed  of  large 
maculo-papules  of  brownish  -red  color,  arranged  in  a  crescentic  form  with 
tracts  of  normal  integument  intervening.  Of  all  the  symptoms  of 
measles,  the  catarrh  of  the  mucous  membranes  is  undoubtedly  the  most 
pathognomonic.  In  the  colored  races,  where  the  recognition  of  the  skin 
lesion  is  often  a  matter  of  difficulty,  this  combination  of  symptoms  should 
be  borne  in  mind.2 

dren,  21  of  whom  were  under  ten  years  of  age  and  all  under  thirteen.  On  analysis  lie 
found  that  12  of  these  came  out  of  the  intercurrent  disease  in  a  worse  condition,  11  were 
unaffected,  and  1  only  seemed  a  little  better.  In  my  personal  experience  I  have  invari- 
ably seen  the  eczemas  of  children  made  worse  by  measles.  I  have  no  wish  to  dispute  the 
trustworthiness  of  the  statistics  quoted  by  Thomas;  indeed,  I  regard  them  as  mostly 
thoroughly  reliable  instances  of  exceptions  to  a  general  pathological  law ;  but  I  wish  it 
to  be  clearly  understood  that  they  are  such,  and  that  measles  is  not  a  disease  to  be  slightly 
regarded  as  to  its  effects  upon  the  system. 

1  Skin  Diseases.  Phila.,  1880,  p.  57. 

5  Corre  (La  MZre  et  V Enfant  dans  les  races  humaines,  Paris,  18S2)  states  that  measles  and 
scarlatina  exist  in  all  climates  and  among  all  races ;  however,  they  are  less  frequent  in 
warm  than  in  cold  climates.  This  relative  rarity  may  be  only  apparent,  and  has_  only 
been  established  by  reason  of  the  difficulty  of  recognizing  exanthems  among  dark-skinned 
peoples.  In  the  negro  the  eruption  (of  measles)  often  escapes  observation,  but  the 
general  symptoms,  the  angina,  coryza,  and  bronchitis,  and  the  special  coloration  of 
the  bucco-pharyngeal  membranes,  permit  the  establishment  of  the  diagnosis.  The 
skin  appears  more  tense,  and  the  face  especially  is  puffed  and  glossy  ;  in  passing  the 
hand  over  the  different  regions  of  the  body  slight  elevations  are  felt— a  difference  in  the 
level  of  the  skin  exists  in  the  affected  and  unaffected  portions.  On  examining  the  sur- 
face of  the  body  obliquely  at  a  well-pronounced  angle  of  incidence,  these  elevations  can 
be  perceived  by  the  eye.  Desquamation,  which  is  very  manifest  in  the  negro,  also  con- 
firms the  diagnosis  ;  this  desquamation  is  formed  of  epidermic  debris;  it  gives  rise  to  a 


576  EUSEOLA. 

In  the  way  of  conjectural  diagnosis,  the  presence  of  an  epidemic  of 
measles  in  the  community  should  be  taken  into  account.  Although 
measles  possesses  features  so  characteristic  and  pronounced,  there  are  a 
number  of  other  diseases  with  which  it  may  be  confounded,  especially  in 
its  earlier  stages. 

There  is  no  other  disease  which  presents  so  close  a  resemblance  to 
measles  as  does  rothelu,  and  it  must  be  confessed  that  under  certain  cir- 
cumstances the  question  of  diagnosis  is  a  perplexing  one.  In  rotheln  the 
appearance  of  the  eruption  is  often  the  first  symptom  of  the  affection, 
whereas  in  measles  there  is  a  prodromic  period,  having  a  peculiar  remit- 
tent type  of  fever,  which  continues  for  three  or  four  days.  According  to 
Liveing,  the  short  duration  of  the  febrile  attack  before  the  eruption 
appears  is  one  of  the  most  constant  and  distinctive  features  wherein 
rotheln  differs  from  ordinary  measles.  In  some  instances,  in  rotheln  the 
premonitory  fever  is  not  at  all  appreciable.  The  catarrhal  involvement 
of  the  mucous  membranes  is  not  nearly  so  marked  as  in  measles,  while 
the  very  frequent  sore  throat  bears  more  resemblance  to  the  angina  of 
scarlet  fever.  In  many  instances,  although  by  no  means  constantly,  the 
eruption  of  rdtheln  first  appears  on  the  chest,  and  not  on  the  face,  as  is 
the  rule  in  measles.  It  is  quite  evident  that  the  eruptive  spots  of  rotheln 
have  presented  different  physical  features  in  different  epidemics ;  but,  as 
a  general  thing,  it  may  be  said  that  they  are  smaller  than  those  in  measles, 
of  a  paler  color,  and,  according  to  Thomas,  not  so  angular,  less  indented, 
and  not  so  often  provided  with  processes,  therefore  less  apt  to  assume  the 
crescentic  arrangement  so  often  seen  in  measles.1  The  incubation  period 
is  longer  in  r5theln  than  in  measles. 

In  scarlet  fever  the  incubation  stage  is  shorter  than  in  measles,  and  the 
constitutional  symptoms  are  apt  to  be  more  pronounced ;  the  temperature 
is  higher,  the  pulse  more  rapid,  and  vomiting  more  frequent.  The  stage 
of  invasion  in  scarlatina  is  but  twenty-four  hours ;  in  measles,  seventy-two. 
There  is  absence  of  the  characteristic  catarrh  of  measles,  and  the  pres- 
ence of  severe  sore  throat,  strawberry  tongue,  and  swelling  of  the  lym- 
phatics at  the  angle  of  the  jaws.  In  measles  the  rash  begins  on  the  face ; 
in  scarlatina,  on  the  neck  and  chest.  In  measles  the  eruption  con- 
sists of  large  papules  arranged  somewhat  crescentically,  with  intervening 
normal  skin,  followed  by  bran-like  desquamation  ;  in  scarlatina  the  rash 
is  made  up  of  large  patches  formed  of  minute  red  spots  on  a  bright  red, 
hypersemic  base,  and  is  followed  by  desquamation  in  large  lamellae.  In 
measles  the  rash  is  brightest  on  exposed  parts ;  in  scarlatina,  most  vivid 
on  covered  regions.  The  sequelae  of  the  two  diseases  are  quite  different. 

There  is  no  great  difference  in  the  duration  of  the  invasion  stages  of 
variola  and  rubeola ;  but  in  the  former  disease  we  have  the  marked 
lumbar  and  sacral  pains  and  vomiting,  while  in  the  latter  the  catarrhal 
symptoms  and  photophobia  are  pathognomonic.  "When  the  eruption  of 

white  dust,  which  is  well  defined  against  the  black  skin.  The  skin  itself  seems  to  have 
lost  its  gloss ;  it  is  completely  dry,  and  no  longer  gives  the  abundant  and  odoriferous 
secretion  characteristic  of  the  subjects  of  that  race. 

1  According  to  Curtman  (St.  Louis  Courier  Hfed.,  June,  1882),  the  eruption  of  rotheln 
consists,  when  not  confluent,  of  single  papules,  each  separated  by  a  distinct  small  red 
areola.  Not  infrequently  the  papules  are  large,  and  sometimes  a  few  pass  into  vesicles 
or  pustules.  In  measles  (he  papules  are  very  small,  mostly  confluent,  from  four  to  six 
landing  on  a  single  areola,  which  is  larger  than  that  of  rotheln. 


PROGNOSIS.  577 

small-pox  appears  there  is  subsidence  of  fever ;  in  measles,  an  exacerba- 
tion. A  point  of  great  importance  in  the  diagnosis  of  variola  is  found 
in  an  examination  of  the  mouth  and  pharynx,  for  in  these  situations  on 
the  fourth  day  we  will  often  find  the  vesicles  fully  developed,  while  on 
the  skin  they  are  still  in  the  stage  of  papulation.  When  measles  assumes 
the  papular  form  (morbilli  papulosi,  rongeole  bouttoueuse),  it  is  often  con- 
founded with  the  papular  stage  of  small-pox.  I  have  seen  a  number  of 
such  mistakes  made.  Attention  to  the  general  symptoms  of  the  two  dis- 
eases, however,  and  particularly  an  examination  of  the  mucous  mem- 
branes, will  generally  clear  up  any  doubt.  At  any  rate,  the  question  will 
generally  settle  itself  in  the  next  twenty-four  hours,  for  if  it  be  variola 
the  papules  will  have  undergone  their  specific  development  and  the  rube- 
olous  elevations  will  have  become  more  decidedly  macular. 

Typhus  sometimes  offers  a  certain  resemblance  to  measles.  According 
to  Buchanan,1  the  eruption  of  typhus  is  occasionally,  though  not  com- 
monly, a  good  deal  like  that  of  measles,  and  appears  about  the  same  time 
after  invasion.  Coryza,  when  present  and  distinct,  points  to  measles. 
The  eruption  of  typhus  is  of  a  smaller  pattern,  discrete,  and  not  raised ; 
that  of  measles,  often  coalescent,  crescent  ic,  and  elevated.  Subcuticular 
mottling  is  present  in  typhus,  and  absent  in  measles.  The  "palatal  mucous 
membrane  should  ajways  be  examined  in  suspected  measles. 

As  I  have  never  been  able  to  convince  myself  of  the  existence  of  an 
independent  disease  called  roseola,  I  am  at  a  loss  to  give  the  points  of 
differential  diagnosis ;  on  the  other  hand,  the  various  forms  of  sympto- 
matic erythema,  occurring  either  as  the  result  of  numerous  slight  derange- 
ments of  the  system,  or  in  connection  with  grave  constitutional  disease, 
should  be  carefully  considered.  In  the  first  group  of  cases  the  absence 
of  premonitory  symptoms,  catarrh,  etc.,  and  the  presence  of  the  smooth, 
rose-colored  macules,  mostly  on  the  trunk,  and  in  the  latter  the  existence 
of  symptoms  belonging  to  the  primary  disease,  should  prove  of  assist- 
ance. The  erythema  papulatum  of  new-born  children  I  have  seen  mis- 
taken for  measles,  but  the  fact  that  rubeola  is  exceedingly  rare  in  suck- 
lings, and  the  absence  of  fever  and  catarrhal  disturbances,  are  sufficient 
grounds  for  a  differential  diagnosis. 

The  erythematous  syphilide  (roseola  syphilitica),  particularly  when 
accompanied  by  fever,  may  bear  some  resemblance  to  the  rash  of  measles ; 
but  the  history  of  the  case,  the  circumscribed,  indolent  character  of  the 
syphilide,  in  many  instances  sparing  the  face,  the  absence  of  pathogno- 
monic  catarrhal  symptoms  of  measles,  and  the  coexistence  of  other  fea- 
tures of  syphilis,  are  quite  distinctive. 

PROGNOSIS. — The  prognosis  of  normal  uncomplicated  measles  is  very 
favorable.  Thus,  of  257  cases  observed  by  Meigs  and  Pepper  (op.  cit.}, 
all  terminated  favorably.  But  in  coming  to  any  conclusion  in  regard  to 
prognosis  a  number  of  different  factors  must  be  taken  into  consideration. 
Among  the  more  important  are — the  hygienic  surroundings  of  the  patient, 
the  age,  the  nature  of  the  complications,  whether  the  measles  be  primary  or 
secondary,  and  the  character  of  the  epidemic.  In  the  first  place,  rubeola 
in  foundling  hospitals  and  among  the  poorer  classes  in  large  cities  gives  a 
larger  ratio  of  deaths  than  among  the  well-to-do  members  of  the  com- 
munity. For  instance,  Bartels  has  shown  that  catarrhal  pneumonia,  one 

1  Art.  "Typhus"  in  Reynolds' s  System  Med.,  Am.  ed,,  p.  262. 
VOL.  I.— 37 


578  RUBEOLA. 

of  the  most  frequent  causes  of  mortality  in  this  disease,  is  particularly 
prone  to  occur  among  those  dwelling  in  crowded,  poorly-ventilated 
houses.  Then,  again,  the  asylums  and  hospitals  for  children  are  peopled 
in  many  instances  with  the  victims  of  depraved  constitutions,  who  readily 
succumb  to  iutercurrent  maladies. 

Leaving  out  of  consideration  sucklings  under  six  months  of  age,  in 
whom  measles  is  rare  and  said  to  be  slight,  most  deaths  from  the  disease 
occur  among  very  young  children,  from  their  greater  liability  to  compli- 
cations. According  to  Beddoes,1  the  mortality  from  measles  is,  beyond 
all  comparison,  greatest  in  the  second  year  of  life,  and  by  the  tenth  has 
become  quite  trifling.  An  examination  of  the  statistics  bearing  on  this 
question  coincides  with  this  general  statement ;  but  Fox's  tables,  already 
quoted,  would  show  that  more  infants  under  one  year  of  age  die  of 
measles  than  has  hitherto  been  supposed.  The  susceptibility  to  measles 
decreases  with  years,  perhaps  on  account  of  the  fact  that  most  adults 
have  already  contracted  the  disease  ;  but  when  it  does  attack  the  unpro- 
tected adult  it  may  prove  fatal.  This  statement  is  borne  out  by  the 
large  death-rate  in  the  so-called  camp  measles  of  our  late  war.2  The 
ravages  of  measles  in  virgin  communities  have  been  referred  to  in  pre- 
ceding pages.  •  The  general  temper  of  the  epidemic  must  also  be  con- 
sidered, since  it  is  well  recognized  that  the  essential  character  of  epidemics 
differs  much  as  to  severity. 

Such  complications  as  diphtheria,  catarrhal  pneumonia,  diarrhoaa,  con- 
vulsions, etc.  necessarily  affect  the  .prognosis  of  measles  most  seriously. 
More  patients  die  of  measles  in  the  second  than  in  the  first  week  of  the 
disease.  The  careful  studies  of  temperature  made  by  Thomas,  Bohn,  and 
others  show  that  an  unusually  high  and  increasing  fever  in  the  prodromal 
stage  is  of  ill  omen,  particularly  on  the  second  and  third  days,  and  a 
fever  heat  measuring  over  105°  F.  at  any  stage  should  be  considered  as 
very  unfavorable.3  Particularly  to  be  feared  is  continuation  of  the  fever 
after  the  subsidence  of  the  eruption,  or  a  sudden  elevation  after  the  nor- 
mal curve  has  been  reached.  In  fact,  it  is  a  safe  rule  to  look  upon  all 
anomalies  of  the  curve  with  suspicion.  Secondary  measles,  or  measles 
grafted  upon  some  serious  existing  affection,  is  particularly  fatal. 

TREATMENT. — There  is  no  remedy  which  will  destroy  the  suscepti- 
bility to  measles.  The  future  may  develop  some  form  of  vaccination 
against  rubeola,  for,  certainly,  the  hopes  held  out  by  the  inoculation  of 
measles  upon  the  healthy  subject  have  not  been  realized,  as  this  proced- 
ure merely  reproduces  the  original  complaint,  without  any  diminution  in 
its  intensity,  and  does  not  lessen  the  probability  of  complications  (Mayr). 
The  matter  of  carrying  out  a  practical  and  efficient  quarantine  in  measles 
is  one  of  unusual  difficulty,  for  the  reason  that  the  disease  is  capable  of 
active  propagation  at  a  time — the  prodromal  stage — when  it  is  not  yet 
sufficiently  characteristic  for  positive  diagnosis.  But,  as  measles  is  by 
no  means  as  trivial  a  disease  as  would  seem  to  be  the  common  impression, 
I  hold  it  as  a  well-established  principle  of  preventive  medicine  that  a 

1  Art.  "Mortality"  in  Q'/mn's  Dictionary  Med.,  p.  1002. 

2  In  the  general  field  hospital  at  Chattanooga  the  death-rate  was  22.4  in  100  cases.     In 
General  Hospital  No.  1,  at  Nashville,  it  was  19.6  in  100,  or  nearly  1  in  5.     Many  died  01 
became  permanently  disabled  from  the  sequelae  (Bartholow). 

8  In  adolescence  a  body  heat  of  107°  F.  has  been  safely  passed  during  the  decline  of 
measles  with  no  marked  complication  (Squire). 


TREATMENT.  579 

strict  isolation  should  be  enforced  whenever,  from  the  nature  of  the  case, 
it  is  at  all  possible ;  certainly,  very  young  children  and  those  suffering 
from  or  showing  a  tendency  to  other  diseases  should  be  jealously  shielded 
from  exposure. 

The  usual  precautions  as  to  disinfection  and  purification  of  the  room, 
bedding,  and  utensils  used  by  patients  should  be  observed,  as  in  other 
infectious  diseases.  Squire  is  of  opinion  that  there  is  danger  of  personal 
infection  for  perhaps  a  month,  and  Hillairet  that  isolation  for  forty  days 
should  be  enjoined.  It  is  quite  certain  that  inunction  lessens  the  danger 
of  infection,  and  Kaposi1  is  authority  for  the  statement  that  a  warm  bath 
administered  after  the  completion  of  desquamation,  or  about  fourteen 
days  from  the  beginning  of  the  attack,  will  effectually  prevent  conta- 
giousness. 

The  apartment  occupied  by  a  patient  suffering  from  measles  should  be 
kept  at  a  uniform  temperature  of  from  66°  to  70°  F.,  and  free  ventila- 
tion, at  the  same  time  avoiding  draughts,  should  be  enforced.  The  room 
should  be  kept  moderately  dark.  The  bed-clothing  should  be  light,  yet 
sufficiently  warm,  and  the  old  notion  of  keeping  the  patient  in  a  profuse 
sweat  the  better  to  bring  out  the  eruption  should  be  discouraged.  The 
diet  should  be  bland  and  nutritious,  and  may  preferably  consist  of  milk, 
gruel,  tapioca,  and  such  like  substances.  As  convalescence  progresses 
there  may  be  a  gradual  return  to  more  substantial  food.  The  patient  may 
be  allowed  cool  water  in  moderation,  as  it  is  cruel  and  useless,  and  even 
harmful,  to  restrict  one  suffering  with  fever  to  warm  or  sweetened  drink. 
The  patient  should  be  confined  to  his  room  until  convalescence  has  been 
fully  established,  and  should  not  be  allowed  to  leave  the  house,  both  on 
his  own  account  and  that  of  others,  until  the  usual  health  has  been 
regained.  Any  of  the  lingering  results  of  the  disease,  such  as  bronchitis, 
otorrhcea,  conjunctivitis,  etc.,  should  receive  prompt  attention;  iron  and 
cod-liver  oil  should  be  prescribed  for  the  weakly  and  strumous,  and 
regular  hours  of  sleep,  careful  diet,  and  appropriate  bathing  and  exercise 
should  be  advised.  It  may  be  said,  without  exaggeration,  that  neglect 
of  the  after-care  of  measles  patients  is,  in  some  instances,  more  to  be 
deprecated  than  a  similar  neglect  in  the  actual  treatment  of  the  disease 
itself. 

Since  we  are  powerless  to  cut  short  an  attack  of  measles  by  any  reme- 
dial agents  at  present  known  to  therapeutics,  the  intervention  of  the 
physician  is  limited  to  assisting  the  cases  through  to  a  safe  termination. 
Quite  a  number  of  cases,  as  seen  in  private  practice,  require  no  special 
medicinal  treatment,  or  at  most  one  that  is  merely  symptomatic.  The 
value  of  the  so-called  specific  treatment,  such  as  by  carbonate  of  ammo- 
nium, etc.,  has  not  been  verified  by  experience. 

In  ordinary  uncomplicated  attacks,  if  the  temperature  should  run  high, 
in  addition  to  the  general  rules  as  to  diet  and  hygiene  referred  to  before 
it  will  usually  be  found  advisable  to  put  the  patient  on  some  diaphoretic 
mixture,  to  which  may  be  added  a  mild  opiate.  I  know  of  nothing  bet- 
ter than  the  formula  found  in  the  work  of  Meigs  and  Pepper  on  the 
Diseases  of  Children: 

Tfy.  Potass.  Citrat.         si; 

Spt.  JEtheris  Nit.    f^ii; 
1  Pathologic  u.  Therapie  der  Hautkrankh.,  Wien,  1880. 


580  RUBEOLA. 


Tr.  Opii  Deodorat.  •njjsii  vel  xxiv; 
Syrupi  feii  ; 

Aquse  foii-     M. 

S.  A  teaspoonful  every  two  or  three  hours  for  a  child  of  five  years  of  age. 

Aconite  in  small  doses  has  been  well  spoken  of  in  this  connection,  but 
I  have  no  personal  experience  in  its  use.  Bromide  of  potassium,  together 
with  a  few  drops  of  syrup  of  ipecac.,  dissolved  in  syrup  of  wild  cherry, 
acts  pleasantly  both  on  the  cough  and  the  nervous  system. 

The  inunction  of  fatty  substances,  as  originally  proposed  by  Schone- 
mann,  and  recently  urged  by  Milton,1  is  an  excellent  routine  practice,  and 
in  addition  to  adding  very  much  to  the  patient's  comfort,  has,  perhaps, 
the  merit  of  lessening  somewhat  the  danger  of  infection  to  others.  For 
this  purpose  one  may  use  leaf  lard,  cold  cream,  or  vaseline,  to  each  ounce 
of  which  it  is  well  to  add  a  few  minims  of  carbolic  acid. 

Stimulants  are  rarely  needed  in  uncomplicated  measles,  but  Squire  very 
wisely  calls  attention  to  the  great  value  of  wine  in  the  depression  follow- 
ing upon  the  crisis. 

In  spite  of  some  excellent  authority  to  the  contrary,  I  cannot  see  that  any 
benefit  is  to  be  derived  from  using  severe  measures  to  bring  out  an  erup- 
tion that  has  undergone  retrocession.  As  stated  in  another  part  of  this 
article,  the  so-called  striking-in  of  the  rash  is  the  result  of  the  superven- 
tion of  some  complication,  and  not  the  cause  of  it  ;  therefore,  a  rational 
course  of  action  would  be  to  ascertain  the  nature  of  the  complicating 
trouble,  and  to  endeavor  to  correct  it,  which,  at  the  same  time,  would  be 
the  very  best  means  of  restoring  the  normal  course  of  the  disease. 

Quinia  is  of  great  value  in  controlling  the  excessively  high  temperature 
which  is  sometimes  observed  either  in  connection  with,  or  independent  of, 
complications.  If  the  quinia  should  prove  ineffectual  or  else  be  rejected 
by  the  patient,  the  physician  should  not  hesitate  to  abstract  heat  by  cold 
water  in  the  shape  of  the  wet  pack  or  the  general  bath.  I  think  the  lat- 
ter method  is  to  be  preferred.  It  is  but  to  employ  the  gradually  cooled 
bath  of  Ziemssen,  perhaps,  commencing  at  90°  F.  and  going  to  80° 
or  70°  F.  The  condition  of  the  patient,  as  ascertained  by  the  ther- 
mometer and  also  the  state  of  the  pulse,  must  be  the  guide  as  to  the  dura- 
tion and  repetition  of  the  baths.  In  Germany  excellent  results  are 
claimed  for  the  treatment  of  hyperpyrexia  in  measles  by  the  cold  pack, 
even  when  the  excessive  temperature  is  due  to  such  a  complication  as 
broncho-pneumonia. 

There  is  little  hope  from  therapeutical  interference  in  malignant  forms 
of  measles,  but  the  medical  attendant  should  endeavor  to  reduce  tempera- 
ture and  support  the  strength  by  free  stimulation  and  nourishing  food. 

It  will  now  be  advisable,  at  the  risk  of  some  repetition,  to  call  attention 
to  the  treatment  of  some  of  the  more  prominent  disturbances  and  compli- 
cations of  measles. 

Epistaxis,  if  severe,  should  be  checked  by  cold  applications  and  astrin- 
gents. Plugging  will  rarely  be  found  necessary.  Trousseau  recommends 
the  injection  of  water  as  hot  as  can  be  borne.  Ergotine  by  the  mouth  or 
hypodermically  will  sometimes  prove  highly  valuable. 

The  lids  should  be  anointed  with  vaseline  or  cold  cream  to  prevent  their 
sticking  together,  and  it  is  well  to  occasionally  evert  them  to  see  that  no 

1  Archives  of  Dermatology. 


TREATMENT.  581 

serious  mischief  has  happened  to  the  eye.  If  the  conjunctivitis  is  intense, 
the  discharges  should  be  removed  and  cold  compresses  applied. 

Since  aural  complications  are  due  to  extension  of  inflammation  from  the 
oral  and  nasal  cavities,  Spencer  urges  the  importance  of  early  and  sys- 
tematic treatment  of  these  parts.  He  advises  astriugeni  applications 
(Monsell's  solution  1  to  4  of  glycerine)  to  the  pharyngeal  mucous  mem- 
brane. Ointments  of  boracic  acid,  zinc,  or  iodoform  are  likewise  useful 
when  introduced  through  the  nostril.  Earache  will  require  warm  opiated 
poultices  and  inflation.  Otorrhcea  is  best  treated  after  the  dry  method. 

For  sickness  of  the  stomach  a  spice  poultice  may  be  applied  and  small 
bits  of  ice  given  to  suck.  If  constipation  exist,  a  little  oil  or  syrup  of 
rhubarb  or  some  stewed  prunes,  or  an  enema,  may  be  ordered.  Active 
purgation  should  be  withheld. 

The  early  diarrhoea  need  give  little  concern,  as  it  usually  soon  ceases ;  but 
if  it  should  persist,  recourse  must  be  had  to  more  energetic  measures, 
such  as  the  use  of  opium  by  mouth  or  enema,  given  cautiously  in  the  case 
of  children,  vegetable  and  metallic  astringents,  and  the  application  of  hot 
poultices  to  the  abdomen.  The  diet  should  be  carefully  guarded. 

The  cough,  even  in  mild  cases,  generally  requires  some  slight  pallia- 
tive, such  as  syrup  of  ipecac.,  and  an  occasional  small  dose  of  Dover's 
powder.  Loeri  very  properly  advises  against  the  use  of  irritating  expec- 
torants. I  think  it  advisable  to  keep  the  chest  well  smeared  with  cam- 
phorated oil,  over  which  should  be  worn  an  oil-silk  jacket.  These  simple 
measures,  perhaps,  diminish  the  tendency  to  thoracic  complications.  The 
sometimes  violent  paroxysms  of  false  croup  are  very  satisfactorily  man- 
aged, after  the  manner  of  Graves,  by  gently  pressing  a  sponge,  soaked  in 
very  hot  water,  under  the  chin  and  over  the  front  of  the  neck.  When 
the  dyspnoea  is  alarming,  emetics,  and  the  general  warm  bath  should  be 
brought  into  requisition. 

Convulsions  in  the  early  stage  require  little  treatment  other  than  the 
warm  bath  and  appropriate  doses  of  the  bromide  of  potassium ;  occurring 
later,  they  are  very  fatal  under  any  treatment,  as  they  generally  super- 
vene in  connection  with  some  of  the  grave  complications  of  the  disease. 
Chloral,  preferably  by  enema,  and  chloroform  may  be  tried.  The  man- 
agement of  the  severe  bronchitis  and  pneumonia  of  measles  requires  great 
care  and  circumspection  on  the  part  of  the  physician.  The  application 
of  a  well-made  flaxseed  poultice,  which  should  be  neither  too  heavy  nor 
too  hot,  is  to  be  regarded  as  invaluable.  To  the  flaxseed  may  be  added 
a  small  quantity  of  mustard.  Over  the  whole  is  to  be  placed  an  oil-silk 
jacket.  Alcoholic  stimulants,  nourishing,  easily-digested  food,  and  expec- 
torants containing  carbonate  of  ammonium  are  to  be  recommended. 

For  the  treatment  of  the  other  complications  and  sequelae  of  measles 
the  reader  is  referred  to  the  appropriate  sections  of  this  work. 


ROTHELK1 

BY  W.  A.  HAKDAWAY,  M.  D. 


SYNONYMS. — Rubeola,  Rubella,  Roseola,  Epidemic  Roseola,  German 
Measles,  French  Measles,  Hybrid  Measles,  False  Measles,  Rubeola  Mor- 
billosse  et  Scarlatinosse. 

DEFINITION. — Rotheln  is  an  acute  infectious  disease,  presenting  an 
eruption  of  reddish  macules  upon  the  skin,  accompanied  by  mild  catar- 
rhal  symptoms,  and  usually  producing  but  slight  disturbance  of  the  gen- 
eral system.  It  is  self-protective,  and  occurs  but  once  in  the  same  indi- 
vidual. It  has  no  relationship  to  measles  or  scarlatina. 

HISTORY. — A  rapid  glance  at  the  interesting  historical  evolution  of 
rotheln  to  a  specific  position  among  the  acute  infectious  diseases  is  all  that 
our  space  will  allow.  Some  writers  have  attempted  to  show  that  this 
affection  was  known  to  the  Arabian  physicians ;  but  since  it  is  only  in 
comparatively  recent  times  that  the  contagious  epidemic  exanthemata  in 
general  have  been  thoroughly  differentiated,  it  is  quite  likely  that  the 
modern  conception  of  it  was  not  held  by  them  nor  by  other  medical  men 
till  many  centuries  later.  Indeed,  in  our  day,  physicians  are  yet  to  be 
found,  though  the  number  is  rapidly  diminishing,  who  refuse  to  recognize 
in  rotheln  a  distinctive  specific  malady.  Certain  German  observers  in 
the  middle  of  the  last  century  (De  Bergen,  1752;  Orlow,  1758)  favored 
the  idea  of  specificity,  but  these  views  were  soon  disputed.  In  the  years 
following  a  number  of  other  physicians  announced  their  belief  in  the 
specific  nature  of  rotheln,  while,  on  the  other  hand,  various  noted  author- 
ities still  insisted  upon  its  connection  with  scarlet  fever  or  measles.  In 
1815,  Maton,  an  English  physician,  most  unequivocally  declared  that 
he  had  observed  cases  of  an  eruptive  disorder  which  resembled  neither 
measles,  scarlatina,  nor  roseola,  and  which  was  worthy  of  a  new  designa- 
tion.2 In  the  second  and  third  decades  of  this  century  Hildebrand,  and 
afterward  the  celebrated  Schonlein,  taught  that  rotheln  was  a  hybrid  of 
measles  and  scarlatina,  although  at  this  time  Wagner  (1834)  advocated 
the  essential  independence  of  rotheln.  There  is  no  doubt  that  under  the 
name  of  rubeola  sine  catarrho  Willan,  Bateman,  and  later  writers 
described  what  we  now  call  rotheln,  for  they  stated  that  this  variety  of 
measles  was  not  self-protective.  Space  will  not  allow  of  a  detailed  men- 
tion of  the  various  writers  who,  during  the  first  half  of  this  century, 

1  In  the  preparation  of  this  article  the  author  has  consulted  the  following  authorities : 
Emminghaus,  in  Gerhardfs  Handb.  cler  Ktnderkrankh.,  Zweiter  Band,  1877 ;  Thomas,  in 
Ziemsseii's  Cyclop.  Pract.  Med.,  vol.  iii.,  Am.  ed.,  1875;  Squire,  in  Quain's  Did.  Med., 
1883.     References  to  current  literature  will  be  found  in  foot-notes  to  the  text. 

2  Squire,  Trans.  Internat.  Me.d.  Congress,  London,  1881. 

582 


ETIOLOGY.  583 

have  contended  for  or  against  the  autonomy  of  rotheln.  It  will  be  well 
to  state,  however,  that  Hebra,  from  the  standpoint  of  the  dermatologist, 
very  properly  regards  the  manifold  roseolas  of  Willan  as  in  many 
instances  merely  symptomatic  erythymata,  or  else  as  irregular  forms 
of  measles  or  scarlatina;  but  he  also  fails  to  recognize  the  distinctive 
features  of  rotheln.  Even  so  recent  a  writer  as  Niemeyer  declares  that 
roseola  arising  from  infection  consists  in  a  modification  of  measles  or  scarlet 
fever.  It  is  only  in  the  last  twenty  years  that  our  present  exact  ideas  of 
rotheln  have  obtained.  For  example,  while  Trousseau1  asserts  that 
rubeola  (rotheln)  is  a  perfectly  distinct  nosological  species,  he  speaks  of 
the  rash  as  appearing  and  disappearing  alternately  for  some  days,  of  its 
frequent  recurrence  in  the  same  individual,  etc.  American  physicians 
were  almost  entirely  ignorant  of  rotheln  till  within  the  last  ten  years, 
when  they  were  made  acquainted  with  it  through  the  medium  of  a  care- 
ful paper  on  the  subject  from  the  pen  of  J.  Lewis  Smith  of  New  York.2 
Before  this  time,  however,  cases  had  been  described  by  Homans,  Sr., 
of  Boston  (1845),  and  in  1&53  and  1871  by  Clotting.  Very  few 
authorities  now  dispute  the  distinctive  specific  nature  of  rotheln  ;  which 
statement  is  borne  out  by  the  fact  that  at  the  last  meeting  of  the  Inter- 
national Medical  Congress,  held  at  London  in  1881,  there  were  but  two 
dissentients  to  this  view  in  the  section  before  which  it  was  discussed.3 

ETIOLOGY. — The  contagium  of  rotheln  is  unknown,  but  that  the 
disease  is  contagious  has  been  fully  demonstrated  by  numerous  observa- 
tions of  epidemics  and  sporadic  cases.  From  my  own  experience  I  should 
judge  that  unprotected  persons  are  not  so  susceptible  of  it  as  is  known  to 
be  the  case  under  similar  conditions  in  measles ; 4  yet  cases  are  recorded 
which  would  prove  that  the  contagion  may  be  conveyed  through  a  third 
person  and  for  some  distance.  It  is  probable  that  the  vehicles  of  con- 
tagion are  the  same  as  in  measles.  At  what  period  of  its  course  the 
disease  is  most  capable  of  transmission  has  not  been  satisfactorily  deter- 
mined. Squire  is  of  the  opinion,  however,  that  the  disease  is  con- 
tagious before  the  appearance  of  the  rash,  and  may  continue  so  for  some 
days  or  for  two  or  three  weeks.  RStheln  may  be  called  a  disease  of  child- 
hood for  the  same  reason  that  the  other  contagious  exanthemata  are — 
namely,  that  the  majority  of  adults  have  already  been  attacked.  From 
an  examination  of  available  statistics  I  am  inclined  to  regard  the  ages 
between  five  and  fifteen — the  years  of  school  attendance — as  the  period 
of  life  most  susceptible  of  the  influence  of  rotheln,  although,  of  course, 
no  time  of  life  is  entirely  exempt.  The  non-susceptibility  of  sucklings, 
as  in  measles,  holds  true  as  a  rule,  although  I  am  in  a  position  to  supply 
exceptions  to  this  from  my  own  experience,  as  well  as  from  that  of  others. 
Sex  seems  to  be  without  influence  in  determining  liability  to  the  disease. 

The  period  of  incubation  is  not  very  definitely  settled,  and,  indeed, 

1  Clinical  Medicine,  vol.  ii.  2  Archives  nf  Dermatology,  Oct.,  1874. 

3  See  especially  Kassowitz's  paper,  "Die  Wirkliclie  Stellung  der  sogenannten  Kubeola, 
etc.,  Trans.  Internal.  Med.  Cong.,  1881. 

*  In  this  regard  it  resembles  scarlatina  more  than  measles,  for  I  have  a  number  ot  times 
seen  the  disease  introduced  into  families,  where  it  would  attack  one  or  two  of  a  number 
equally  exposed.  J.  L.  Smith  regards  it  as  feebly  contagious,  and  quotes  Chadbourne  s 
experience  to  the  same  effect.  Liveing  declares  that  rotheln  is  more  distinctly 
epidemic  in  Great  Britain  than  either  measles  or  scarlet  fever,  although  probably  less 
contagious. 


584  R6THELN. 

owing  to  the  generally  trivial  character  of  the  affection,  evidence  on  this 
pointTis  difficult  to  obtain.  Taken  as  a  whole,  it  is  probably  longer  than 
is  observed  in  measles.  According  to  J.  Lewis  Smith,  in  the  epidemic 
observed  by  him  the  incubation  period  varied  from  seven,  or  less  than 
seven,  to  twenty-one  days ;  Emminghaus  places  it  at  from  two  to  three 
weeks;  Thomas,  from  two  and  a  half  to  three  weeks;  Squire,  mostly  a 
fortnight,  the  extreme  being  twenty-one  days ;  Cheadle,  from  eleven  to 
twelve  days. 

There  is  nowhere  recorded  a  trustworthy  instance  of  a  second  attack 
of  rotheln,  although  from  analogy  such  an  event  is  to  be  expected.  As 
in  measles,  true  recurrences  of  rotheln — that  is,  the  result  of  a  fresh 
infection — are  not  to  be  confounded  with  relapses.  I  have  never  wit- 
nessed a  relapse,  but  cases  of  such  a  nature  have  been  recorded  by  other 
observers  (Lindwurm,  Emminghaus,  Kortlin,  Kingsley). 

Rotheln  is  a  disease  sui  generis,  and  is  in  no  way  related  to  either 
measles  or  scarlatina ;  that  is  to  say,  it  is  not  an  irregular  form  of  either 
of  these  nor  a  hybrid  of  them,  nor  has  it  ever  been  observed  to  propa- 
gate anything  but  itself.  That  it  is  not  connected  with  any  of  the  symp- 
tomatic skin  eruptions — the  so-called  roseolse — is  proved  by  its  con- 
tagiousness and  epidemic  character.  I  quite  agree  with  other  observers 
in  declaring  that  rotheln  has  very  little  clinical  resemblance  to  scarlatina, 
and  that,  on  the  other  hand,  in  the  greatest  number  of  cases  the  points 
of  likeness  are  with  measles.  In  the  section  on  diagnosis  the  differential 
points  between  rotheln,  measles,  and  scarlatina  will  be  considered ;  there- 
fore in  this  place  it  will  only  be  necessary  to  call  attention  to  certain 
general  facts.  Thus,  aside  from  the  marked  divergence  in  clinical  symp- 
toms— incubation,  invasion,  fever,  eruption,  complications,  and  sequelae — 
we  are  at  once  met  by  the  positive  fact  that  epidemics  of  rotheln,  while 
always  presenting  identical  features,  prevail  without  regard  to  the  exist- 
ence of  similar  epidemics  of  measles  and  scarlatina — following  or  preced- 
ing them — and  that  attacks  of  rotheln  offer  no  bar  to  the  reception  of  their 
contagions,  or  vice  versa.  Literature  is  so  full  of  examples  of  this  state- 
ment that  it  need  scarcely  be  dwelt  upon.  By  way  of  illustration,  how- 
ever, the  accurate  observations  of  J.  Lewis  Smith  may  be  quoted  in  this 
connection.  Of  48  cases  recorded  by  him  prior  to  May  1st  in  the  New 
York  epidemic  of  1874, 19  had  had  measles.  Rotheln  in  the  N.  Y.  Found- 
ling Hospital  in  1873-74  followed  an  epidemic  of  measles.  During  the 
epidemic  of  1880-81  the  same  fact  was  observed — namely,  that  a  previous 
attack  of  measles,  as  well  as  scarlatina,  afforded  no  protection  from  rotheln. 
I  could  multiply  such  examples  from  my  own  experience.  A  single  inter- 
esting instance  may  be  noted  here.  A  physician  asked  the  writer  to 
examine  his  child,  suffering,  as  he  thought,  from  measles.  A  careful 
investigation  revealed  a  typical  rotheln.  A  number  of  weeks  later  an 
older  child  got  measles,  from  which  the  rotheln  patient  acquired  a 
characteristic  attack  of  the  same.  In  the  following  year  both  children 
were  taken  with  scarlet  fever. 

The  only  escape  for  those  who  would  deny  the  autonomy  of  rotheln  is 
in  the  bold  assertion  that  both  measles  and  scarlatina  more  frequently 
recur  in  the  same  individual  than  universal  experience  and  observation 
will  allow ;  and  this  leaves  them  in  the  dilemma  of  determining  to  which 
group  rotheln  must  be  relegated.  The  hypothesis  of  the  hybrid  nature 


SYMPTOMS  AND  COURSE.  585 

of  rotheln  cannot  be  accepted  by  the  pathologist  nor  the  clinician,  if  for 
no  other  reason  than  that  no  one  has  ever  seen  rotheln  generate  anything 
but  rotheln,  and  in  no  case  give  rise  to  either  scarlatina  or  measles. 

SYMPTOMS  AND  COURSE. — As  already  stated,  the  probable  average 
duration  of  the  incubation  period  in  rotheln  is  about  fourteen  days,  vary- 
ing, however,  within  the  limits  of  from  six  to  twenty-one  days.  In  this 
respect  rotheln  resembles  scarlatina  more  than  measles,  the  period  of 
latency  in  the  latter  observing  considerable  uniformity.  No  deviations 
from  the  general  health  are  to  be  noted  in  the  incubation  stage. 

In  most  cases  prodromal  symptoms  are  entirely  absent,  the  presence  of 
the  eruption  being  the  first  thing  to  show  the  existence  of  rotheln  in  the 
system.  On  the  other  hand,  in  a  certain  proportion  of  cases  there  will 
be  present  for  a  half  day,  or  even  longer,  the  general  symptoms  of 
malaise,  such  as  slight  nausea,  some  sore  throat,  pain  in  the  limbs,  stiff- 
ness of  the  neck,  etc.  Vomiting  is  generally  absent.  J.  L.  Smith 
records  one  case  of  convulsions  in  the  stage  of  invasion,  and  I  have  notes 
of  a  single  case  in  which  the  prodromal  stage  was  initiated  by  mild 
delirium  and  fever,  the  latter  anticipating  the  eruption  for  two  days  and 
a  half,  and  disappearing  when  the  rash  came  out.  As  Thomas  well 
observes,  however,  such  cases  are  anomalous,  and  indicate  either  abnormal 
sensibility  on  the  part  of  the  patient  or  are  due  to  a  secondary  rotheln. 

Most  observers  (Emminghaus,  Thomas,  Smith,  Squire)  describe  the 
rash  as  coming  out  in  the  order  usual  in  measles — namely,  first  upon  the 
face,  scalp,  and  neck,  then  the  trunk  and  arms,  and  finally  the  legs. 
Others  (Liveing,  Morris)  have  stated  that  the  rash  first  appears  upon  the 
back  and  chest.  In  many  cases  in  my  own  experience  this  has  seemed  to 
be  true.  It  is  quite  probable  that  the  situation  of  the  exanthem  in 
rotheln,  as  in  measles  and  scarlatina,  may  present  various  irregularities ; 
but  I  am  inclined  to  believe  that  a  careful  investigation  will  in  most 
instances  show  that  the  normal  course  of  the  eruption  is  as  first  stated. 
Now,  a  marked  characteristic  of  the  rash  of  rotheln  is  that,  unlike  that 
of  measles,  there  is  no  period,  however  short,  in  which  its  maximum  is 
simultaneous  over  the  whole  body  ;  on  the  contrary,  the  eruption  will 
have  reached  its  full  development  upon  the  face,  and  will  be  almost  or 
quite  faded  again,  before  the  exanthem,  for  example,  will  have  blossomed 
upon  the  trunk,  and  especially  upon  the  lower  extremities.  The  duration 
of  the  eruption  upon  individual  parts  of  the  body  is  probably  from  a  few 
hours  to  half  a  day  at  most  (Thomas).  A  consideration  of  these  facts 
explains,  according  to  Emminghaus,  how  different  observers  have  described 
the  eruption  as  having  its  seat  upon  this  or  that  region  of  the  body  ;  in 
other  words,  it  is  probable  that  in  a  certain  proportion  of  the  cases  in 
which  the  rash  was  supposed  to  have  begun  on  the  chest  it  had  already 
run  its  course  upon  the  face.  The  eruption  usually  continues  altogether 
about  four  days,  sometimes  disappearing  sooner,  and  sometimes  being 
visible,  especially  as  a  fine  mottling,  for  some  days  longer.  So  far  as  the 
individual  lesions  of  the  eruption  are  concerned,  there  is  no  question  that 
they  present,  within  a  certain  range,  varying  aspects ;  and  this  clinical 
fact  has  been  taken  advantage  of  by  the  opponents  of  the  idea  of  speci- 
ficity in  order  to  make  it  appear  that  the  disease  is  not  sui  generis,  inas- 
much as  it  lacks  uniformity  of  expression.  Such  an  argument  wants 
force  when  we  consider  that  in  making  up  a  given  diagnosis  we  lay  stress 


586  ROTHELN. 

not  upon  special,  but  upon  the  ensemble  of,  symptoms.  For  example,  no 
one  would  deny  to  measles  an  independent  position  because  the  eruption, 
as  is  well  known,  may  assume  this  or  that  form  (morbilli  Isevis,  m.  papu- 
losi,  etc.)  j  on  the  contrary,  we  recognize  a  particular  case  or  series  of 
cases  to  be  measles  from  a  due  appreciation  of  all  the  symptoms  present. 
So  it  is  to  be  expected  that  while  the  cutaneous  lesions  will  present  a  cer- 
tain similarity  of  feature,  as  they  do,  there  will  also  exist  minor  differ- 
ences in  detail. 

In  the  greatest  number  of  cases  in  my  own  experience  the  exanthem 
is  composed  of  ill-defined,  roundish,  punctate  macules,  without  special 
grouping.  These  are  usually  discrete,  but  in  certain  situations  they  may 
coalesce.  The  color  is  of  a  pale  rosy  red,  quite  difficult  to  describe,  but 
less  purplish  than  in  measles,  and  not  so  livid  a  red  as  in  scarlatina.  I 
have  occasionally  observed  large  irregular  spots  not  unlike  those  of 
measles.1 

Thomas  distinguishes  three  types  of  eruption — one  with  large  spots, 
which  is  rare ;  one  with  medium-sized  spots  ;  and  one  with  small  spots. 
Emminghaus  describes  a  discrete  and  a  more  confluent  variety.  I  have 
observed  one  case  where  the  maculae  on  the  back  had  undergone  a  vesicu- 
lar transformation.  Others  have  mentioned  this  occurrence.  Itching  of 
the  skin  is  marked  in  some  cases,  and  a  fine  desquaniatiou  is  observed 
after  the  rash,  but  by  no  means  invariably. 

The  mucous  membranes  are  implicated  to  a  slight  degree  in  rotheln,  but 
the  amount  of  involvement  varies  considerably.  In  some  cases  that  I 
have  observed  the  catarrh  of  the  mucous  membranes  has  been  barely 
appreciable.  As  a  rule,  however,  the  eyes  are  somewhat  suffused,  and 
there  is  slight  lachrymation  and  photophobia.  Sneezing  may  be  noted, 
but  there  is  little  discharge  from  the  nose.  Sore  throat  is  not  uncommon, 
perhaps  the  most  constant  feature,  and,  according  to  Liveing,  is  apt  to 
persist  after  the  subsidence  of  the  rash.  The  fauces  are  injected,  and  the 
tonsils  are  red  and  swollen,  but  with  no  evidence  of  ulceration.  J.  Lewis 
Smith  and  others  state  that  the  buccal  mucous  membrane  shows  a  more  or 
less  diffuse  patchy  and  spotted  redness.  The  tongue  may  be,  and  usually 
is,  covered  by  a  white  fur,  through  which  protrude  a  few  enlarged  red 
papillae.  There  may  be  slight  cough.  Loeri2  describes  the  mucous 
membranes  of  the  pharynx,  larynx,  and  trachea  as  presenting  a  spotted 
or  uniform  hypersemia.  There  is  no  marked  participation  of  the  intes- 
tines in  the  catarrh.  Some  few  writers  have  noted  a  transient  albumi- 
nuria,  but  it  is  safe  to  say  that  such  cases  are  entirely  anomalous,  if  not, 
indeed,  in  some  instances,  examples  of  mistaken  diagnosis. 

A  very  constant  feature  is  the  swelling  of  the  lymphatic  glands  of  the 
neck,  especially  those  back  of  the  sterno-mastoid ;  the  swellings  may 
come  on  before  the  rash  appears.  In  all  the  cases  that  have  fallen  under 
my  notice  this  symptom  has  not  been  absent  in  a  single  instance.  Less 
constantly,  and  it  would  seem  in  proportion  to  the  development  of  the 
rash,  engorgement  of  the  glands  may  be  noted  elsewhere. 

1  According  to  Emminghaus  (op.  cit.,  p.  345),  the  eruption  generally  forms  roseolas  of 
pin-head,  lentil,  or  small  bean  size.  They  are  mostly  round,  sometimes  oval,  and  bordered 
by  well-defined  or  by  blurred  edges.  The  intervening  skin  is  not  always  unchanged,  for 
here  and  there  we  find  upon  it  small  dilated  blood-vessels,  and  from  the  spots  processes 
extend  with  a  certain  regularity  to  other  spots  in 'such  a  way  as  to  give  the  skin  a  marbled 
appearance.  2  Jahrb.f.  Kinderk.,  xix.  Bd.,  1  Heft. 


COMPLICATIONS  AND  SEQUEL^.— DIAGNOSIS.  587 

There  is  but  slight  disturbance  of  the  temperature  in  rotheln,  and  when 
it  does  occur  it  is  usually  limited  to  the  first  few  hours  of  the  eruption. 
This  has  been  the  rule  in  my  observation,  and  certainly  holds  good  for 
the  majority  of  cases.  In  a  minority,  varying  degrees  of  fever  may  be 
present ;  thus,  the  temperature  may  reach  102°  F.  or  103°  F.,  and  then 
rapidly  sink  by  the  second  day  of  the  disease,  or,  having  fallen  a  degree, 
it  may  continue  at  this  point  till  the  subsidence  of  the  rash,  or,  it  is  said, 
may  retain  its  initial  height  till  the  end  of  the  disease.  During  the 
following  week  Squire  states  that  the  temperature  may  be  readily  dis- 
turbed— either  elevated  by  exertion  or  depressed  by  fatigue  or  chill. 
A  relapse  or  recrudescence  of  the  rash  may  be  looked  for  at  this  time.1 

COMPLICATIONS  AND  SEQUELAE. — In  the  vast  majority  of  cases  neither 
complications  nor  sequelae  have  been  observed  in  connection  with  rotheln. 
J.  Lewis  Smith  has  recorded  instances  of  diphtheritic  inflammation  as  a 
complication,  which,  however,  as  he  justly  remarks,  may,  when  prevalent, 
attack  any  inflamed  surface.  Pneumonia  and  bronchitis  have  been  occa- 
sionally reported  as  complicating  or  following  rotheln.  Liveing  and 
Duckworth  mention  albuminuria,  but,  so  far  as  I  know,  they  are  alone  in 
this  experience.  I  have  known  otorrhrea  and  ciliary  blepharitis  to  occur 
as  sequelse.  It  would  not  be  a  matter  of  surprise  that  in  weakly  children 
various  chronic  ailments  should  be  set  up  by  rotheln,  as  by  any  other  dis- 
turbance of  the  general  health. 

DIAGNOSIS. — There  is  no  other  disease  which  so  much  resembles  rotheln 
as  measles.  Especially  is  this  true  of  atypical  cases  occurring  sporadi- 
cally. In  rotheln  the  whole  course  of  the  disease  is  much  milder  than  in 
measles,  the  incubation  is  longer  as  a  rule,  and  the  fact  of  a  previous 
attack  of  rubeola  is  of  much  importance,  since  we  know  that  recurrences 
are  very  rare.  In  measles  there  is  a  prodromic  period,  having  a  charac- 
teristic temperature  curve,  and  presenting  pathognomonic  catarrhal  symp- 
toms, which  precedes  the  eruption  for  three  or  four  days ;  in  rotheln  the 
appearance  of  the  rash  is  often  the  first  sign  of  the  aifection.  The  sore 
throat  of  rotheln  resembles  that  seen  in  scarlatina  more  than  the  angina 
of  measles,  and  the  general  catarrhal  implication  of  the  mucous  mem- 
branes, so  marked  a  feature  of  measles,  is  either  absent  in  rotheln  or  exists 
to  a  very  trivial  extent.  Measles  is  essentially  a  febrile  disease,  having  a 
peculiar  type  of  fever ;  rotheln  may  run  its  whole  course  without  appre- 
ciable rise  of  temperature.  As  will  be  seen  in  the  preceding  pages,  the 
development  and  progress  of  the  exanthem  of  measles  differs  materially 
from  that  witnessed  in  rotheln.  In  measles  the  lesions  are  larger,  more 
vivid,  more  angular  and  indented,  more  frequently  provided  with  pro- 
cesses, and  therefore  more  apt  to  assume  the  crescentic  arrangement,  than 
in  rotheln.  Finally,  it  must  be  urged  that  the  tout  ensemble  of  the  case 
should  be  taken  into  consideration,  and  not  some  special  feature  of  the 
skin  eruption. 

The  incubation  period  of  scarlet  fever  is  much  shorter  than  in  rotheln, 
and  all  of  the  constitutional  symptoms  are,  as  a  rule,  infinitely  graver. 
In  scarlatina  there  is  a  febrile  invasion  stage  of  twenty-four  hours ;  in 
rotheln,  if  fever  is  present  at  all,  it  is  most  generally  simultaneous  with 

^headle  (Trans.  Internal,  Med.  Congress,  London,  1881)  has  reported  an  epidemic  of 
rotheln  of  a  very  severe  type,  all  the  'symPtoma  of  tlie  disease  as  ordinarily  recognized 
being  very  much  exaggerated. 


588  RfJTHELN. 

the  rash,  and  rapidly  disappears,  while  in  the  former  it  persists  for  a  num- 
ber of  days  longer.  Vomiting  is  common  in  scarlet  fever,  rare  in  rotheln. 
In  scarlet  fever  the  lymphatic  glands  are  notably  involved  at  the  angles 
of  the  jaw,  in  rothelu  at  the  sides  and  back  of  the  neck.  Sore  throat  is 
a  feature  common  to  both  scarlet  fever  and  rotheln,  but  it  is  very  much 
less  marked  in  the  latter.  Thomas l  says  that  in  scarlatina  only  the  pos- 
terior parts,  the  uvula,  the  arches  of  the  palate  and  their  vicinity  are  affected, 
while  in  rothelu  the  anterior  parts  are  also  affected,  and  both  in  much  the 
same  degree.  In  scarlet  fever  the  rash,  which  mostly  begins  on  the  neck 
and  chest,  is  made  up  of  large  patches  formed  of  minute  red  spots  on  a 
bright-red  hypersemic  base;  in  rothelu  the  eruption  is  composed  of  round- 
ish pea-sized  macules,  with  normal  integument  intervening.  In  cases  of 
doubt — for  example,  when  the  rash  of  rothelu  consists  of  very  small  spots 
which  have  become  confluent — the  further  development  and  persistence  of 
the  scarlatinal  efflorescence,  the  temperature,  the  pulse,  the  angina,  and 
the  character  of  the  desquamation  must  be  taken  into  consideration.  The 
complications  and  sequelae  are  very  different  in  the  two  diseases. 

The  symptomatic  eruptions  of  the  skin  which  pass  under  the  name  of 
roseola  bear  no  resemblance  to  rotheln.  They  usually  occur  as  the  result 
of  some  trivial  derangement  of  the  system  or  in  the  course  of  some 
primary  affection.  They  are  not  contagious,  the  lymphatic  glands  and 
the  mucous  membranes  are  not  involved,  and  the  rash  is  quite  different  in 
character. 

PROGNOSIS. — The  prognosis  of  simple  uncomplicated  rotheln  is  invari- 
ably good.  Complications  arising  in  delicate  children  necessarily  affect 
the  prognosis,  as  would  any  other  disturbance  of  the  general  health. 

TREATMENT. — Simple  cases  of  rothelu  require  no  treatment,  as  the 
patients  are  rarely  sick  enough  to  be  confined  to  bed.  Graver  forms  of  the 
disease  must  be  met  by  such  measures  as  are  indicated  by  the  symptoms 
present.  The  after-management  must  be  conducted  on  general  principles 
having  reference  to  the  previous  and  present  condition  of  the  person 
attacked. 

1  Article  "  Scarlatina,"  ov.  cit. 


MALARIAL  FEVERS. 

BY   SAMUEL    M.  BEMISS,  M.  D. 


IN  the  medical  nomenclature  of  this  country  the  term  malaria  ia 
synonymous  with  swamp  or  ague  poison. 

Malarial  affections,  therefore,  comprise  all  those  diseases  or  morbid 
manifestations  which  the  swamp  poison  produces  in  the  human  organism. 

This  article  is  not  designed  to  notice  in  a  systematic  manner  any  of 
these  disorders  which  are  not  properly  classifiable  under  the  head  of 
malarial  fevers.  It  will,  however,  be  necessary  to  make  such  references 
to  the  pathology  of  chronic  malarial  toxaemia  as  may  serve  to  explain  the 
influence  this  condition  exerts  in  occasioning  departures  from  type  in  the 
febrile  attacks. 

When  a  poison  generated  outside  the  human  system  obtains  admission 
to  it,  and  produces  deleterious  effects,  three  questions  naturally  arise : 
What  is  the  essential  character  and  natural  history  of  this  noxious  agent? 
How  does  it  obtain  access  to  the  human  system  ?  What  is  its  mode  of 
action  when  received? 

In  reference  to  the  first  of  these  questions,  it  must  be  admitted  that  the 
substantive  essentiality  of  the  malarial  poison  remains  as  yet  undemon- 
strated.  It  is  true,  however,  that  the  attempts  at  an  objective  study  of 
this  poison  by  means  of  the  microscope  and  the  cultivating  retort  point 
to  the  conclusion  that  it  is  an  organism. 

Its  subjective  or  analogical  study  affords  quite  incontestable  evidence  in 
support  of  this  conclusion.  The  leading  features  in  the  natural  history 
of  malaria  are  closely  coincident  with  those  of  certain  known  organisms. 
It  requires  for  its  production  suitable  conditions  of  moisture,  temperature, 
and  a  properly  circumstanced  breeding-place.  Within'  certain  bounds 
these  conditions  are  requisite  to  the  life  and  perpetuity  of  all  organisms. 

Again,  when  all  the  above-enumerated  conditions  correspond  apparently 
in  the  most  favorable  degree,  their  continuous  concurrence  for  a  lapse  of 
time  is  necessary  before  the  poison  manifests  its  presence.  It  is  not 
improbable  that  this  period  of  development  may  differ  in  different 
climates,  but  in  this  country  we  assume  it  to  be  about  thirty  days.  If 
these  facts  related  to  some  noxious  organism  visible  to  the  eye,  no  doubt 
would  be  entertained  that  the  presence  of  its  germs  in  the  places  where  it 
appeared  was  the  indispensable  condition.  It  would  then  follow  that  the 
concurrence  of  suitable  meteorologic  and  telluric  conditions  with  sufficient 
time  for  its  growth  and  maturity  were  merely  accessories  to  its  perfect 
development.  According  to  this  theory,  the  coincidence  of  five  circum- 
stances is  necessary  before  malaria  can  be  fully  matured — viz.:  Its  own 

589 


590  MALARIAL  FEVERS. 

specific  germ  ;  suitable  soil  or  pabulum  ;  suitable  moisture  ;  suitable  tem- 
perature ;  sufficient  time  for  its  growth  and  development. 

Certain  physical  qualities  which  pertain  to  the  malarial  poison  can  also 
be  profitably  made  points  of  subjective  study.  These  are  very  closely 
connected  with  the  answer  to  the  second  question,  or  "  How  the  malarial 
poison  obtains  access  to  the  human  system."  ^  They  will  ^ therefore  ^  be 
briefly  noticed  in  relation  to  the  instrumentality  of  each  in  conveying 
malaria  into  the  system. 

The  first  to  be  mentioned  is  ponderability,  which  the  following  facts 
prove  that  malaria  possesses : 

Those  different  atmospheric  states  which  affect  the  range  of  diffusion 
of  known  air-borne  yet  ponderable  subtauces  exert  similar  influences  upon 
the  malarial  poison. 

Altitude  illustrates  the  ponderability  of  malaria  by  powerfully  retard- 
ing its  diffusion. 

High  readings  of  the  barometer  favor  its  aerial  dissemination. 

Fogs,  smoke,  dust,  or  floating  particles  presumably  more  buoyant  than 
this  poison  may  exert  greater  or  less  influence  in  overcoming  the  obstacle 
which  ponderability  attaches  to  malaria  as  an  air-borne  agent. 

Currents  of  air  passing  continuously  and  steadily  in  one  direction  over 
the  breeding-places  of  malaria  increase  the  limits  and  intensity  of  toxic 
range. 

The  atmosphere  is  undoubtedly  the  medium  by  means  of  which 
malarial  poison  is  most  frequently  brought  into  the  human  system. 
Liability  to  intoxication  is  increased  in  direct  ratio  to  the  proximity  of 
points  of  exposure  to  places  of  development;  to  similarity  of  level;  to 
situation  in  the  line  of  prevailing  winds  which  have  traversed  the  breed- 
ing-ground ;  and,  lastly,  to  the  extent  and  fertility  of  the  locality  of  pro- 
duction. 

Whether  malaria  passes  through  the  respiratory  apparatus  directly  into 
the  circulation,  or  is  lodged  upon  the  fauces  and  absorbed  through  some 
other  surface,  is  not  clearly  ascertainable.  It  is  certainly  not  deprived  of 
its  noxious  qualities  by  stomach  digestion,  and  therefore,  sometimes  at 
least,  may  reach  the  blood  through  the  alimentary  canal. 

Malaria  is  miscible  with  water.  It  is  capable  of  being  carried  by  cur- 
rents of  water  through  distances  and  periods  of  time  altogether  undeter- 
mined, without  losing  either  its  toxic  effects  or,  perhaps,  the  faculty  of 
reproduction.  It  is  more  than  likely  that  this  means  of  conveyance  has 
effected  its  distribution  to  continents  and  islands  too  widely  separated  to 
justify  a  belief  that  it  was  wind- wafted.  No  observations  need  be  ad- 
duced to  establish  the  water-borne  habit  of  the  malarial  poison,  or  the 
positive  liability  to  its  toxic  effects  when  received  into  the  stomach 
through  this  medium.  These  facts  have  been  well  understood  from  the 
time  of  Hippocrates. 

The  matter  of  communicability  of  malaria  by  means  of  drinking  water 
should  not  be  dismissed  without  some  allusion  to  the  great  probability 
that  other  fluids  or  solids  are  open  to  a  similar  charge.  There  is  a  wide- 
spread popular  prejudice,  especially  notable  in  the  southern  part  of  the 
United  States,  that  drinking  milk  occasions  attacks  of  the  endemic  fevers. 
It  is  the  usual  custom  to  pour  the  evening  supply  of  milk  into  broad 
uncovered  pans,  and  allow  it  to  remain  exposed  in  the  open  air  for  con- 


MORBID  EFFECTS  AND  PHENOMENA,   ETC.  591 

sumption  at  the  morning  meal.  This  viscid  fluid,  so  tenacious  of  ordi- 
nary air-borne  particles,  may  well  be  suspected  of  entangling  sufficient 
quantities  of  swamp  poison  to  produce  sickness  if  exposed  where  it  is  rife 
during  a  whole  night. 

A  similar  popular  prejudice  exists  in  regard  to  the  muscadine  grape, 
which  flourishes  best  in  swampy  localities.  The  rough  skin  of  this  fruit, 
frequently  covered  with  its  own  juice,  offers  favorable  conditions  for  the 
adhesion  of  air-borne  particles. 

The  malarial  poison  is  not  reproduced  within  the  human  system.  This 
proposition  is  undeniable,  since  no  intensification  of  the  poison  is  pro- 
duced by  any  degree  of  crowding  of  the  sick  which  can  be  practised ; 
neither  do  any  conditions  of  contact  with  the  sick  ever  impart  malarial 
affections. 

Malarial  poison  is  specific.  This  allegation  is  sufficiently  established 
by  its  specific  effects  on  the  human  economy.  There  is  no  other  agent 
known  which  is  capable  of  originating  morbid  phenomena  characterized 
by  such  marked  diurnal  periodicity. 

It  is  not  interchangeable  with  other  specific  poisons.  This  statement 
may  be  rested  upon  all  fairly  collected  clinical  observations. 

There  are  no  facts  which  justify  the  belief  that  malaria  is  capable 
of  becoming  mixed  in  the  atmosphere,  or  outside  the  system,  with  any 
other  specific  morbific  germ,  so  as  to  produce  a  third  something  which 
may  give  rise  to  compound  forms  of  disease. 

The  answer  to  the  second  question  which  is  best  supported  is,  that  the 
malarial  poison  is  brought  into  the  system  principally  by  breathing  an 
atmosphere  impregnated  with  this  miasm. 

It  is  also  ingested  by  being  held  in  suspension  in  fluids  used  as  drink 
or  food ;  perhaps  also  by  eating  certain  fruits  or  vegetables  in  their 
natural  state  whose  external  surfaces  afford  favorable  conditions  for  its 
lodgment. 

MORBID  EFFECTS  AND  PHENOMENA  WHICH  FOLLOW  ITS  INTRO- 
DUCTION INTO  THE  HUMAN  SYSTEM. — The  discussion  of  the  morbid 
process  established  by  the  malarial  poison  involves  some  difficult  prob- 
lems. A  period  of  incubation  must  be  admitted  to  follow  the  inception 
of  the  ague  germs.  But  this  period  has  no  definitely  marked  limits. 
Perhaps  it  is  a  shifting  one,  according  to  the  quantity  or  quality  of  the 
poison  received,  or  the  sudden  or  gradual  manner  in  which  it  is  received, 
or  the  state  of  receptivity  of  the  system. 

Certain  facts  seem  to  indicate  very  clearly  that  malarial  poison  is  very 
slowly  removed  from  a  system  which  has  been  brought  under  its  influence. 
These  evidences  of  long  systemic  residence  of  the  poison  are  principally 
displayed  in  those  attacks  which  occur  after  long  periods  of  removal  from 
any  surrounding  where  intoxication  was  possible.  Vernal  attacks  may 
be  classed  in  the  same  connection.  In  many  instances  the  subjects  of 
these  long-delayed  attacks  have  never  suffered  a  paroxysmal  seizure,  and 
yet  when  some  accidental  derangement  of  health  occurs,  as  from  a  fit  of 
indigestion  or  a  sudden  wetting,  they  fall  sick  with  one  or  another  form 
of  malarial  fever. 

It  does  not  appear  to  me  that  we  are  justified  in  assuming  that  such 
attacks  as  I  refer  to  are  to  be  ascribed  to  secondary  changes  produced  in 
either  the  fluids  or  solids  of  the  system  by  the  malarial  poison.  In  so 


592  MALARIAL  FEVERS. 

far  as  the  clinical  phenomena  are  worth  anything  in  demonstrating  the 
presence  and  agency  of  the  specific  malarial  poison  in  these  deferred 
attacks,  they  are  precisely  similar  to  those  observed  in  paroxysms  arising 
after  a  few  hours'  or  a  few  days'  exposure  to  marsh  miasm. 

But  we  find  further  proofs  of  the  long-continued  and  silent  manner  in 
which  malaria  exerts  its  pathological  influences  in  those  enlargements  of 
the  spleen  which  occur  without  specific  attacks  of  sickness.  The  altera- 
tions of  nutrition  in  this  organ  are  so  characteristic  of  malaria  that  they 
can  scarcely  be  supposed  to  depend  upon  those  chances  which  determine 
the  nature  of  secondary  blood-impurities. 


Intermittent  Fever — Simple  Forms. 

The  clinical  phenomena  of  intermittent  fevers  afford  strong  support  to 
the  opinion  that  this  type  of  malarial  attacks  illustrates  more  strongly 
than  any  other  the  primary  influence  of  the  poison  upon  the  human  sys- 
tem. Fits  of  ague  often  occur  very  shortly  after  exposure  in  infected 
localities,  and  the  persons  thus  suddenly  attacked  may  present  little  or  no 
evidence  of  cachexia  before  or  after  the  paroxysm.  Indeed,  they  fre- 
quently resume  their  ordinary  avocations  after  the  paroxysms,  apparently 
as  well  as  if  they  had  not  occurred. 

It  is  therefore  my  opinion  that  the  pathology  of  an  intermittent  fever 
does  not  necessarily  involve  an  hypothesis  that  the  attacks  are  the  results 
of  certain  changes  which  the  poison  undergoes  after  its  inception,  nor,  on 
the  other  hand,  that  certain  perversions  of  systemic  chemistry  are  required 
to  inaugurate  the  paroxysms. 

In  accordance  with  these  conclusions,  it  seems  likely  that  the  phenom- 
ena of  intermittent  malarial  fever  result  from  the  primary  effects  of  its 
specific  poison  exerted  directly  upon  the  fluids  and  solids  of  the  system, 
and  disturbing  their  functions,  and  especially  the  nerve-function. 

Those  malarial  attacks  which  ensue  almost  immediately  after  exposure 
are  principally  manifested  in  persons  exposed  at  points  of  unusually  abun- 
dant evolution.  The  rule  of  malarial  attacks  in  temperate  latitudes  is, 
that  they  require  repeated  exposure  to  infection  for  their  production. 
The  long  residence  of  the  poison  in  the  system  may  render  additional 
doses  possible,  until  a  point  of  saturation  is  reached  which  occasions  par- 
oxysmal explosions.  In  these  cases  the  period  of  incubation  is  reckoned 
from  the  first  date  of  exposure,  thus  forming  the  most  striking  contrast 
with  the  incubative  periods  of  the  cases  occurring  almost  immediately 
after  exposure. 

Whether  the  quiescent  period  after  exposure  to  malaria  be  long  or  short, 
attacks  are  seldom  abrupt  in  their  announcement.  The  symptoms  which 
usually  precede  pronounced  attacks  consist,  for  the  most  part,  in  some 
derangement  of  the  functions  presided  over  by  the  organic  nervous  sys- 
tem. Derangement  of  digestion,  vitiated  taste,  coating  of  the  tongue, 
loaded  urine,  and  sallow  skin  are  ordinarily  found  among  the  prodromic 
symptoms.  Next  in  succession  come  feelings  of  malaise,  hot  and  cold 
flushes,  and  those  neuralgias  which  precede  and  attend  malarial  paroxysms. 

The  symptoms  of  an  ordinary  or  typical  malarial  paroxysm  are  so 
characteristic,  as  to  be  generally  readily  interpreted.  Creeping,  chilly, 


INTERMITTENT  FEVER— SIMPLE  FORMS.  593 

sensations  over  the  surface,  especially  along  the  spine,  yawning,  livid 
coloration  beneath  the  finger-nails,  retreat  of  blood  from  superficial  capil- 
laries, and  that  consequent  papillary  elevation  which  is  commonly  called 
goose-skin,  comprise  the  earliest  symptoms.  Then  decided  shiverings 
with  chattering  of  _the  teeth  come  on,  and  the  patient  asks  for  blankets  to 
be  heaped  upon  him  and  hot  applications  to  be  made,  even  though  the 
atmospheric  temperature  may  be  decidedly  elevated. 

Nausea  and  vomiting  are  frequent  symptoms,  no  doubt  due  to  the  fact 
that  the  portal  system  of  blood-vessels  is  so  often  the  seat  of  congestion 
during  a  chill.  No  intelligent  practitioner  can  watch  a  patient  during  the 
cold  stage  of  a  malarial  paroxysm  without  realizing  how  important  the 
attendant  congestion  is  as  a  pathological  state.  It  should  first  be  consid- 
ered that  every  chill  necessarily  implies  a  condition  of  congestion  in  some 
part  of  the  system.  The  blood  driven  from  the  surface  and  extrem- 
ities must  be  accounted  for  elsewhere ;  and  the  amount  of  blood  which 
is  lost  from  one  part  of  the  circulatory  tree  must  correspond  with  that 
accumulated  elsewhere.  But  in  treating  of  the  pernicious  forms  of  mala- 
rial fevers  this  question  will  again  receive  notice. 

In  our  present  state  of  knowledge  we  are  no  more  able  to  explain  those 
perversions  of  the  normal  action  of  the  physical  forces  of  the  system 
which  occasion  the  phenomena  of  a  chill  than  we  are  to  explain  how  the 
altered  circulation  in  the  first  steps  of  an  inflammation  is  brought  about. 
The  theory  which  Cullen  adopted  is  quite  as  explanatory  and  consistent 
as  any  which  has  been  promulgated  since  his  time.  According  to  this,  a 
state  of  spasm  of  the  arterioles  and  capillaries  causes  the  chill,  while  the 
fever  is  merely  the  rebound  of  functions  held  in  abeyance  during  the 
chill. 

After  a  variable  length  of  time  there  occurs  a  change  in  these  symp- 
toms :  the  patient  begins  to  remove  the  blankets  which  covered  him ;  the 
face  shows  signs  of  returning  circulation ;  the  veins  of  the  whole  surface 
gradually  fill  again,  apparently  beyond  their  normal  state.  But  the 
reaction  goes  far  beyond  any  normal  physiological  state.  The  face 
becomes  flushed  and  the  eyes  injected,  and  the  patient  complains  of  head- 
ache, thirst,  dryness  and  heat  of  the  surface ;  he  will  not  permit  any  cov- 
ering, and  constantly  shifts  his  place  in  the  bed  in  the  hope  that  some 
new  position  may  afford  him  more  comfort.  Nausea  and  vomiting  are 
commonly  present.  If  the  fever  runs  high,  delirium  is  apt  to  occur. 
The  thermometer  seldom  shows  a  temperature  above  105°,  but  I  have 
seen  106.5°  recorded  in  the  axilla  in  the  hot  stage  of  a  paroxysm  of 
simple  intermittent  fever. 

The  duration  of  the  hot  stage  is  different  in  different  cases.  Accord- 
ing to  Aitken,  the  mean  duration  is  three  to  eight  hours. 

There  is  a  very  old  and  quite  well-supported  opinion,  that  the  cold 
stage  is  shorter  in  the  quotidian  than  in  the  tertian  type,  and  also  that 
the  hot  stage  is  longer  in  the  former  than  in  the  latter.  It  may  certainly 
be  affirmed  that  in  individual  cases  of  either  type  there  is  no  fixed  rela- 
tion between  the  duration  of  the  chill  and  that  of  the  hot  stage. 

The  decline  of  the  hot  stage  begins  by  the  appearance  of  a  gentle 
perspiration,  limited  at  first  to  the  forehead,  face,  and  neck.  This 
gradually  extends  itself  over  the  surface  and  increases  in  quantity  until 
the  whole  body  is  bathed  in  a  profuse  sweat.  During  this  period  the 

VOL.  I.— 38 


594  MALARIAL  FEVERS. 

patient's  symptoms,  both  subjective  and  objective,  undergo  wonderful 
mitigation,  and,  although  this  stage  is  usually  short,  it  often  happens  that 
by  the  time  it  is  concluded  a  restoration  to  ordinary  health  seems  to  have 
occurred. 

The  sweating  stage  terminates  a  malarial  paroxysm.  The  intermission 
now  begins,  and  lasts  until  the  inauguration  of  another  paroxysm.  The 
intermission  is  longer  or  shorter  accordingly,  first,  as  the  paroxysm  occu- 
pies less  or  more  time ;  and,  second,  as  the  interval  may  affect  it.  The 
interval  is  that  period  of  time  which  reaches  from  the  beginning  of  one 
paroxysm  to  the  beginning  of  another.  It  therefore  furnishes  the  basis 
of  classification  of  simple  intermittents  into  the  following  forms  :  quoti- 
dian, tertian,  and  quartan. 

Statistics  gathered  from  a  great  many  sources  and  relating  to  many 
countries  and  climates  indicate  that  quotidian  intermittents  are  more 
common  than  tertian.  It  may  then  be  assumed  that  the  natural  type 
of  intermittents  is  that  form  characterized  by  diurnal  paroxysms.  It 
must  be  remarked,  however,  that  if  any  natural  law  does  exist  establish- 
ing the  quotidian  as  the  typical  form  of  intermittent  fevers,  it  is  very 
often  set  aside  by  unknown  influences.  In  certain  epidemics  the  tertian 
cases  preponderate,  and  under  all  circumstances  convertibility  may  be  wit- 
nessed between  the  various  forms. 

It  is  probable  that  the  statistics  gathered  by  the  medical  staff  of  the 
United  States  Army  during  the  late  Civil  War  afford  the  most  valuable 
data  which  we  possess  touching  these  points,  in  so  far  as  they  relate  to 
this  country.  During  three  years  of  the  war  724,284  cases  of  intermit- 
tent fever  were  recorded,  tabulated  as  follows  : 

Quotidian,  370,401  cases,  388  deaths — equivalent  to  1047  +  deaths  per 
1,000,000  cases. 

Tertian,  318,704  cases,  324  deaths — equivalent  to  1007  -f-  deaths  per 
1,000,000  cases. 

Quartan,  35,179  cases,  79  deaths — equivalent  to  2245+  deaths  per 
1,000,000  cases. 

It  has  been  remarked  by  several  writers  that  quartan  attacks  have  a 
smaller  ratio  in  the  Southern  States  than  in  other  parts  of  the  Union. 
My  observations  on  this  point  have  not  been  sufficiently  well  recorded  to 
make  them  especially  authoritative,  but  they  support  such  a  conclusion. 

The  morbid  anatomy  of  malarial  fevers  is  more  properly  discussed  in 
treating  of  the  graver  forms,  since  the  paroxysms  of  simple  intermittent 
do  not  often  occasion  death. 

TREATMENT. — This  must  necessarily  vary  with  the  stage  of  the  par- 
oxysm and  condition  of  the  patient  at  the  time  of  the  first  visit. 

Let  us  suppose  this  to  be  the  incipiency  of  the  paroxysm,  or  the  early 
part  of  the  cold  stage.  However  little  the  danger  to  life  from  the  parox- 
ysm of  a  simple  intermittent  attack,  the  practitioner  should  not  forget 
that  whatever  danger  does  exist  is  to  be  ascribed  to  damages  suffered  dur- 
ing or  in  consequence  of  the  chill.  There  are  few  exceptions  to  this  rule, 
and  those  will  be  noticed  presently.  With  this  fact  in  view  the  prac- 
titioner's duties  are  much  simplified.  He  should  first  endeavor  to  remove 
any  complications  present  which  tend  to  aggravate  the  cold  stage.  If 
the  chill  has  come  on  after  a  full  meal  or  after  eating  indigestible  food, 
the  stomach  should  be  promptly  emptied ;  otherwise  the  cold  stage  will 


INTERMITTENT  FEVER— SIMPLE  FORMS.  595 

be  prolonged  aud  rendered  more  violent.  Large  draughts  of  warm  water 
will  frequently  produce  sufficient  emesis.  If  this  should  fail,  ipecacuanha 
may  be  added.  The  warm  infusion  of  eupatorium  perfoliatuni  answers  well 
as  an  emetic,  producing  also  a  laxative  effect.  But  it  is  disgusting  to  the 
palate,  and  sometimes  prolongs  its  action  beyond  desired  results.  The 
effect  of  an  emetic  in  abridging  a  chill  by  revulsive  action  are  uncertain,  and 
I  avoid  resorting  to  them  for  this  purpose  alone  in  simple  intermittents. 

The  patient's  subjective  complaints  of  suffering  should  receive  a  due 
degree  of  attention.  Additional  blankets  and  warm  applications  should 
be  allowed  when  solicited.  I  always  discourage  hot  or  heating  drinks, 
except  for  the  purpose  just  mentioned.  I  especially  oppose  alcoholic 
stimulants,  because  they  seldom  do  any  good  in  mitigating  the  chill, 
oftener  aggravating  the  patient's  symptoms  during  the  hot  stage,  particu- 
larly the  headache  and  vomiting,  and  sometimes  directly  occasioning  per- 
plexing perturbations.  For  example,  I  have  seen  convulsions  speedily 
follow  a  strong  brandy  toddy  given  to  shorten  a  chill. 

While  the  removal  of  complications  is  imperatively  indicated,  it  is 
also  important  to  use  promptly  those  means  which  are  designed  to 
modify  and  shorten  the  chill.  It  is  a  remarkable  fact  that  all  the 
agents  found  to  be  useful  for  this  purpose  are  such  as  directly  influ- 
ence nervous  function.  Opium  in  some  form  enters  into  all  prescrip- 
tions which  I  have  found  efficient  in  modifying  a  chill.  It  is  quite 
efficacious  when  given  alone,  but  I  think  its  therapeutic  energy  and  cer- 
tainty are  increased  by  the  addition  of  other  agents  of  the  same  class.  I 
have  often  exhibited  twenty  to  thirty  drops  of  chloroform  with  an  equal 
quantity  of  laudanum  with  excellent  results.  The  tincture  of  opium  may 
be  combined  with  aromatic  spirit  of  ammonia,  or  with  bromide  of  potas- 
sium, or  with  chloral  hydrate.  In  combination  with  either  of  the  latter 
medicines  it  may  be  given  by  rectal  injection.  If  the  stomach  is  intol- 
erant, or  by  preference  because  of  facility  of  dosage  and  quickness  of 
effect,  the  opiate  may  be  given  hypodermically.  For  this  purpose  one- 
sixth  to  one-quarter  of  a  grain  of  morphia  may  be  given,  together  with 
one-sixtieth  to  one-fortieth  of  a  grain  of  atropia.  It  is  rarely  necessary  to 
repeat  the  dose  whichever  form  may  be  adopted. 

After  much  experience  in  these  methods  of  mitigating  and  abridging 
the  chills  of  intermittent  fever,  I  feel  entitled  to  say  that,  whether  the 
objects  be  achieved  or  not,  no  injurious  consequences  ensue. 

The  conditions  of  the  circulatory  and  digestive  organs  are  not  favor- 
able for  the  introduction  of  quinia  or  of  any  preliminary  purgative  which 
may  be  supposed  to  be  necessary,  and  I  therefore  delay  their  exhibition. 
It  may  be  excepted,  however,  that  sometimes  a  very  obstinately  irritable 
stomach  or  exceedingly  vitiated  state  of  the  fluids  can  be  appropriately 
met  by  gr.  x  to  xx  of  calomel. 

The  hot  stage  of  a  simple  intermittent  seldom  calls  for  medical  interfer- 
ence on  account  of  excessive  temperature.  If  the  headache  is  very  violent  or 
the  vomiting  troublesome,  a  subcutaneous  dose  of  morphia  will  bring  speedy 
relief.  The  existence  of  high  temperature  does  not  centra-indicate  its  use, 

I  am  in  the  habit  of  giving  opium  in  the  following  combinations : 
!$5.  Morphise  Acet.  gr.  ss ; 

Liq.  Ammon.  Acet.    f 3iv.     M. 
8.  Two  tablespoonfuls  every  second  hour. 


596  MALARIAL  FEVERS. 

Or,  occasionally,  the  following : 

]$!.  Sodii  Bicarb.  gr.  xx. 

Morphiae  Sulph.  gr.  i ; 

Aquae  Lauro-Cerasi, 
Aquae  Menth.  Pip.  da.  f^iv.     M. 
S.  Teaspoon  ful  pro  re  nata. 

I  do  not  limit  the  use  of  opiates  in  the  hot  stage  to  old  and  infirm 
subjects,  as  Dickson  suggests,  but  give  them  in  all  cases  where  vomit- 
ing, headache,  or  other  neuralgias  are  excessive,  or  where  unusual  rest- 
lessness and  jactitation  are  present. 

The  propriety  of  giving  purgatives  as  a  preliminary  measure  of  treat- 
ment during  the  hot  stage  must  be  determined  by  symptoms  connected 
with  individual  cases.  In  the  majority  of  cases  falling  under  my  care 
purgatives  are  avoided.  When  regarded  necessary,  gentle  purgation  is 
solicited  by  administering  bitartrate  of  potassium  in  lemonade  or  by  com- 
bining mild  mercurial  doses  with  antiperiodics  when  these  latter  are 
resorted  to  during  the  fever.  In  some  cases  a  very  furred  tongue,  sallow 
skin,  and  costive  bowels  indicate  more  active  purgatives,  which  may  be 
exhibited  during  the  febrile  stage. 

The  most  important  question  which  relates  to  medication  during  the 
hot  stage  is  in  respect  to  the  administration  of  antiperiodics.  It  may  be 
safely  stated  that  practitioners  of  this  country  were  the  first  to  adopt  this 
method  of  procedure  in  malarial  fevers.  Here  it  has  been  well  demon- 
strated that  a  competent  dose  of  quinia,  given  during  any  part  of  the 
hot  stage,  is  so  often  followed  by  the  defervescence  of  the  fever  that  it 
would  be  illogical  to  attribute  the  change  to  any  other  cause.  Sometimes 
the  remedy  fails  in  producing  this  result;  then  excessive  physiological 
disturbances  may  follow,  and  perhaps  some  general  aggravation  of  the 
patient's  symptoms. 

There  are  four  different  circumstances,  each  of  which,  in  my  opinion, 
calls  for  the  exhibition  of  quinia  during  the  hot  stage,  whether  the  fever 
has  reached  its  maximum  point  or  not : 

First.  If  the  period  which  has  elapsed  since  the  beginning  of  the 
paroxysm  is  so  considerable  that  further  delay  might  prevent  sufficient 
cinchonism  to  intercept  the  next  accession. 

Second.  When  the  fever  is  so  excessive  that  quinia  should  be  given 
as  an  antipyretic. 

Third.  When  apprehensions  exist  that  the  fever  will  occasion  some 
complication  or  accident. 

Fourth.  When  the  tongue  is  clean  and  the  state  of  the  system  is 
favorable  to  absorption. 

The  hot  stage  is  not  usually  favorable  to  absorption,  and  consequently 
the  economical  use  of  quinia  must  not  be  attempted.  It  should  be 
given  in  doses  varying  from  ten  to  twenty  grains,  preferably  in  solu- 
tion. I  may  remark  that  I  have  seldom  failed  in  getting  good  results 
from  the  powder  or  pills  if  lemonade  or  some  fluid  facile  of  absorption 
be  given  at  the  same  time.  The  mixtures  previously  formulated  answer 
this  purpose  very  well,  and  at  the  same  time  mitigate  the  disagreeable 
physiological  effects  of  the  quinia. 

Allusion  has  been  made  to  certain  symptoms  occasionally  connected 


INTERMITTENT  FEVER—SIMPLE  FORMS.  597 

with  the  hot  stage  which  involve  danger.  Convulsions  are  among  the 
most  important  of  these.  They  occur  most  often  among  children,  but 
occasionally  with  adults.  They  should  be  met  by  chloroform,  cold  to  the 
head,  hypodermic  injection  of  morphia,  and  cupping  or  leeching  if  the 
face  is  flushed,  the  eyes  injected,  and  the  carotids  pulsating  forcibly. 

The  sweating  stage  may  be  classed  with  the  intermission  in  respect  to 
medication.  No  time  should  be  lost  in  securing  cinchonism.  From  the 
moment  the  sweating  stage  announces  itself  the  fluids  of  the  system  begin 
to  resume  their  normal  physiological  functions.  Absorption  from  the 
intestinal  surfaces  is  again  restored,  and  remedies  may  be  administered 
with  confidence  in  their  effects. 

The  question  is  now  no  longer  whether  antiperiodics  should  be 
administered,  but  how  they  shall  be  given.  Many  practitioners  prefer 
exhibiting  them  in  one  large  dose  ;  others  think  it  better  to  give  them  in 
repeated  small  doses.  I  have  usually  adopted  the  latter  method.  Begin- 
ning with  the  sweating  stage,  I  give  three  grains  of  quinia  every  hour 
or  two  hours,  until  eighteen  grains  have  been  taken.  This  would  occupy 
periods  of  five  to  ten  hours  to  complete  the  doses,  ordinarily  quite  a  suffi- 
cient length  of  time  to  obtain  cinchonism  before  the  advent  of  another 
paroxysm.  If  the  physician  elects  to  give  his  antiperiodic  in  one  or  two 
large  doses,  he  should  not  trust  to  so  small  an  amount  as  eighteen  grains. 
Allowance  must  be  made  for  the  loss  incident  to  the  probable  over-taxa- 
tion of  the  power  to  dissolve  and  receive  a  large  amount  into  the  circula- 
tion. 

Purgation  should  not  be  induced  to  a  sufficient  degree  to  hurry  the 
quinia  off  before  absorption  takes  place.  Some  practitioners  favor  the 
employment  of  adjuvants  to  the  quinia.  Very  few  of  these  have 
appeared  to  me  to  be  of  service  except  opium.  A  very  convenient 
formula  is  a  solution  of  quinia  in  peppermint-water  by  addition  of 
dilute  sulphuric  acid,  in  such  proportions  that  fej  of  the  solution  shall 
represent  five  grains  of  quinia  and  seven  and  a  half  drops  of  laudanum. 

But,  however  we  may  boast  of  the  efficacy  of  cinchona  as  the  anceps 
remedium  for  malarial  diseases,  we  are  forced  to  admit  that  it  is  not  cer- 
tainly an  immediate  cure,  and  very  commonly  fails  in  producing  a  per- 
manent curative  effect.  If  we  could  in  all  cases  discern  and  ^remove  the 
impediments  to  its  immediate  or  temporarily  curative  action,  its  claims  to 
be  regarded  as  a  practical  specific  would  be  undeniable.  It  is  probable 
that  these  impediments  generally  rest  upon  the  fact  that  either  the 
remedy  does  not  gain  admission  to  the  circulation  or  that  some  complica- 
tion exists  not  within  the  range  of  its  therapeutic  action. 

The  failure  of  cinchona  to  cure  a  malarial  attack  in  such  a  permanent 
manner  that  it  shall  not  be  liable  to  return  is  probably  owing  to  the 
incompetent  action  of  the  drug  because  of  its  transitory  stay  ^  in  the 
system  as  compared  with  that  of  the  malarial  poison.  Some  objections 
apply  to  this  theory,  because  when  the  succession  of  intermittent  attacks 
is  broken  by  quinia  and  it  is  continuously  administered^  afterward,  the 
paroxysms  occasionally  recur  in  spite  of  its  presence  in  the  system. 
These  objections  may  be  answered  by  pleading  that  under  these  circum- 
stances secondary  blood-poisons  precipitate  the  attacks,  and  cinchona 
should  not  be  expected  to  cure  these  conditions. 

The  best  methods  of  practice  I  know  of  to  prevent  a  recurrence  of 


598  MALARIAL  FEVERS. 

intermittent  fever  after  having  interrupted  the  succession  of  attacks  are, 
fust,  to  continue  the  cinchona  for  at  least  forty-eight  hours,  giving  at 
lea.-i  three  three-grain  doses  a  day.  After  this  no  medicine  need  be 
given  except  such  as  may  be  required  to  correct  chronic  to\;eniic  states 
of  the  system  or  to  act  as  blood-restoratives  until  such  time  as  prodromes 
of  another  paroxysm  may  exhibit  themselves.  At  the  instant  when 
these  manifest  themselves  ten  to  fifteen  grains  of  <iuinia  in  solution 
should  be  taken.  In  order  that  no  loss  of  time  should  occur  in  applying 
this  method,  I  always  advise  patients  to  keep  a  solution  of  quinia 
within  immediate  reach.  The  following  prescription  has  sometimes 
appeared  to  effect  a  permanent  exemption  from  recurrence  of  paroxysms: 
1$.  Ferri  Redacti  gr.  xl ; 

Acid.  Arseniosi  gr.  j  ; 

Quinise  Sulph.   gr.  xl ; 

Ol.  Pip.  Nigr.    gtt.x.     M. 

Ft.  pil.  No.  xx. 
S.  One  pill  three  times  daily. 

It  seems  sometimes  to  occur  that  intermittent  attacks  so  impress  the 
nervous  system  that  they  become,  like  epilepsy,  more  liable  to  recur 
because  of  an  established  habit.  I  have  known  chills  to  occur  when  the 
ears  were  ringing  with  quinia.  Strychnia  fails  to  arrest  them  ;  arsenic 
has  more  value,  but  frequently  fails.  Pure  nitric  acid,  properly  diluted, 
in  doses  of  six  to  ten  drops,  given  every  four  to  six  hours  without  regard 
to  the  stage  of  the  paroxysm,  succeeds  more  often  than  any  medication  I 
have  ever  resorted  to. 

Before  dismissing  the  subject  of  the  treatment  of  simple  intermittent 
lever  it  may  be  proper  to  mention  that  I  have  made  trials  of  cure  by 
carbolic  acid,  administered  by  mouth  and  subcutaneously,  and  also  of 
the  sulphites,  with  no  results  worthy  of  recommendation. 


Remittent  Fever. 

The  difference  in  definition  between  the  words  remittent  and  intermit- 
tent expresses  the  clinical  distinction  between  these  two  forms  of  fever  in 
a  very  satisfactory  manner. 

Remittent  fever  exhibits  oscillations  of  temperature  regulated  as  to 
hours  of  recurrence  by  laws  similar  to  those  which  govern  the  periodic 
returns  of  intermittent  fever ;  but  there  is  no  complete  defervescence  of 
the  fever.  While  the  lowest  angles  of  the  fever  curve  approximate  the 
normal  body  heat  more  or  less  closely,  they  never  decline  to  a  standard 
of  apyrexia. 

That  remittent  fever  is  a  malarial  disease,  produced  by  a  cause  identical 
with  that  which  produces  intermittent  fever,  is  well  proven  by  the  follow- 
ing facts  : 

First.  Cases  occur  in  close  relation  with  cases  of  intermittent  fever  in 
populations  similarly  exposed  to  malaria,  and  at  the  same  periods  of  the 

year. 

Second.  The  two  forms  of  disease  are  readily  convertible,  the  one  with 
the  other. 

In  non-tropical  countries  remittent  fever  cannot  be  regarded  as  the 


RXMfTTEXT  FEVER.  699 

natural  tyjx^  of  malarial  lovers.  At  least,  it  may  lx>  afiirmod  that  the 
proportion  of  cases  which  begin  as  remittent  attacks  is  so  small  that 
we  are  warranted  in  looking  upon  them  as  departures  from  type.  In 
the  United  States  army  during  the  years  18l>M>t>,  inclusive,  there 
occurred  280,400  cases  of  remittent  fever.  The  fatal  eases  were  8853, 
being  a  mortality-rate  of  13,450  per  1,000,000  eases.  By  comparing 
these  statistics  with  those  of  intermittent  fever  recorded  in  a  previous 
section  it  will  be  found  that  remittent  fever  is  more  than  twelve  times 
as  fatal  to  life  as  the  simple  intermittent  forms. 

If  we  accept  this  view  of  the  pathology  of  remittent  fever,  it  is  of 
interest  to  the  sanitarian  or  practitioner  to  endeavor  to  arrive  at  the 
causes  which  occasion  these  departures  from  type.  Some  of  these  are 
undoubtedly  extraneous  to  the  system,  and  relate  wholly  to  circum- 
stances affecting  the  malarial  poison  as  a  disease-producing  agent.  In- 
creased quantity  of  malaria  is  well  understood  to  enlarge  the  ratio  of 
remittent  cases.  There  is  also  strong  presumptive  evidence  supporting 
the  hypothesis  that  different  annual  crops  of  malaria  vary  in  respect  to 
the  noxious  qualities  of  this  agent.  The  same  presumption  relates  to  all 
crops  produced  in  certain  localities  as  contrasted  with  others.  Other 
causes  which  determine  remittent  rather  than  intermittent  attacks  are 
personal  to  patients.  They  may  be  classed  as  follows: 

First.  Unusual  personal  receptivity  or  impressibility  to  malaria  may 
exist,  either  because  of  some  constitutional  idiosyncrasy  or  of  some  state 
the  system  at  the  time  of  exposure. 

Second.  Want  of  timely  medical  treatment  or  of  proper  medical  treat- 
ment may  convert  intermittents  into  remittents. 

Third.  The  rapid  occurrence  of  secondary  blood  infectious,  extraordi- 
nary in  character  or  amount,  may  cause  the  fever  to  be  continuous. 

Fourth.  The  existence  of  complications,  inflammatory  in  their  nature, 
may  change  intermittent  into  remittent  attacks. 

However  various  or  complex  the  causes  may  be  which  operate  to  con- 
vert intermittent  attacks  into  remittent  forms  of  fever,  each  one  must  be 
supposed  to  act  by  disturbing  the  functions  of  those  centres  which  preside 
over  the  normal  physiological  and  chemical  changes  of  the  system. 

SYMPTOMS  AND  DIAGNOSIS. — Attacks  of  remittent  fever  are,  as  a  rule, 
more  abrupt  in  their  advent  than  intermittents.  When  prodromic  symp- 
toms exist,  they  are  similar  to  those  which  precede  ordinary  cases  of  ague. 

The  chill  is  seldom  attended  by  such  violent  symptoms  as  the  cold 
stage  of  intermittents.  The  duration  of  the  cold  stage  is  also  more  brief. 
In  a  small  proportion  of  cases  severe  vomiting  with  large  bilious  ejections 
complicate  the  cold  stage.  The  chill  is  quickly  followed  by  the  hot  stage. 

The  mildest  cases  of  remittent  fever  are  not  readily  distinguishable 
from  the  intermittent  forms.  In  these  cases  the  temperature  curve -s  arc 
marked  by  sharp  angles  and  long  tracings  between  the  lowest  and  highest 
records.  As  cases  become  more  decided  in  diagnosis,  and  consequently 
represent  higher  degrees  of  departure  from  the  intermittent  tvpe,  the 
angles  of  temperature  curves  become  more  obtuse  and  exhibit  a  more  or 
less  high  average  range.  The  accompanying  temperature  diagram  (l<\g. 
23)  shows  the  thermometric  record  of  an  unusually  protracted  and  grave 
case.  The  patient  was  a  near  relative  of  my  colleague,  Prof.  Logan,  a 
leading  practitioner  of  New  Orleans,  and  the  clinical  records  may  be 


600 


REMITTENT  FEVER.  601 

accepted  as  altogether  accurate.  It  is  somewhat  to  be  regretted  that 
the  records  of  temperature  were  not  begun  at  an  earlier  period,  but  the 
gravity  of  the  case  was  not  manifest  until  the  continued  type  of  fever  was 
found  to  exist.  The  latter  part  of  the  diagram  illustrates  the  lapse  of  the 
remittent  fever  into  an  intermittent.  This  is  so  commonly  a  mode  of  cure 
that  the  practitioner  watches  with  solicitude  for  increasing  oscillations  of 
temperature  to  announce  mitigations  of  severity  in  his  gravest  cases. 

The  differential  diagnosis  of  intermittent  and  remittent  fevers  may  be 
looked  upon  as  practically  unimportant.  All  cases  so  near  the  border- 
line as  to  make  differential  diagnosis  a  question  should  receive  identical 
treatment. 

There  are,  however,  two  other  very  grave  forms  of  fever  which  are 
liable  to  give  trouble  in  differentiation  from  remittent  fever.  These  are 
typhoid  and  yellow  fevers.  The  sanitary  protection  of  communities 
exposed  to  cases  of  the  latter,  and  also  the  practical  treatment  of  the 
sick,  call  for  early  and  correct  differentiation. 

But  it  is  only  in  the  early  stages  of  the  pathological  processes  of  these 
affections  that  difficulties  of  diagnosis  are  liable  to  obtain.  The  facial 
expression  of  patients  suffering  with  remittent  is  sufficiently  characteristic 
to  afford  some  diagnostic  inferences.  During  the  pyrexia  the  face  is 
flushed  and  the  eyes  injected,  but  the  redness  is  more  vivid  and  the 
countenance  more  animated  than  in  either  typhoid  or  yellow  fever. 
It  would  not  be  inaccurate  to  say  that,  however  great  may  be  the 
flushing  or  other  alterations  of  the  countenance  in  remittent  fever,  the 
natural  facial  expression  is  better  preserved  than  in  either  of  the  fevers 
under  comparison  with  it.  Sallowness  of  the  skin  is  an  early  and  almost 
constant  event  in  remittent  fever.  It  comes  on  as  a  secondary  manifesta- 
tion, and  appears  in  a  large  ratio  of  cases  to  bear  some  relation  to  the  high 
temperature  preceding  its  occurrence.  The  icteric  hue  is  seldom  intense, 
indeed  very  infrequently  equalling  the  orange-yellow  of  jaundice  result- 
ing from  obstruction.  There  is  an  exception  to  this  statement  in  those 
cases  in  which  remittent  fever  attacks  a  person  already  jaundiced.  I  have 
seen  many  cases  in  which  the  jaundice  preceded  the  remittent  fever,  and 
became  more  strongly  marked  after  its  incursion,  particularly  in  those 
persons  who  had  remained  for  some  time  in  a  malarial  region  and  suffered 
repeated  attacks.  In  all  cases  of  remittent  fever  it  seems  reasonable  to 
ascribe  the  more  or  less  jaundiced  state  to  one  or  both  of  two  factors, 
viz. — the  accumulation  of  excrementitious  material  and  bile  constituents 
in  the  blood  from  primary  derangement  of  its  chemistry ;  and  that  exces- 
sive activity  of  the  liver  which  the  malarial  poison  appears  to  induce. 
Whether  the  latter  mentioned  factor  results  from  some  action  of  malaria 
directly  affecting  the  nutritive  processes  of  the  liver,  as  it  does  those  of 
the  spleen,  or  whether  the  altered  blood-currents  during  the  paroxysms 
cause  this  supposed  hypersecretion  of  bile,  we  certainly  know  that  to 
malaria  only  can  we  ascribe  those  fevers  which  are  marked  by  such  pecu- 
liar symptoms  of  biliousness  or  superabundance  of  bile  as  to  justify  the 
prefix  bilious  fever  or  bilious  remittent  fever. 

The  state  of  the  alimentary  tract  may  properly  receive  notice  after  these 
remarks.  In  the  early  stages  of  remittent  fever  the  tongue  may  be 
moist  and  large,  and  covered  with  a  white  or  lead-colored  or  yellowish 
coat.  The  edges  may  be  indented  with  imprints  of  the  teeth.  This  is 


602  MALARIAL  FEVERS. 

Osborne's  malarial  tongue,  and  its  appearance  is  worth  something  in 
diagnosis. 

Later  in  the  progress  of  remittent  fever  the  tongue  may  become  dry, 
brown,  cracked,  and  difficult  of  protrusion,  but  seldom  showing  the 
tremulousness  of  a  typhoid-fever  tongue,  and  differing  also  from  the 
yellow-fever  tongue  in  the  fact  that  in  this  disease  the  appearance  of  the 
tongue  is  usually  indifferent  as  a  symptom,  except  that  in  advanced  stages 
it  is  liable  to  be  smeared  with  blood. 

The  stomach  is  irritable  from  the  very  beginning  of  an  attack,  and  the 
acts  of  emesis  are  generally  in  striking  contrast  with  those  of  typhoid  or 
yellow  fever,  both  in  respect  to  their  violence  and  to  the  relative  amount 
of  bile  they  eject. 

The  bowels  are  ordinarily  costive,  and  when  moved  by  purgatives  the 
stools  contrast  strongly  with  those  of  typhoid  or  yellow  fever  by  pre- 
senting evidences  of  the  bile-coloring  principles  which  attend  all  excretions 
in  malarial  fever,  and  are  found  in  the  urine,  the  perspiration,  and  occa- 
sionally the  sputa. 

Some  unusually  violent  cases  of  malarial  fever,  which  may  become 
remittent,  are  inaugurated  with  convulsions,  profuse  diarrhoea,  and  coma. 

Before  closing  the  remarks  concerning  the  digestive  organs  in  remit- 
tent fever  I  should  mention  that  in  the  long  array  of  cases  I  have 
treated  I  cannot  recall  one  solitary  instance  of  black  vomit.  It  is, 
however,  true  that  I  have  observed  hemorrhage  from  the  bowels  in  quite 
a  number  of  cases.  These  occurred  late  in  protracted  'cases,  and  were 
sometimes  the  cause  of  death.  Whether  it  be  merely  a  coincidence  I  am 
unable  to  say,  but  it  is  true  that  the  majority  of  these  cases  have  been 
in  young  females  just  after  the  establishment  of  the  catameuia. 

Hemorrhage  from  the  nose  is  frequent  in  remittent  fever,  but  I  have 
never  seen  a  case  with  general  tendency  to  hemorrhage. 

The  pulse  in  remittent  fever  differs  from  that  of  the  typhoid  or 
yellow  fevers  by  being  more  synochal  in  character,  firmer,  and  more 
resisting  to  pressure.  The  longer  the  duration  of  the  case  the  less  is  this 
characteristic  discernible. 

The  nervous  system  shows  less  ataxia.  Delirium  may  occur  in  any 
stage  of  the  disease,  but  differs  from  the  delirium  of  typhoid  and  yellow 
fevers  in  showing  a  lessened  degree  of  perversion  of  the  reasoning  facul- 
ties. The  neuralgias  have  nothing  special. 

The  urine  is  acid,  high-colored,  and  scanty.  I  have  never  found  much 
albumen  in  the  urine  of  a  case  of  remittent  fever,  unless  there  was  some 
other  cause  to  account  for  its  presence.  A  small  amount  may  be  detected 
during  excessive  fever.  Blood  is  a  rare  constituent. 

Mild  cases  of  remittent  fever  should  terminate  in  recovery  in  from  five 
to  seven  days.  Fatal  attacks  usually  end  from  the  fifth  to  the  tenth  day. 
Many  cases  pursue  a  course  which  lasts  from  twenty  to  forty  days.  Under 
proper  treatment  the  usual  termination  is  in  recovery,  either  directly  or 
by  conversion  into  the  intermittent  type. 

POST-MORTEM  APPEARANCES. — When  death  occurs  in  remittent  fever 
the  post-mortem  changes  generally  consist  of  those  which  are  principally 
due  to  chronic  malarial  toxaemia  and  those  ascribable  to  the  acute  attack. 

Under  the  former  division  are  permanent  enlargements  of  the  spleen 
and  liver,  and  pigmentary  matter  in  the  blood  and  deposited  in  various 


REMITTENT  FEVER.  603 

organs.  Under  the  latter  are  to  be  classed  hyperaemic  or  even  inflamma- 
tory states  of  the  stomach  and  intestines,  and  those  degenerative  changes 
which  are  the  consequence  of  continuous  hyperpyrexia.  The  post-mortem 
changes  which  are  so  uniformly  found  as  to  be  most  often  appealed  to  in 
the  establishment  of  diagnoses  are  enlargements  of  the  liver  and  spleen. 
These  may  be  due  in  part  to  hyperplasia  and  in  part  to  blood-engorge- 
ment. The  brown  or  slate  color  of  an  enlarged  liver  is  strongly  diag- 
nostic of  malarial  affections.  It  contrasts  strongly  with  the  yellow  and 
natural-sized  liver  of  yellow  fever  and  with  the  negative  liver  of  typhoid 
fever. 

The  skin  is  generally  yellow,  sometimes  quite  intensely  icteric,  but 
seldom  showing  the  ecchymotic  extravasations  of  yellow  fever.  In 
remittent  fever  we  never  find  the  cadaver  oozing  blood  from  the  nose 
and  the  mouth,  nor  are  the  stomach  or  intestines  ever  found  to  contain 
black  vomit. 

TREATMENT. — The  indications  of  treatment  in  remittent  fevers  diifer 
from  those  of  intermittents  in  two  leading  essentials. 

First.  It  is  a  far  graver  form  of  fever,  and  calls  for  more  promptitude 
and  energy  in  treatment  for  its  successful  management. 

Second.  The  important  pathological  condition  to  be  combated  is  the 
hyperpyrexia,  and  not  the  cold  stage,  as  in  intermittents. 

But  even  with  a  clear  realization  of  the  practical  importance  of  these 
facts  in  governing  the  treatment  of  remittents,  the  practitioner  must  still 
exercise  care  and  self-control,  lest  he  shall  unconsciously  adopt  the  doc- 
trine that  inflammatory  lesions  must  be  present  to  occasion  such  violent 
pyrexia  as  often  exists.  The  physician  who  comes  directly  from  a  case 
of  pneumonia  or  rheumatic  fever  and  finds  a  patient  suffering  from  remit- 
tent fever,  with  temperature  higher  and  pulse  more  bounding  than  those 
of  the  patient  he  has  just  left,  is  pardonable  for  finding  it  difficult  to 
realize  that  these  furious  symptoms  are  not  also  associated  with  inflamma- 
tion. 

Attempts  to  cure  remittent  fevers  by  an  exclusively  antiphlogistic  treat- 
ment either  result  fatally  or  induce  long  periods  of  confinement  and  suf- 
fering before  recovery  is  reached.  The  great  indication  is  to  secure  cin- 
chonism  as  promptly  and  completely  as  possible.  Nothing  should  divert 
our  attention  from  this  object.  The  condition  of  the  patient  as  it 
respects  fever,  delirium,  or  state  of  the  tongue,  should  form  no  bar  to  the 
administration  of  quinia.  There  are  no  practitioners  who  have  had 
much  experience  in  treating  these  grave  forms  of  malarial  fever  after  this 
method  who  are  not  able  to  recall  the  numerous  instances  of  most  aston- 
ishing and  gratifying  amelioration  of  symptoms  as  soon  as  saturation 
with  quinia  was  brought  about.  The  dry  tongue  becomes  moist,  the  skin 
is  bathed  in  gentle  perspiration,  the  delirium  ceases,  and  the  patient  sinks 
into  a  quiet  sleep. 

The  amount  of  quinia  necessary  to  produce  cinchonism  must  be  esti- 
mated for  each  particular  case  according  to  the  measure  of  its  severity  or 
to  states  of  the  system  more  or  less  favorable  to  its  absorption.  It 
must  be  borne  in  mind,  however,  that  questions  concerning  the  patient's 
safety  are  paramount  to  those  of  economy.  In  the  mildest  cases  I  never 
trust  to  a  smaller  amount  than  from  twenty  to  thirty  grains. .  In  violent 
attacks  I  have  administered  scruple  doses  every  fourth  hour  until  a  suf- 


604  MALARIAL  FEVERS. 

ficient  test  had  been  made  of  its  capability  to  arrest  or  modify  the  febrile 
paroxysm.  I  have  never  met  with  any  of  those  exaggerated  physio- 
logical effects  which  some  observers  teach  us  to  fear  from  the  exhibition 
of  cinchona  preparations  during  fever.  Certainly,  I  can  declare  that  no 
permanent  deafness  or  other  lasting  lesion  of  nerve-function  has  ever 
occurred  under  my  observation.  I  must  also  add  that  I  know  of  no 
reasons  why  remissions  afford  more  favorable  conditions  for  the  adminis- 
tration of  quinia,  beyond  the  fact  that  the  system  is  in  a  better  state  for 
its  absorption  and  assimilation.  The  quinia  is  preferably  given  in  solu- 
tion, but  may  be  exhibited  in  the  form  of  pills,  or  in  powder  suspended 
in  black  coffee,  or  in  the  thick  mucilage  of  the  slippery  elm. 

The  considerations  of  treatment  which  are  naturally  connected  with 
those  just  advocated  relate  to  measures  which  it  may  be  proper  to 
associate  with  the  quinia.  The  answers  to  the  two  following  questions 
comprise  all  that  is  necessary  to  be  said  on  this  point — viz.: 

Are  conditions  of  the  system  present  which  may  interfere  with  the  spe- 
cific treatment  by  quinia,  and  which  are  not,  in  themselves,  curable  by  it? 

Are  any  medicines  to  be  given  as  succedanea  to  the  specific  remedy  for 
the  purpose  of  rendering  its  action  more  sure  or  prompt  ? 

In  regard  to  the  first  inquiry,  it  must  be  admitted  that  in  quite  a  large 
proportion  of  cases  of  remittent  fever  specific  treatment  fails  to  cure.  I 
suppose  that  may  be  a  reasonable  proposition  which  holds  that  in  the 
majority  of  these  cases  the  presence  of  secondary  blood- impurities  annuls 
the  ordinary  specific  effects  of  cinchona.  These  nmst  be  gotten  rid  of  by 
depurative  medicines.  The  intestinal  canal,  the  skin,  and  the  kidneys  are 
the  emunctories  through  which  elimination  must  be  effected.  It  is  there- 
fore proper  for  the  physician  to  endeavor  to  recognize  cases  where  such 
impurities  exist,  and  to  so  modify  his  treatment  as  to  remove  them.  The 
indications  for  depurative  treatment  are  jaundiced  skin  and  eyes,  furred 
tongue,  costive  bowels,  and  scanty,  loaded  urine.  These  are  more  or  less 
positively  expressed  symptoms  in  a  large  majority  of  cases.  It  is  there- 
fore proper  that  in  this  large  majority  of  cases  of  remittent  fever  depura- 
tive treatment  should  be  conjoined  with  the  specific  treatment.  In  my 
opinion,  no  drugs  meet  this  indication  so  well  as  mercurials  and  saline 
purges  and  diuretics.  Calomel  or  blue  mass  may  be  given  either  simul- 
taneously with  the  quinia  or  in  alternate  doses. 

There  are  three  very  important  rules  to  be  observed  in  regard  to 
cathartics :  They  should  never  be  carried  to  such  an  extent  that 
absorption  of  the  quinine  is  interrupted.  They  should  not  be  given  in 
such  large  or  repeated  doses  as  to  produce  prolonged  irritation,  or  it  may 
be  even  inflammation,  of  the  alimentary  canal.  Purgatives  should  be 
used  for  their  depurative  effects,  and  never  as  antiphologistics. 

Opium  exercises  excellent  effects  in  preventing  local  irritation  or  hyper- 
catharsis,  and  in  relieving  derangements  of  nerve-function  and  insomnia. 
It  is  preferably  given  in  small  doses,  combined  either  with  purgatives  or 
with  the  quinia. 

I  have  found  bitartrate  of  potassium  the  most  grateful  and  efficient 
saline  for  depurative  action.  I  have  generally  given  it  in  lemonade  in 
such  amounts  as  to  secure  a  gentle  aperient  and  diuretic  effect.  I  hold 
strongly  to  a  conviction  that  all  drugs  as  soluble  as  this  faciltate  the 
absorption  of  those  less  soluble — as,  for  example,  of  quinia. 


PERNICIOUS  MALARIAL  FEVER.  605 

If  the  first  efforts  to  break  the  febrile  paroxysms  fail,  it  is  better  to  dis- 
continue the  quinia  and  place  the  patient  under  symptomatic  treatment, 
and  await  conditions  of  the  system  more  favorable  for  its  repetition.  Of 
course  the  high  temperature  is  generally  the  symptom  requiring  most  care 
and  attention. 

Vomiting  is  one  of  the  troublesome  symptoms  of  remittent  fever.  As 
internal  medication  minute  doses  of  morphia,  dry  upon  the  tongue  or 
in  solution  in  cherry-laurel  water,  or  in  combination  with  eight  or  ten 
drops  of  chloroform,  are  generally  efficacious.  Swallowing  pellets  of  ice 
or  frequently  taking  iced  effervescing  mixtures  are  good  measures  of 
treatment.  Occasionally,  a  mild  emetic,  such  as  warm  chamomile  infu- 
sion, or  warm  water  alone,  will  arrest  the  vomiting  temporarily.  It  is 
doubtful,  however,  whether  this  relief  is  secured  by  the  ejection  of  any 
offending  matter  from  the  stomach.  It  is  more  than  probable  that  the 
forced  dilatation  of  the  stomach  has  arrested  the  spasms,  for  filling  this 
viscus  with  cold  drinks  to  repletion  will  often  effect  the  same  result. 

Of  all  applications  to  the  epigastrium,  a  cold  wet  towel  occasionally 
sprinkled  with  chloroform  is  the  best. 

A  tympanitic  or  tender  abdomen  requires  stupes  wrung  from  warm 
water.  They  may  be  dashed  with  turpentine  at  first,  and  afterward 
consist  of  warm  water  with  whiskey.  I  have  occasionally  given  two 
or  three  doses  of  turpentine  emulsion  with  benefit,  but  from  much  obser- 
vation I  am  forced  to  protest  against  the  turpentine  treatment,  as  it  is 
called,  which  is  to  give  twenty  drops  of  turpentine  every  two  to  four 
hours  as  a  curative  agent. 

Hemorrhage  from  the  bowels  must  be  met  by  haemostatic  treatment — 
preferably,  in  my  experience,  by  the  use  of  five  grains  of  gallic  acid  in 
half  an  ounce  of  camphor-water  every  two  hours,  of  morphia  subcutane- 
ously,  and  of  cold  cloths  over  the  bowels.  As  in  all  diseases  liable  to 
cause  death  from  exhaustion,  careful  attention  must  be  paid  to  the  nutri- 
ment, and  stimulants  must  be  administered  as  required. 


Pernicious  Malarial  Fever. 

Certain  departures  from  the  ordinary  types  of  malarial  fever  are 
termed  pernicious,  because  of  their  great  tendency  to  inflict  more  than 
usual  systemic  damage  and  danger  to  life  upon  those  who  suffer  such 
attacks.  The  word  pernicious  is  used  in  its  common  English  sense  of 
being  hurtful  or  injurious. 

It  is  entirely  unnecessary  to  enter  upon  a  discussion  respecting  the  pro- 
priety of  employing  this  adjective  to  designate  a  class  of  cases  of  disease 
which  are  primarily  due  to  the  same  poison  which  produces  simple  inter- 
mittent attacks.  The  extreme  hurtfulness  and  danger  of  the  attacks  to 
be  described  in  this  section,  and  the  awful  suddenness  with  which  they 
often  occasion  death,  form  striking  contrasts  with  the  more  typical  forms 
of  malarial  fever,  and  appear  fully  to  justify  the  use  of  the  qualifying 
adjective  pernicious. 

While  all  these  various  departures  from  type  to  be  grouped  under  the 
term  pernicious  possess  the  quality  ascribed  to  them,  they  nevertheless 
differ  so  widely  in  their  modes  of  inflicting  injury  that  it  seems  desirable 
to  arrange  them  under  distinct  sub-classifications. 


606  MALARIAL  FEVERS. 

Some  cases  of  pernicious  malarial  fever  preserve  the  periodicity  of 
simple  attacks  sufficiently  well  to  enable  one  to  classify  them  as  intermit- 
tent or  remittent  in  form.  But  more  commonly  it  is  impossible  to  deter- 
mine this  classification,  and  for  practical  purposes  it  is  unimportant'  to 
attempt  to  make  any  such  distinction. 

The.  classification  which  appears  to  me  most  true  to  nature  is  the 
following : 

First.  The  algid  or  congestive  form ; 

Second.  The  comatose  form ; 

Third.  The  hemorrhagic  form. 

The  algid  or  congestive  form  occurs  more  frequently  than  either  of  the 
others.  Its  perniciousness  is  due  to  an  aggravation  or  sheer  exaggeration 
of  the  cold  stage  of  an  intermittent  attack. 

The  following  brief  clinical  histories  of  two  cases  will  serve  to  illustrate 
the  symptomatic  phenomena  of  this  form  of  pernicious  malarial  fever : 

M.  S.,  aged  fourteen,  had  accompanied  his  father  to  a  malarious 
locality  in  the  country,  and  had  remained  with  him  during  September 
and  a  portion  of  October.  Shortly  after  his  return  I  was  asked  to  visit 
him  because  of  some  unusual  symptoms  attending  a  chill.  I  found  him 
in  a  stupor,  from  which  he  was  with  difficulty  aroused  sufficiently  to  be 
able  to  swallow  a  dose  of  quinia  combined  with  laudanum.  His  face 
was  pallid  and  inexpressive ;  the  skin  cool  and  moist ;  extremities 
shrunken  and  cold ;  pulse  small,  easily  obliterated  by  pressure,  and 
irregular ;  tongue  large  and  moist ;  and  pupils  rather  dilated. 

My  second  visit  was  at  12  M.,  one  hour  and  a  half  later  than  the  first. 
Patient  was  found  in  a  deep  stupor ;  surface  cold  ;  extremities  and  face 
shrunken  and  blue ;  pulse  barely  perceptible  ;  large  liquid  and  offensive 
stools  occasionally  escaped  from  the  bowels  without  the  consciousness  of 
the  patient.  Death  at  3  o'clock  p.  M. 

Miss  H.,  living  in  a  malarious  situation,  complained  about  noon  of 
September  19th  of  great  cerebral  fulness  and  unaccountable  sleepiness 
and  debility.  She  retired  to  her  room,  and  after  a  few  hours'  sleep 
resumed  her  household  occupations.  On  the  20th  similar  symptoms 
manifested  themselves,  but  earlier  in  the  day.  She  again  slept  for  some 
hours,  but  complained  of  great  prostration  after  the  sleep.  On  the  21st, 
about  10  A.  M.,  she  complained  of  a  return  of  the  stupor,  and  while 
retiring  to  her  room  requested  that  I  should  be  called  if  she  did  not 
awake  in  a  better  condition.  At  1  P.  M.  she  was  found  profoundly  coma- 
tose, with  cold  extremities  and  surface  and  bathed  in  perspiration.  When 
I  reached  her  residence  at  3  P.  M.  she  had  expired. 

There  is  a  common  belief  among  non-professional  people  that  the  third 
congestive  chill  is  necessarily  fatal.  There  is  no  foundation  for  this  opin- 
ion, except  in  the  fact  that  when  congestive  chills  are  waxing  in  their 
perniciousness  the  subject  is  seldom  able  to  survive  the  third  recurrence 
if  the  second  or  first  should  not  prove  fatal. 

It  is  difficult  to  account  for  the  pathological  dissimilarity  between  the 
simple  and  congestive  types  of  malarial  fevers.  If  we  say  that  conges- 
tive chills  are  produced  by  an  intensification  of  those  causes  which  pro- 
duce and  govern  an  ordinary  chill,  we  make  an  explanation  which,  how- 
ever unsatisfactory,  represents  very  nearly  the  full  extent  of  our  know- 
ledge on  this  point. 


PERNICIOUS  MALARIAL  FEVER.  607 

It  cannot  be  admitted  that  alterations  of  quantity  or  quality  of  the 
malarial  poison  exercise  the  sole  influence  in  determining  the  occurrence 
of  congestive  cases.  All  experienced  practitioners  understand  that  cer- 
tain constitutional  conditions  may  pervert  simple  chills  into  congestive 
forms  by  producing  prolongation  or  aggravation  of  the  states  of  con- 
gestion always  present  in  ordinary  chills.  Weakened  cardiac  function, 
from  whatever  cause,  may  be  reckoned  among  these  conditions.  In 
these  cases  the  feeble  vis  a  tergo  yields  readily  to  those  perturbations 
of  vaso-motor  influence  which  occasion  passive  blood-accumulations 
in  the  small  veins  and  capillaries.  I  may  say  further,  in  speaking 
of  the  influence  of  the  vaso-motor  nerves  in  governing  the  phenomena 
of  a  chill,  that  we  know  that  in  congestive  chills  the  cerebro-spinal  sys- 
tem is  much  less  the  seat  of  symptomatic  phenomena  than  in  simple 
attacks.  On  the  other  hand,  the  organic  system  is  far  more  profoundly 
aifected. 

However  we  may  account  for  the  perversions  of  normal  circulation 
underlying  and  producing  congestive  chills,  the  great  degree  of  injury 
they  are  liable  to  inflict  is  so  well  understood  as  to  awaken  the  most 
serious  apprehensions  whenever  we  are  called  upon  to  treat  them.  Con- 
gestion, however  occasioned,  may  destroy  life  through  abolishment  of 
function  by  the  sheer  physical  change  of  infarction,  or,  again,  through  those 
inevitable  consequences  which  arrested  circulation  entails  upon  the  blood. 
Blood-stasis  is  followed  by  separation  of 'its  constituents,  and  its  disquali- 
fication as  a  circulatory  fluid  in  a  degree  proportionate  to  the  duration  of  the 
stoppage,  and  probably  also  to  the  actual  extent  of  the  passive  engorgement. 
Thence  result  the  formation  of  coagula  in  the  congested  vessels  and 
deposits  of  pigmentary  matter.  If  partial  reaction  should  occur,  por- 
tions of  this  blood-debris  may  be  floated  to  various  parts  of  the  circula- 
tory system,  and  give  rise  to  greater  or  less  important  alterations  of 
function. 

Among  the  white  soldiers  of  the  United  States  army  from  May  1, 
1861,  to  June  20,  1866,  13,673  cases  were  diagnosed  as  congestive  inter- 
mittent fever.  Of  this  number,  3370  died,  being  a  mortality-rate  of 
23.91  per  cent.  The  aggregate  number  of  malarial  cases  returned  was 
1,255,623.  It  would  therefore  appear  that  1  case  in  not  quite  372  was 
congestive  in  its  type,  or  1.08  per  cent.  The  late  Dr.  Cook  of  Washing- 
ton, La.,  estimated  2  per  cent,  of  his  malarial  cases  to  be  of  the  conges- 
tive type.  It  can  scarcely  be  doubted  that  the  ratio  of  congestive^  attacks 
is  greater  in  the  more  southern  belts  of  latitude  than  in  the  middle  or 
northern  parts  of  the  United  States.  Chronic  malarial  toxaemia  and  the 
enervating  effects  of  long-continued  heat  upon  the  circulation  must  occasion 
an  increased  proportion  of  such  attacks,  but  my  own  observations  show 
slightly  more  than  1  per  cent,  of  the  cases  treated  in  the  Charity  Hospital 
to  have  been  of  the  congestive  form. 

The  cure  of  a  congestive  chill  is  one  of  the  most  difficult  problems  the 
physician  can  possibly  encounter.  It  is  nothing  less  than  the  proposi- 
tion to  remove  a  perverted  state  of  the  blood-vessels  which  is  dependent 
upon  some  influence  exerted  through  a  nervous  apparatus  whose  thera- 
peutics and  experimental  physiology  are  imperfectly  understood.  While 
a  satisfactory  solution  of  this  problem  will  probably  be  a  remote  achieve- 
ment in  medicine,  it  was  long  ago  empirically  ascertained  that  certain 


608  MALARIAL  FEVERS. 

agents  exercised  some  degree  of  control  over  the  cold  stage  of  febrile 
attacks.  For  the  most  part,  these  agents  are  addressed  to  those  perver- 
sions of  nerve-function  which  constitute  so  important  a  part  of  the  pathol- 
ogy of  a  chill.  They  are  identically  the  same  remedies  whose  aid  we 
invoke  to  allay  many  other  forms  of  perturbed  nervous  action. 
Opium,  chloroform,  belladonna,  chloral  hydrate,  and  bromide  of  potas- 
sium have  proved  more  or  less  valuable,  according  to  the  idiosyncrasy  of 
the  patient  or  the  circumstances  under  which  they  have  been  used.  I 
consider  opium  the  most  valuable  of  these  remedies.  It  should  be  given 
in  moderate  doses,  and  preferably  combined  with  chloroform  or  ammonia, 
or,  if  more  expedient  to  administer  per  rectum,  combined  with  solutions 
of  chloral  hydrate  or  bromide  of  potassium.  One-sixth  of  a  grain  of 
morphia,  combined  with  one-fortieth  or  one-fiftieth  of  a  grain  of  atropia, 
is  an  available  and  useful  prescription  when  given  hypodermically. 
Rubbing  the  extremities  or  the  spine,  or  indeed  the  whole  surface, 
with  ice,  is  a  mode  of  practice  well  worthy  of  attention.  In  the  event 
of  inability  to  procure  ice,  douches  of  cold  water,  followed  by  frictions 
with  coarse  towels,  may  be  substituted.  I  have  used  nitrite  of  amyl  by 
inhalation,  but  its  effects  are  too  transitory  to  prove  serviceable. 

Some  practitioners  speak  highly  of  alcoholic  stimulants.  My  own 
experience  has  not  been  favorable  to  their  use.  Perhaps  their  benefits 
are  altogether  restricted  to  those  cases  in  which  previously  weakened 
heart-function  existed.  But  it  is  important  that  alcohol  be  added  in  all 
those  cases  of  pernicious  malarial  fever,  whatever  the  type  may  be,  where 
cardiac  stimulation  and  improvement  of  nutrition  are  leading  indications. 

I  am  sure  I  have  often  derived  benefit  from  enemas  consisting  of  four 
ounces  of  well-prepared  beef  essence  with  a  half  ounce  of  whiskey  or 
brandy  and  a  half  ounce  of  strong  infusion  of  coffee. 

The  value  of  the  hypodermic  syringe  in  treating  congestive  chills  must 
never  be  lost  sight  of.  The  suspension,  or  even  reversal,  of  normal  sys- 
temic currents  is  made  evident  by  the  serous  vomiting  and  purging  attend- 
ing congestion  of  the  abdominal  cavity.  Medicine  placed  in  the  stomach 
under  these  circumstances  is  virtually  thrown  away. 

The  term  comatose  is  applied  to  certain  cases  of  pernicious  malarial 
fever  because  they  present  coma  as  a  marked  symptom.  To  appreciate 
the  propriety  of  this  classification,  it  must  be  well  understood  that  the 
coma  present  is  not  due  to  cerebral  congestion.  Further  than  this  one 
restriction  upon  the  application  of  the  word  there  is  in  its  employment 
no  declaration  of  any  pathological  views  respecting  the  cases  it  is  intended 
to  define.  While,  therefore,  the  term  is  unquestionably  liable  to  criticism, 
I  suppose  its  use  may  still  be  admitted,  provided  it  is  accompanied  by  a 
satisfactorily  explicit  account  of  the  symptoms  and  probable  pathological 
conditions  of  the  cases  included  under  its  caption. 

There  is  a  sharp  line  of  distinction  between  the  symptoms  and  conjec- 
tural pathology  of  comatose  cases  and  of  those  of  the  congestive  form  of 
pernicious  fever.  The  following  notes  of  cases  will  sufficiently  establish 
this  statement : 

C.  L.,  fisherman,  aged  forty-four,  brought  into  Ward  20,  Charity 
Hospital,  in  an  insensible  condition,  November  18,  1875.  Tempera- 
ture at  time  of  admission  104.8°,  pulse  120,  respiration  40;  able  to 
swallow  liquids  placed  far  back  in  his  mouth.  Ordered  9ij  of  quinia  in 


PERNICIOUS  MALARIAL  FEVER.  609 

solution,  ten  grains  to  be  given  every  fourth  hour.  Nov.  19th,  patient 
has  taken  and  retained  all  the  quinia  ordered ;  is  perspiring  profusely ; 
temperature  97.8°,  pulse  88;  more  conscious;  takes  food  and  water  when 
oifered  him.  Ordered  blue  mass,  comp.  extr.  colocynth.,  dd  gr.  v,  to 
be  taken  at  once.  To  drink  through  the  day  bitartrate  potass.  §j,  dis- 
solved in  lemonade,  until  bowels  are  moved.  Evening  temperature  99.3°. 
Nov.  20th,  temperature  98°;  patient  placed  under  convalescent  treatment ; 
discharged  from  hospital  Nov.  29th. 

Another  comatose  patient  was  admitted  to  Ward  19  on  the  29th  of 
October,  entirely  insensible.  He  was  treated  by  large  doses  of  quiuia  in 
solution  per  rectum,  and  by  calomel  gr.  xx,  sodii  bicarb,  gr.  v,  placed  upon 
base  of  tongue,  and  caused  to  be  swallowed  by  a  tablespoonful  of  water 
trickled  over  the  powder.  As  the  patient  began  to  recover  it  was  noticed 
that  his  right  arm  was  paralyzed.  A  history  subsequently  obtained 
showed  that  the  patient  was  an  engineer,  and  had  been  engaged  in 
making  some  land  surveys  in  a  swampy  portion  of  the  State  of  Louisi- 
ana, and  had  been  often  obliged  to  wade  or  swim  across  the  bayous  and 
to  sleep  at  night  in  the  open  air,  sometimes  without  any  protection  from 
the  weather.  He  had  previously  enjoyed  good  health,  and  was  altogether 
unable  to  account  for  the  paralysis  of  his  arm.  During  convalescence  he 
was  treated  with  iron,  strychnia,  and  preparations  of  cinchona,  and  by 
cold  douches  and  frictions  to  the  paralyzed  arm.  Convalescence  was  slow, 
but  he  was  discharged,  completely  recovered,  on  November  20th. 

In  typical  cases  the  differential  diagnosis  between  the  congestive  -form 
and  the  comatose  is  made  without  difficulty.  In  a  congestive  chill  the 
surface  is  cold,  blue,  or  livid,  the  pupils  dilated,  and  the  pulse  generally 
slower  than  natural  and  irregular.  In  the  comatose  form  the  surface  is 
preternaturally  warm,  of  a  muddy,  semi-jaundiced  hue,  and  the  pulse  and 
temperature  both  indicate  the  feverish  rather  than  the  algid  state. 

The  subjects  of  attacks  of  the  comatose  form  of  malarial  fever  are  for 
the  most  part  persons  who,  having  contracted  attacks  of  fever  in  malarial 
regions,  continue  to  reside  in  the  same  localities  and  yet  use  no  proper 
medication,  either  for  cure  or  for  prophylaxis.  We  have  in  these  cases 
accumulations  of  secondary  blood-poisons  quite  sufficient  to  greatly 
impede  brain-function,  and  the  additional  doses  of  the  primary  toxic 
agent  must  exercise  more  or  less  influence  in  determining  the  phenomena 
of  the  attacks. 

Very  little  need  be  said  of  treatment,  beyond  a  recommendation  of  the 
courses  pursued  in  the  cases  cited.  Hypodermic  medication  must  be 
resorted  to  when  necessary.  Efforts  to  nourish  the  patient  must  never 
be  relaxed.  One  must  see  many  of  these  cases  before  he  can  realize  how 
often  they  recover,  from  conditions  apparently  utterly  hopeless,  when 
promptly  treated  and  properly  nourished. 

The  hemorrhagic  form  of  pernicious  malarial  fever  can  scarcely  be 
regarded  as  an  original  type.  Malaria  is  not  a  hemorrhage-inducing 
poison.  Indeed,  it  may  be  positively  stated  that  malaria  never  estab- 
lishes the  hemorrhagic  diathesis  as  a  primary  effect ;  and  it  is  only  by 
changes  effected  in  the  human  economy  by  its  prolonged  influence  that 
it  appears  to  become  capable  of  doing  so.  The  most  experienced  and 
accurate  observers  of  malarial  affections  concur  in  the  opinion  that  this 
rule  is  almost  without  exception. 

VOL.  I.— 39 


610  MALARIAL  FEVERS. 

The  morbid  conditions  whose  concurrence  entails  upon  malarial  fevers 
a  tendency  to  hemorrhages  may  be  classed  together  as  follows :  First.  The 
blood-changes  of  chronic  malarial  toxaemia  so  alter  the  consistency  of  that 
fluid  as  to  favor  the  occurrence  of  hemorrhage.  Second.  The  long  per- 
sistent states  of  malnutrition  in  chronic  malarial  cachexias  produce  tex- 
tural  weakening  of  the  vascular  walls  and  increased  liability  to  their  rup- 
ture. Third.  There  should  be  added  to  these  one  other  factor,  which  is 
mainly  operative  during  a  malarial  paroxysm — namely,  the  increased 
blood-pressure  put  upon  the  vascular  walls  by  passive  congestions. 

Two  of  these  factors,  as  above  enumerated,  are  more  or  less  general  to 
the  system,  being  the  consequence  of  general  cachectic  states.  The  third 
factor  acts  in  a  purely  dynamical  manner  in  causing  hemorrhages,  and 
must  necessarily  have  its  area  of  influence  confined  to  some  certain  por- 
tion or  portions  of  the  vascular  tree,  since  the  congestions  of  malarial 
paroxysms  cannot  by  any  possibility  be  general.  It  is  an  interesting  fact 
that  the  influence  of  this  last-mentioned  factor  is  so  frequently  paramount 
in  producing  malarial  hemorrhages.  These  hemorrhages  occur  in  such 
immediate  relation  to  chills  that  we  are  forced  to  the  conclusion  that 
while  altered  blood  and  weakened  blood-vessels  were  previously  present, 
yet  some  increase  of  pressure  beyond  the  normal  was  required  to  precipi- 
tate the  hemorrhage. 

More  than  once  in  the  presence  of  medical  classes  I  have  illustrated  the 
influence  of  these  various  factors,  respectively,  by  showing  the  arm  of  a 
patient  suffering  with  chronic  malarial  cachexia,  with  no  extravasation  of 
blood,  but  upon  which  the  slightest  suction  with  the  lips  would  produce 
exaggerated  ecchymoses.  This  explains  the  fact  that  hemorrhages  in 
malarial  fevers  are  never  general,  but  only  manifest  themselves  upon 
those  surfaces  or  into  those  structures  which  are  the  seats  of  congestion 
during  the  cold  stage  of  an  intermittent. 

I  do  most  earnestly  assert  that  during  a  practice  of  almost  half  a  century, 
nearly  all  of  which  has  been  passed  in  malarious  localities,  I  have  never 
once  seen  a  malarial-fever  patient  with  a  general  hemorrhagic  tendency, 
if  yellow  fever  and  other  hemorrhage-inducing  diseases  could  be  authori- 
tatively excluded.  The  medical  profession  cannot  be  too  watchful  in 
guarding  itself  against  erroneous  entries  upon  mortuary  records  to 
account  for  deaths  from  fevers  accompanied  by  hemorrhages  from  mul- 
tiple surfaces  of  the  body.  Such  aliases  as  hemorrhagic  malarial  fever, 
climatic  fever,  rice  fever,  hsematemesic  paludal  fever,  and  many  more 
of  the  same  character,  should  receive  the  severest  examination  before 
approval  and  adoption. 

When  hemorrhage  does  attend  malarial  fevers,  it  may  occur  from  one 
or  another  of  a  variety  of  surfaces  or  into  shut  cavities  or  in  parenchy- 
matous  structures.  Some  years  ago  I  visited  a  gentleman  who  was  suffer- 
ing from  an  attack  of  malarial  fever,  with  hsematuria.  He  made  a  rapid 
and,  apparently,  a  complete  recovery.  Disobeying  my  injunctions,  he 
returned  to  the  intensely  malarious  locality  where  he  had  formerly 
resided.  After  a  few  weeks  he  was  seized  with  a  chill,  followed  by  apo- 
plectic symptoms,  hemorrhage,  and  death  on  third  day.  It  is  hardly  to  be 
doubted  that  his  death  was  caused  by  cerebral  hemorrhage.  But,  how- 
ever much  in  consonance  with  ascertained  facts  the  foregoing  remarks  may 
appear  to  be,  there  are  certain  points  of  pathology  connected  with 


PERNICIOUS  MALARIAL  FEVER.  611 

malarial  hemorrhagic  fevers  not  easy  of  explanation.  Within  the  last 
score  of  years  hsematuria  has  been  a  far  more  common  form  of  hemor- 
rhage in  malarial  fevers  than  formerly.  In  many  localities  and  during 
certain  seasons  it  has  been  very  prevalent. 

In  the  present  state  of  our  knowledge  it  is  not  at  all  possible  to  explain 
why  it  is  that  diifereut  epidemics  of  malarial  diseases  should  give  rise  to 
such  a  diversity  of  phenomena,  so  that  one  epidemic  will  be  characterized  by 
a  peculiar  train  of  symptoms  which  shall  be  absent  in  another,  being  there 
replaced  by  different  symptoms  equally  distinctive  of  the  second  epidemic. 
Whatever  may  be  the  cause  of  these  epidemical  peculiarities,  it  must  rest  in 
a  something  which  is  capable  of  acting  as  a  force  upon  the  human  system. 
We  must  think  of  that  unknown  agency  which  exercises  this  force  and  gives 
it  some  peculiar  direction  as  possessing  at  least  a  conventional  essentiality. 
It  is  not  satisfactory  to  say  that  the  renal  blood-vessels  are  the  first  to  give 
way,  because  they  are  accidentally  more  weakened  than  other  parts  of  the 
vascular  system,  or  accidentally  more  often  the  seat  of  congestion.  When 
accidents  become  as  numerous  as  these  cases  sometimes  are,  they  acquire 
the  authority  of  laws. 

The  following  notes  of  two  cases  of  malarial  hemorrhagic  fever  may  be 
found  of  interest : 

C.  E.,  aged  twenty-six  years,  was  admitted  to  Ward  19,  Charity  Hos- 
pital, Nov.  18,  1872.  Had  been  in  America  more  than  a  year,  and 
for  several  months  had  been  working  in  an  intensely  malarial  district 
preparing  the  bed  of  a  railroad;  has  had  malarial  diseases  for  several 
mouths,  and  suffered  a  severe  chill  the  day  before  admission.  A  few 
hours  after  admission  temp.  103°,  pulse  120,  respiration  29 ;  effusion  in 
both  thoracic  cavities,  and  very  marked  in  abdominal  cavity  ;  lower  lobe 
of  right  lung  cedematous,  legs  anasarcous,  pitting  greatly  on  pressure, 
with  several  ulcers  of  long  standing.  Urine  loaded  with  albumen  and 
showing  under  the  microscope  abundant  blood-corpuscles;  considerable 
jaundice  present,  which  the  patient  states  to  have  occurred  suddenly. 
Ordered  five  grains  each  of  calomel  and  bicarbonate^  of  sodium,  to  be 
followed  after  catharsis  with  ten  grains  of  quinia  in  solution  every  two 
hours.  Nov.  22d,  patient  has  taken  and  retained  one  hundred  and  eight 
grains  of  quiuia;  secretion  of  urine  abundant;  no  blood  present,  and 
only  a  trace  of  albumen  ;  ordered  twenty  drops  of  tincture  of  chloride  of 
iron  three  times  daily.  Discharged  cured  December  12th.  The  above 
comprises  the  whole  treatment  in  this  case,  except  one  important  measure, 
which  consisted  in  determined  and  persistent  efforts  at  forced  nutrition. 
Meat  essences,  milk,  eggs,  and  milk-punch  were  given  as  methodically  as 
drugs. 

H.  K.,  fifteen  years  of  age,  was  admitted  to  Charity  Hospital  Sept. 
15,  1872;  has  a  history  of  malarial  poisoning  for  several  months; 
was  considerably  jaundiced  at  time  of  admission,  with  anasarcous  legs. 
Under  the  administration  of  a  mercurial,  followed  by  quinia  and  iron, 
he  improved  so  greatly  that  he  was  discharged  from  my  wards  and 
placed  upon  some  duty  in  the  hospital.  Dec.  19th,  at  11  A.  M.,  had  a 
chill  which  lasted  several  hours ;  this  was  followed  by  violent  fever,  with 
rapid  but  compressible  pulse ;  much  jactitation ;  incessant  vomiting  of  a 
greenish-black  fluid ;  urine  loaded  with  blood ;  and  sudden  supervention 
of  intense  jaundice.  Ordered  quinia  gr.  xij  by  hypodermic  injection  ; 


612  MALARIAL  FEVERS. 

small  doses  of  calomel  and  soda  to  be  placed  upon  the  base  of  the  tongue 
and  washed  down  with  ice-water.  Secretion  of  urine  ceased  on  the  morn- 
ing of  the  20th,  followed  by  death  at  11  p.  M.  Autopsy  showed  both 
kidneys  dark-colored  and  swollen  from  complete  blood-engorgement. 

The  treatment  of  hemorrhagic  malarial  fevers  may  be  included  undei 
the  following  indications : 

First,  to  secure  cinchonism  as  early  as  possible ; 

Second,  to  arrest  the  extravasation  of  blood  ; 

Third,  to  sustain  the  patient's  strength,  and  to  preserve  the  systemic 
fluids  at  as  near  a  healthy  standard  as  may  be  possible. 

The  first-mentioned  indication  is  certainly  the  first  in  importance.  If 
the  hemorrhage  originates  during  a  chill,  or  exhibits  degrees  of  aggrava- 
tion in  such  close  relation  to  the  cold  stage  of  malarial  paroxysms  as  to 
point  to  a  relation  of  cause  and  effect,  then  that  course  of  treatment  which 
breaks  the  recurrence  of  paroxysms  will  at  the  same  time  mitigate  the 
hemorrhage,  if,  in  truth,  it  should  fail  to  stop  it  entirely.  Quinia  should 
be  given  in  large  doses  by  the  mouth  or  rectum,  or  both,  or  subcutaueously 
if  demanded  by  the  urgency  of  the  symptoms.  I  have  generally  used 
carefully  prepared  solutions  of  the  sulphate  for  hypodermic  injections,  but 
many  practitioners  prefer  solutions  of  the  hydrobromate  for  this  mode  of 
exhibition.  I  have  never  witnessed  any  symptoms  following  the  adminis- 
tration of  cinchona  salts  which  justified  a  belief  that  they  increased  th& 
hemorrhage.  My  rule  of  practice  has  invariably  been  to  endeavor  to 
prevent  the  occurrence  of  another  paroxysm,  without  regard  to  this  very 
questionable  charge. 

In  regard  to  the  second  indication,  it  may  be  stated  that  patients  are  not 
likely  to  die  from  actual  loss  of  blood  in  any  form  of  hemorrhagic  malarial 
fever.  The  blood  which  is  poured  out  on  free  surfaces  and  escapes  by  some 
outlet  is  seldom  so  much  as  to  endanger  life,  but  the  hemorrhagic  process  is 
likely  to  involve  deeper-seated  vessels.  This  is  especially  true  in  malarial 
hsematuria.  Hemorrhages  into  the  stroma  of  the  kidneys,  the  Malpighian 
tufts,  and  the  uriniferous  tubules  arrest  urinary  secretion,  and  thus  entail 
death.  In  order  to  prevent  these  results  haemostatics  should  be  resorted  to 
as  often  as  attendant  circumstances  will  permit.  Generally  these  are  such  as 
to  admit  of  the  use  of  haemostatics  without  prejudicing  the  effects  of  other 
remedies.  In  my  experience  ergot  in  combination  with  gallic  acid  and 
dilute  sulphuric  acid  has  been  very  efficient.  The  following  prescription 
has  been  usually  given  : 

fy  Ext,  Ergot.  Fluid,      fsiv  ; 
Acid.  Gallic.  gr.  xl; 

Acid.  Sulphuric,  dil.   f  3j  ; 
Syr.  Zingiber.  f  siij  ; 

Aquae  q.  s  ad  f  .lij.    M. 

S.  Dessertspoonful  every  four  hours,  diluted  with  water. 

Some  practitioners  place  a  very  high  estimate  upon  the  haemostatic 
effects  of  turpentine.  This  is  undoubtedly  a  most  valuable  and 
accessible  remedy.  Dr.  Schnell  of  Plaquemine  Parish,  La.,  has  found 
the  tincture  of  chloride  of  iron  the  best  haemostatic.  He  places  fgij  in 
f  §iv  of  water,  and  directs  a  dessertspoonful  every  hour  as  long  as  the 
hemorrhage  continues.  In  a  great  majority  of  cases  of  malarial  haematuria 
occurring  under  my  observation  solutions  of  bitartrate  of  potassium  have 


PERNICIOUS  MALARIAL  FEVER.  613 

been  given  with  great  apparent  benefit.  Its  action  is  certainly  not  that 
of  a  direct  haemostatic,  but  by  setting  up  currents  through  the  kidneys, 
and  perhaps  by  some  solvent  power  over  exudations  in  the  uriniferous 
tubules,  it  has  acted  as  a  renal  deobstructive. 

In  the  arrest  of  renal  secretion  diuretics,  cupping  over  the  lumbar  region, 
and  large  injections  of  warm  water  into  the  bowels  may  be  resorted  to. 
Some  practitioners  state  that  they  have  found  buchu  beneficial. 

The  third  indication  involves  a  twofold  duty.  One  relates  to  judicious 
and  vigilant  attention  to  the  patient's  nutrition ;  the  other  relates  to  such 
measures  for  depuration  as  may  be  called  for  in  each  particular  case. 

It  must  be  admitted  that  there  is  a  degree  of  antagonism  in  the  measures 
of  practice  proper  to  effect  these  two  purposes,  which  renders  their  coinci- 
dent exercise  a  difficult  practical  question.  In  many  cases  of  hemorrhagic 
malarial  fever  a  competent  supply  of  properly  prepared  foods  is  sufficient. 
In  other  cases — and  this  is  especially  true  of  malarial  hsematuria — depu- 
rative  medication  becomes  paramount.  A  person  suffering  under  the 
effects  of  chronic  malarial  poisoning  is  seized  with  a  chill ;  this  is  followed 
by  bloody  urine,  and  in  the  course  of  four  or  five  hours  intense  jaundice 
appears.  Incessant  vomiting,  delirium,  and  jacititation  also  occur. 
The  experienced  physician  is  at  once  brought  to  the  conclusion  that 
he  has  to  deal  with  a  case  of  blood-poisoning  bearing  a  close  resem- 
blance in  symptoms  to  uraemia.  To  render  this  conclusion  still  more 
absolute,  he  has  only  to  recall  the  suddenness  of  the  occurrence  of  the 
jaundice  and  to  inquire  what  has  occasioned  it.  Its  appearance  is  too 
rapid  to  permit  us  to  ascribe  it  to  obstruction.  It  is  altogether  improbable 
that  it  is  due  to  sudden  hypersecretion  in  such  pathological  states  of  the 
system  as  are  present.  If,  however,  we  account  for  it  by  saying  that  the 
addition  of  a  new  toxic  constituent,  urea  and  its  congeners,  to  an  already 
profoundly  poisoned  fluid  suddenly  arrests  those  processes  which  dispose 
of  bile  in  physiological  conditions  of  the  system,  it  seems  to  me  that  we 
adopt  the  most  rational  theory.  It  is  then  jaundice  from  lack  of  consump- 
tion. The  mere  probability  of  truth  in  this  theory  will  impress  the  prac- 
titioner with  the  great  importance  of  eliminant  practice  in  these  conditions. 

Calomel  has  been  the  medicine  to  which  I  have  principally  trusted.  I 
give  it  merely  as  a  depurative,  and  not  as  an  alterative.  Doses  of  from 
two  to  ten  grains  may  be  repeated  at  suitable  intervals  until  catharsis  has 
been  produced.  Bitartrate  of  potassium,  Seidlitz  powders,  or  solutions  of 
citrate  of  magnesia  may  be  also  administered  if  indicated.  After  purga- 
tion the  vomiting  is  mitigated,  if  not  altogether  relieved.  On  this 
account,  and  because  of  bettered  states  of  the  system  for  absorption  and 
assimilation,  the  way  is  now  clear  to  the  physician.  He  can  ply  his  anti- 
periodics,  his  properly  prepared  sustenance,  and  his  alcoholic  stimulants 
according  to  the  exigencies  of  each  particular  case. 

The  following  propositions  may  seem  not  inappropriate  in  closing  this 
section : 

1st.  Attacks  of  pernicious  malarial  fever  are  attended  by  more  danger 
to  life  or  subsequent  health  than  simple  attacks ;  therefore  more  prompt 
and  energetic  efforts  should  be  made  to  cut  them  short  by  cinchonism. 

2d.  The  blood  depravations  of  pernicious  malarial  fevers,  far  exceed 
those  of  simple  cases ;  and  therefore  it  becomes  a  leading  indication  of 
treatment  to  correct  faulty  conditions  of  this  fluid  as  early  as  possible. 


614  MALARIAL  FEVERS: 

In  endeavoring  to  secure  this  end  assimilable  foods,  stimulants,  and 
depurants  must  have  a  shifting  scale  of  value  according  to  the  exigencies 
of  each  particular  case. 

3d.  The  complications  of  attacks  of  pernicious  fever  are  far  more 
important  than  those  of  simple  forms ;  and  therefore  symptomatic  treat- 
ment is  often  urgently  required. 

1th.  Attacks  of  pernicious  fever  may  be  greatly  diminished  in  number 
by  properly  directed  treatment  of  chronic  malarial  toxaemia,  and  espe- 
cially also  by  the  removal  of  persons  suffering  under  this  cachexia  to 
non -malarious  localities. 


Typho -Malarial  Fever. 

The  prefix  typho-  is  properly  applicable  to  a  class  of  malarial  fevers 
which  are  complicated  by  the  specific  poison  which  produces  typhoid 
fever. 

This  term  was  introduced  into  medical  nomenclature  by  Surgeon  J.  J. 
Woodward  of  the  United  States  Army.  His  classical  paper  on  this 
subject  has  been  published  in  the  Transactions  of  the  International  Medical 
Congress  at  Philadelphia  in  1876.  The  following  extract  from  the  pro- 
ceedings of  this  congress  will  show  the  interpretation  of  this  term  by 
Woodward : 

"  On  motion  of  Dr.  Woodward,  seconded  by  Dr.  Pepper,  the  following 
was  adopted  as  expressing  the  opinion  of  the  section  :  Typho-malarial 
fever  is  not  a  specific  or  distinct  type  of  disease,  but  the  term  may  be 
conveniently  applied  to  the  compound  forms  of  fever  which  result  from 
the  combined  influence  of  the  causes  of  the  malarious  fevers  and  of 
typhoid  fever." 

It  follows,  therefore,  that  .the  term  should  be  so  restricted  as  to  define 
a  disease  compounded  of  the  two  pathological  factors  which  when  acting 
separately  produce  either  typhoid  or  malarial  fever. 

When  understood  in  this  sense,  and  carefully  employed,  the  term 
appears  to  me  unobjectionable.  Perhaps,  indeed,  it  may  be  a  convenient 
addition  to  medical  nomenclature.  If  such  a  name  had  not  been  intro- 
duced, we  would  be  forced  to  speak  of  these  cases  of  compound  disease 
as  complications.  As  it  is  customary  to  regard  the  minor  or  less  import- 
ant affection  as  the  complicating  disorder,  we  would  often  have  confusion 
in  determining  whether  the  case  should  be  typhoid  fever  complicated  by 
malaria  or  malarial  fever  complicated  by  typhoid.  This  term  leaves  all 
questions  of  precedence  or  predominance  in  abeyance. 

There  are  no  facts,  however,  which  support  a  conclusion  that  the 
malarial  poison  is  capable  of  forming  combinations  with  the  particular 
poisons  of  other  specific  fevers  and  give  birth  to  a  new  special  poison, 
which  may  be  perpetuated  by  successive  generations,  and  thus  produce 
epidemics  of  a  new  but  compound  disease. 

The  importance  of  a  proper  use  of  the  term  typho-malarial  implies 
co-ordinate  care  in  diagnosing  the  true  nature  of  the  malady  it  should 
define. 

It  may  be  said,  in  brief,  that  the  diagnosis  of  typho-malarial  fever 
must  rest  upon  the  blending  of  the  symptomatic  phenomena  peculiar 


TYPHO-MALARIAL  FEVER.  615 

to  each  one  of  the  two  fevers  which  enter  into  combination.  In  other 
words,  if  the  differential  diagnosis  between  the  two  diseases  when  they 
are  distinct  is  made  by  contrasting  the  symptoms  peculiar  to  each,  the 
compound  disease  is  to  be  recognized  by  more  or  less  positive  combinations 
of  these  symptoms. 

These  blended  symptoms  should  not  be  expected  to  exhibit  the 
results  of  a  copartnership  in  which  each  member  exerts  equal  influ- 
ence. It  is  well  understood  that  when  two  diseases  coincide,  that  one 
which  is  more  violent  or  excessive  in  its  morbid  process  holds  so  much 
sway  as  in  some  cases  almost  to  extinguish  the  symptoms  of  the  weaker 
member  of  the  combination.  Consequently,  in  typho-malarial  fever,  the 
typhoid,  being  the  graver  of  the  two  forms  of  disease,  ordinarily  rules  the 
pathology. 

The  following  notes,  accompanied  by  a  temperature  chart,  will  illus- 
trate the  clinical  course  of  a  case  of  typho-malarial  fever  : 

J.  L.,  aged  thirty  years,  of  French  nativity,  but  a  resident  of  New 
Orleans  for  three  years,  was  admitted  to  Ward  21,  Bed  311,  Charity 
Hospital,  on  the  night  of  December  10,  1881.  Had  been  ill  some  days 
with  ague.  The  house-surgeon  administered  gr.  x.  of  quinia  in  solution 
and  gtt.  xv.  of  tincture  of  opium. 

The  records  and  temperature  date  from  the  12th  of  December.  Dur- 
ing the  llth  he  took  3y  sulph.  cinch,  in  solution. 

Dec.  13th,  tenderness  and  gurgling  in  ileo-csecal  region ;  epistaxis ; 
rose  spots  on  abdomen;  deafness  and  ataxia;  no  stools  since  llth. 
Ordered 

~Bp.  Acid.  Sulphuric,  dil., 

Syr.  Aurantii  Cort.    da.  f  sij  ; 
Tinct.  Cinchonse  Co.        f  3j.     M. 
S.  Teaspoonful  in  water  every  four  hours. 

Also  ordered  beef-essence,  milk-punch,  and  milk. 

Dec.  13th,  two  very  offensive  liquid  stools;  ataxia  greater;  skin  yellow 
and  countenance  dull  and  listless.  Dec.  14th,  fresh  rose  spots ;  tongue 
brown  and  dry;  three  stools;  much  jactitation.  Dec.  15th,  more  ataxia; 
some  delirium ;  pulse  100,  weak.  Gave  gr.  iiss  quinia  in  solution,  with 
tincture  opium  gtt.  iii,  every  two  hours.  Dec.  16th,  pulse  128,  weak; 
delirious.  Dec.  17,  new  rose  spots;  belly  tympanitic;  tongue  brown, 
dry  ;  sordes  on  teeth  and  lips ;  eyes  injected ;  very  delirious.  Treatment 
continued ;  nutrition  and  stimulants  given  methodically.  From  17th  to 
22d  but  little  change  in  condition  or  treatment.  Diet  and  stimulants 
administered  regularly.  Dec.  22d,  coma  vigil;  completely  delirious. 
Ordered 

^.  Liq.  Morphise  Sulph., 

Tinct.  Digitalis  da.  f siij  ; 

Spts.  ^Ether.  Nitrosi          fgij  ; 
Liq.  Potass.  Citrat.  fgiij.     M. 

S.  Tablespoonful  every  three  hours.  t  . 

As  the  oscillations  of  temperature  became  more  marked,  quinia  was 
resorted  to,  apparently  with  good  effect.  The  patient  was  discharged 
from  the  hospital  Feb.  8,  1882.  . 

It  should  be  observed  that  after  the  14th  of  December  the  patient  s 
bowels  were  rather  costive,  and  the  stools  occasionally  moulded  and  very 


616  MALARIAL  FEVERS. 

dark  in  color.  On  the  forty-fifth  day  after  admission  the  patient  had  a 
severe  chill,  followed  by  a  rise  of  temperature  to  104°.  This  yielded  to 
competent  doses  of  sulphate  of  cinchonidia. 

This  was  a  typical  case  of  typho-malarial  fever.  The  blended  symp- 
toms, as  well  as  those  special  to  each  disease,  are  sufficiently  exhibited  in 
the  clinical  account.  The  presence  of  typhoid  fever  was  established  by 
the  rose  spots  and  the  marked  nervous  symptoms.  The  typhoid  process 
seems  to  have  been  unusually  mild  in  so  far  as  evidence  of  bowel  lesions 
were  made  manifest. 

The  history  of  the  patient  before  admission,  the  color  of  his  skin  and 
stools,  and  the  temperature  curves  gave  abundant  proofs  of  the  malarial 
element  in  the  pathology  of  the  case. 

Perhaps  nothing  need  be  added  on  the  subject  of  diagnosis.  I  may,  how- 
ever, remark  that  I  am  very  cautious  in  asserting  the  diagnosis  of  typho- 
malarial  cases  unless  the  nervous  symptoms,  positively-marked  bowel 
symptoms,  or  rose  spots  are  present  to  vindicate  such  a  decision.  The 
presence  of  malarial  poison  may  be  determined  with  less  difficulty  from 
the  previous  history  of  the  case  and  its  special  symptoms  in  the  early 
stages  of  an  attack.  But  if  the  morbid  processes  of  the  typhoid  poison 
are  violent,  there  are  likely  to  be  stages  of  the  disease  when  it  is  not  possi- 
ble to  detect  symptoms  which  indicate  the  presence  of  malaria.  On  the  other 
hand,  it  is  unquestionably  true  that  the  typhoid  condition,  as  it  is  termed, 
which  so  often  complicates  malarial  fevers,  can  very  generally  be  differ- 
entiated from  true  typhoid  fever.  While  certain  cases,  or  even  epidemics, 
of  malarial  fevers  are  attended  by  remarkable  adynamia,  often  manifest- 
ing itself  from  the  very  incipiency  of  attacks,  it  differs  widely  from  that 
utter  nervous  ataxia  which  characterizes  typhoid  fever.  Again,  the 
adynamia  of  malarial  attacks  is  generally  ascribable  to  some  cause  not 
essential  to  those  affections.  Imperfect  reaction  from  a  chill,  long  per- 
sistent hyperpyrexia,  diarrhoea  or  vomiting,  or  chronic  paludal  cachexia, 
or,  it  may  be,  some  epidemic  influence,  may  produce  it.  The  ataxia  of 
typhoid  fever  is  part  of  its  morbid  process. 

Woodward's  statistics  show  that  49,871  cases  of  fever  diagnosed  as 
typho-malarial  occurred  among  the  white  forces  of  the  United  States 
during  the  late  Civil  War.  Of  this  number,  4059  proved  fatal,  a  mortality- 
rate  of  8.13-)-  per  cent.  Among  the  colored  troops  7529  cases  occurred, 
with  1301  deaths,  a  mortality-rate  of  17.27.  Statistics  borrowed  from 
the  same  excellent  authority  give  the  number  of  cases  of  unmixed  typhoid 
fever  (or  fever  classed  as  typhoid  without  reference  to  any  complication) 
as  75,368  among  the  white  troops,  with  27,056  deaths,  a  mortality-rate 
of  35.89.  Among  the  colored  troops  4094  cases  occurred,  and  2280  died, 
a  mortality-rate  of  55.68.  These  figures  show  very  singular  compara- 
tive results.  They  prove  that  typhoid  fever  as  an  uncomplicated  malady, 
was  four  and  a  half  times  as  fatal  among  the  whites  as  the  same  disease 
when  in  combination  with  malarial  poison.  Among  the  colored  troops 
typhoid  fever  was  three  and  a  half  times  more  fatal  than  typho-malarial 
fever. 

It  is  highly  probable  that  inaccuracies  exist  in  statistics  gathered  in  the 
confusion  of  a  great  civil  war,  but  I  am  not  prepared  to  say  that  the  con- 
clusions they  point  to  are  incorrect.  When  an  acute  inflammation  is  com- 
plicated by  malaria,  its  prognosis  is  rendered  more  grave.  This,  no  doubt, 


FIG.  24. 


104 

•103° 


99 


PART  I.,  showing  the  temperature-curve  from  December  12th  to  31st,  inclusive,  during  which  time  the  more 
characteristic  typhoid  symptoms  predominated. 


PART  II.,  showing  the  temperature-curve  in  same 


case  from  January  1st  to  20th,  inclusive,  during  which  the 


influence  of  the  associated  malarial  poison  was  prominent. 


617 


618  MALARIAL  FEVERS. 

is  due  in  part  to  degradations  of  the  fluids  of  the  system  by  the  malarial 

g)ison,  and  in  part  to  the  revulsions  of  circulation  during  paroxysms, 
ut  it  does  not  follow  from  this  fact  that  the  presence  of  malaria  in  the 
blood,  or  its  effects  upon  that  fluid,  exercise  an  unhappy  influence  upon 
diseases  due  to  other  specific  poisons.  It  may,  on  the  contrary,  be  ascer- 
tained in  the  future  that  it  modifies  the  typhoid  process,  so  as  to  deprive 
it  of  some  of  its  most  dangerous  features. 

Further  investigations  are  required  to  determine  the  facts  in  regard  to 
these  questions.  But  it  may  be  premised  that  if  such  a  conclusion  shall 
ever  be  reached,  it  will  influence  our  expectations  of  cure  rather  than  our 
practice.  If  the  malarial  poison  is  capable  of  modifying  the  toxic  effects 
of  the  typhoid  poison,  it  must  do  so  in  the  very  formative  stages  of  that 
affection,  if  not  in  its  incubative  period,  so  that,  having  accomplished  all 
the  good  it  is  capable  of  effecting,  we  may  proceed  at  once  to  rid  ourselves 
of  its  presence. 

In  entering  upon  the  treatment  of  two  diseases  compounded  in  the 
same  patient,  if  one  should  ordinarily  be  amenable  to  specific  treatment, 
it  must  certainly  be  wise  practice  to  endeavor  to  simplify  the  case  by  sub- 
tracting that  one  from  its  composition.  This  is  more  especially  true  if 
the  treatment  does  not  affect  the  course  of  the  other  disease  in  any  injuri- 
ous manner.  It  is  therefore  proper  to  begin  the  treatment  of  a  case  of 
typho-malarial  fever  by  administering  large  doses  of  quinia.  A  scruple 
may  be  given  every  fourth  hour,  until  its  effects  in  eliminating  symptoms 
ascribable  to  malaria,  and  also  as  an  antipyretic,  have  been  sufficiently 
tested.  In  the  early  stages  of  typho-malarial  attacks  the  febrile  exacerba- 
tions conform  to  those  laws  of  periodicity  which  govern  uncomplicated 
malarial  fevers.  After  the  first  week,  or  when  the  typhoid  process  has 
become  well  established,  periodic  returns  of  the  fever  are  less  plainly 
observable.  It  is  possible  that  in  some  cases  in  which  the  typhoid  process 
manifests  itself  with  great  severity  the  temperature  curves  may  be  very 
characteristic  of  that  disease.  I  am  satisfied  that  the  indications  for  giv- 
ing quinia  to  eliminate  the  malarial  element  must  be  based  upon  the 
fever  curves  which  mark  the  case.  Perhaps  a  more  frequent  application 
of  the  thermometer  would  often  exhibit  malarial  periodicity  where  it  may 
otherwise  remain  unsuspected.  I  know  this  to  be  very  often  the  case  in 
pneumonia  complicated  by  a  malarial  fever. 

Whether  thorough  cinchonism  in  the  early  progress  of  the  attack  rids 
the  case  of  symptoms  due  to  malaria  or  not,  only  a  very  few  days  are 
likely  to  elapse  before  oscillations  of  temperature  call  for  its  repetition. 

The  typhoid  processes  require  very  much  the  same  measures  which  are 
applicable  in  uncomplicated  cases  of  that  disease.  The  stools  of  the  early 
stages  of  attacks  should  not  be  checked  unless  excessive,  and  mercurials 
and  laxatives  should  be  more  freely  used  than  in  simple  typhoid  fever. 
The  effects  of  the  malarial  fever  and  of  the  hyperpyrexia  of  typhoid 
fever,  when  combined,  must  almost  necessarily  entail  more  accumulation 
of  excrementitious  material  in  the  blood  than  would  occur  either  disease 
existing  separately.  On  this  account  eliminating  treatment  is  an  important 
indication.  When  it  becomes  necessary  to  check  the  diarrhoea  because 
excessive  or  on  account  of  failing  strength,  diuretics  subsequently  prove 
serviceable.  Effervescing  solutions  of  potassium  or  ammonium,  lemonade, 
Apollinaris  water,  iced  tea,  strawberry,  mulberry,  or  raspberry  juice,  are 


TYPHO-MALAEIAL  FEVERS.  619 

grateful  beverages  and  increase  renal  activity.  The  mineral  acids  may  be 
given  during  the  ulcerative  periods  of  the  disease.  Insomnia  must  be 
relieved  by  opiates,  chloral  hydrate,  or  other  hypnotics. 

Tympanites  should  be  met  by  warm  stupes,  large  enemas  of  warm 
water  with  fgj  tincture  of  asafcetida  or  f  3j  of  whiskey.  Small  doses  of 
turpentine  in  emulsion  are  often  beneficial. 

In  the  early  progress  of  cases  the  diet  should  consist  of  farinaceous 
foods,  with  milk  and  the  pulps  or  juices  of  fresh  fruits,  given  either 
cooked  or  in  their  natural  state  as  the  physician  may  determine  for  each 
patient.  Methodical  and  forced  nutrition  becomes  necessary  at  more  or 
less  early  periods  in  different  cases. 

The  stools  and  all  ejecta  of  the  sick  should  be  disinfected  and  disposed 
of  with  the  same  care  and  for  the  same  purpose  as  those  of  unmixed 
typhoid  fever. 


PAROTITIS. 

By   JOHN   M.    KEATING,    M.  D. 


THE  term  parotitis  is  applied  to  a  condition  of  painful  enlargement  of 
one  or  both  parotid  glands,  inflammatory  in  nature,  acute  in  its  course, 
and  usually  subsiding  by  resolution,  but  sometimes  ending  in  suppura- 
tion. The  different  methods  of  termination,  together  with  certain  etio- 
logical  distinctions,  form  the  basis  of  a  division  of  the  affection  into  two 
sub-classes — namely,  1,  idiopathic  parotitis ;  and  2,  symptomatic  or  meta- 
static  parotitis.  These  demand  separate  consideration. 


I.  Idiopathic  Parotitis. 

Idiopathic  parotitis,  parotitis  epidemica,  or  mumps,  as  it  is  variously 
named,  is  an  acute  contagious  inflammation  of  one  or  both  parotid  glands, 
which  usually  appears  but  once  in  a  lifetime,  and  which,  although  by  no 
means  limited  to  children,  is  commonly  met  with  between  the  second  year 
and  the  age  of  puberty.  In  certain  exceptional  cases  the  disease  affects 
the  submaxillary  glands  alone. 

NATURE. — The  undoubted  contagiousness  of  mumps,  with  the  fact  of 
its  frequently  occurring  in  extended  epidemics,  entitles  it  to  a  place  among 
the  zymotic  diseases,  from  which  it  differs,  however,  in  the  marked  dis- 
proportion between  the  local  and  constitutional  symptoms,  the  former 
being  well  developed,  the  latter  but  slight  or  altogether  absent. 

ETIOLOGY. — While  it  is  more  than  probable  that,  like  the  other  diseases 
of  the  zymotic  class,  mumps  is  due  to  a  contagium  that  finds  its  way  into 
the  body  in  the  inspired  air  or  with  the  food  or  drink,  nothing  is  known 
of  the  nature  of  this  infecting  principle. 

The  predisposing  agencies  are  better  understood.  Age  is  one  of  these, 
the  greater  number  of  cases  occurring,  as  already  stated,  between  the 
second  and  the  fifteenth  year.  Infants  at  the  breast  are  almost  entirely 
exempt,  and  so,  too,  are  individuals  advanced  in  years.  In  extended 
epidemics  it  is  not  unusual  to  meet  with  cases  in  adults,  but  it  will  gener- 
ally be  found  on  careful  examination  that  these  patients  have  escaped  the 
disease  during  childhood.  Sex  exerts  some  influence,  a  much  larger  per- 
centage of  males  being  attacked  than  females.  Epidemics  appear  more 
frequently  in  the  spring  and  fall  than  at  the  other  seasons  of  the  year,  so 
that  cold  and  dampness  of  the  atmosphere  must  be  looked  upon  as  pre- 
disposing causes.  Mumps  bears  a  peculiar  relation  to  measles,  scarlet 
fever,  and  diphtheria,  epidemics  being  apt  to  occur  directly  before,  during, 
or  immediately  after  the  prevalence  of  either  of  these  affections,  especially 

620 


IDIOP4-THIC  PAROTITIS.  621 

the  first.  The  popular  idea  of  mutual  protection  is  entirely  without 
foundation. 

Certain  peculiarities  are  presented  by  the  disease  in  its  mode  of  occur- 
rence and  in  the  duration  and  intensity  of  its  epidemics.  Thus,  some 
localities  are  visited  annually,  others  only  at  intervals  of  thirty  years  or 
more ;  again,  one  epidemic  may  last  but  a  few  weeks  and  aifect  a  small 
number  of  individuals,  while  another  extends  over  months  and  attacks 
all  the  children  and  many  of  the  adults  in  the  affected  region. 

ANATOMICAL,  APPEARANCES. — The  exact  pathological  lesion  in  mumps 
is  obscure,  since  the  trifling  nature  of  the  disease  and  the  almost  invari- 
able termination  in  recovery  afford  no  opportunity  for  post-mortem 
investigation.  According  to  Foerster,  who  seems  to  have  made  exami- 
nations in  cases  where  mumps  occurred  as  one  of  the  accidental  complica- 
tions of  other  and  fatal  diseases,  the  affected  gland  at  first  becomes  hyper- 
semic,  and  is  then  the  seat  of  serous  exudation.  It  is  reddened,  swollen, 
and  on  section  presents  a  uniform  flesh-like,  moist  appearance,  in  place 
of  the  ordinary  granular  aspect.  The  tumor  is  often  greatly  increased  in 
size  by  a  simultaneous  serous  infiltration  of  the  periglandular  connective 
tissue,  and  occasionally  this  tissue  alone  is  involved,  the  gland  itself  being 
entirely  free  from  lesion.  The  great  point  in  favor  of  this  view  of  the 
pathology  is  the  rapid  and  complete  subsidence  of  the  parotid  swelling  by 
resolution — a  termination  to  be  expected  only  when  the  inflammatory  pro- 
cess stops  short  of  suppuration  or  fibrinous  exudation. 

Virchow  regards  all  cases  of  parotitis  as  the  result  of  an  extension  of 
a  more  or  less  malignant  catarrh  originally  affecting  the  gland-ducts. 
This  is  undoubtedly  true  in  some  cases,  but  that  it  is  far  from  being  the 
rule  is  proved  by  the  infrequency  of  parotitis  as  a  secondary  complication 
of  catarrhal  affections  of  the  mucous  membrane  of  the  mouth. 

COURSE  AND  SYMPTOMS. — The  course  of  the  disease  is  susceptible  of 
a  division  into  three  stages — a  period  of  incubation,  of  invasion,  and  of 
actual  attack. 

The  stage  of  incubation  extends  over  a  period  variously  estimated  as 
from  seven  to  fourteen  days.  It  is  marked  by  no  symptoms,  though 
sometimes  a  history  of  impaired  appetite  and  digestion,  irregular  bowels, 
and  languor  during  the  last  two  or  three  days  may  be  obtained. 

The  period  of  invasion  is  short,  lasting  only  twelve,  or  at  the  most 
twenty-four,  hours.  The  patient  is  pale  and  languid,  has  slight  rigors, 
pains  in  the  breast  and  head,  and  loss  of  appetite ;  later,  local  pain  in  the 
parotid  region  on  moving  the  jaws  or  on  taking  acid  liquids  into  the 
mouth.  The  surface  temperature  increases  from  hour  to  hour,  and  just 
before  the  glandular  swelling  appears  it  reaches  100°  or  101°  F.  In 
some  cases  the  invasion  is  characterized  by  the  same  train  of  _  symptoms 
that  ushers  in  the  acute  exanthemata,  such  as  repeated  vomiting,  diar- 
rhoaa,  restlessness  and  anxiety,  a  disposition  to  syncope,  and,  in  very  irri- 
table children,  convulsions.  Contrasted  with  this  violent  invasion  other 
cases  are  met  with,  in  which  there  are  no  prodromes  whatever  except  a 
gradual  rise  in  temperature,  imperceptible  without  the  use  of  the  ther- 
mometer. 

The  first  symptom  of  actual  attack  is  a  peculiar  slight  stitch-like 
pain  in  one  parotid  region,  usually  the  left.  This  radiates  toward  the 
ear  of  the  affected  side,  and  is  increased  by  movements  of  the  jaw,  as  in 


622  PAROTITIS. 

chewing  or  talking,  and  by  external  pressure.  The  pain  rapidly  grows 
more  intense,  and  soon  becomes  associated  with  swelling.  The  tumor 
first  appears  in  the  depression  between  the  mastoid  process  and  the  ramus 
of  the  jaw,  which  it  fills  up,  and  at  the  same  time  thrusts  outward  the 
lobe  of  the  ear.  As  the  gland  alone  is  swollen  at  first,  the  tumor  has 
the  outline  of  a  triangle,  with  the  apex  directed  downward  and  forward ; 
soon,  however,  the  connective  tissue  becomes  oedematous  and  the  swelling 
is  greatly  extended,  involving  the  cheeks  and  neck,  in  the  latter  region, 
in  severe  cases,  running  forward  as  far  as  the  median  line,  downward 
nearly  to  the  shoulder  and  backward  toward  the  spine.  The  most  promi- 
nent point  is  directly  in  front  of  the  ear.  The  oedema  also  extends  inter- 
nally, involving  the  pharynx,  the  tonsils,  and  sometimes  even  the  larynx. 
The  skin  covering  the  tumor  is  either  perfectly  natural  in  color  or  slightly 
reddened.  The  central  portion  is  firm  and  elastic  to  the  touch,  the 
periphery  doughy,  and  pressure  here  often  produces  pitting.  There  is 
but  moderate  tenderness.  The  swelling  reaches  its  height  in  three  days, 
remains  stationary  for  two  days  longer,  and  then  rapidly  declines,  the 
oedema  first  disappearing  and  afterward  the  glandular  swelling,  the  pro- 
cess of  resolution  occupying  four  or  five. days  and  being  attended  with  a 
slight  desquamation  of  the  cuticle. 

While  mumps  almost  uniformly  begins  on  one  side,  both  glands  are, 
as  a  rule,  affected  during  the  attack.  The  second  tumor  begins  to  develop 
twenty-four  to  forty-eight  hours  after  the  first,  though  its  appearance 
may  be  delayed  much  longer,  even  until  resolution  has  begun  on  the  side 
primarily  affected.  As  the  course  of  the  inflammation  is  similar  in  both 
parotids,  the  whole  duration  of  the  attack  will  depend  on  the  time  of 
involvement  of  the  second  gland. 

Among  the  other  symptoms  an  alteration  of  expression  is  prominent. 
At  first,  the  head  is  inclined  toward  the  affected  side ;  later,  when  both 
glands  are  involved,  it  is  held  perfectly  erect,  and,  as  the  slightest  move- 
ment increases  the  pain,  it  is  maintained  stiffly  in  this  position.  The 
swelling  of  the  cheeks  prevents  all  play  of  the  features,  and  this,  com- 
bined with  widely-open,  staring  eyes  and  increased  thickness  of  the  neck, 
gives  the  patient  a  stupid,  almost  idiotic,  expression.  The  swelling  of 
the  neck  is  sometimes  so  great  that  its  diameter  exceeds  that  of  the  head, 
and  the  shoulders,  neck,  and  head,  viewed  together,  have  the  outline  of  a 
truncated  pyramid. 

As  any  movement  of  the  lower  jaw  greatly  augments  the  suffering, 
the  mouth  is  kept  closed,  often  so  tightly  that  it  is  impossible  to  see  more 
than  the  tip  of  the  tongue.  All  efforts  at  mastication  are  suspended,  and 
deglutition  is  so  painful,  especially  when  the  tonsils  become  enlarged, 
that  the  sufferer  bears  the  pangs  of  hunger  and  thirst  rather  than  endure 
the  agony  entailed  in  satisfying  his  wants.  The  act  of  speaking  even 
augments  the  pain ;  the  voice,  when  heard,  has  a  nasal  tone.  The  acute- 
ness  of  hearing  is  impaired,  there  are  singing  noises  and  shooting  pains 
in  the  ears,  headache,  and  sometimes,  in  extreme  cases,  symptoms  of 
cerebral  hyperaemia  due  to  pressure  upon  the  cervical  veins. 

The  tongue  is  heavily  coated,  the  mouth  is  either  dry  or  there  is  an 
increased  flow  of  saliva,  and  the  fluid  dribbling  from  the  mouth  adds 
another  element  to  the  idiotic  expression  already  referred  to.  There  is 
loss  of  appetite,  increased  thirst,  occasionally  vomiting,  and  commonly 


IDIOPATHIG  PAROTITIS.  623 

constipation.  The  temperature  is  elevated  and  the  pulse  increased  in 
frequency,  botli  to  a  moderate  degree.  The  respiration  is  unaffected, 
except  when  the  oedema  has  invaded  the  submucous  connective  tissue 
of  the  larynx ;  then  the  movements  are  increased  in  frequency  and 
difficult. 

Throughout  the  attack  the  pain,  unless  intensified  by  some  extraneous 
influence,  as  pressure  or  the  act  of  speaking  or  swallowing,  is  only 
moderately  severe.  In  ordinary  cases  the  patient  rests  quietly  and  sleep 
is  undisturbed,  unless  the  tonsils  are  enlarged,  when  it  is  liable  to  inter- 
ruption from  loud  snoring.  When  the  attack  is  severe  and  in  nervous, 
excitable  children  there  is  restlessness,  sleeplessness,  and  slight  delirium 
at  night. 

The  general  symptoms  keep  pace  with  the  local  in  their  increase,  but 
they  commence  to  subside  before,  beginning  to  disappear  while  the  swell- 
ing remains  stationary.  As  soon  as  resolution  sets  in  the  general  and 
local  improvement  are  both  rapid,  and  by  the  end  of  the  week  nothing 
is  left  but  a  trifling  weakness  and  pallor,  which  disappear  in  a  few  days 
more,  leaving  the  patient  perfectly  well. 

Besides  the  ordinary  symptoms,  mumps  in  certain  instances  shows  a 
peculiar  tendency  to  metastasis,  or  secondary  involvement,  of  the  testicle 
and  scrotum  in  males,  and  the  mammae,  vulva,  and  ovaries  in  females. 
This  metastasis  occurs  much  more  frequently  in  males  than  in  females, 
and  is  usually  met  with  in  pubescents  and  adults,  being  very  rare  either 
in  childhood  or  old  age.  It  generally  begins  six  or  eight  days  after  the 
appearance  of  the  parotid  tumor.  The  latter,  as  a  rule,  subsides  on  the 
occurrence  of  any  of  these  metastatic  affections,  though  occasionally  the 
two  run  a  simultaneous  course.  This  occurrence,  together  with  the  fact 
of  the  secondary  inflammation  appearing  at  the  date  on  which  the  paro- 
titis naturally  begins  to  disappear,  tends  to  support  Niemeyer's  view,  that 
the  two  affections  are  in  reality  due  to  the  same  cause,  and  that  no  true 
transference  of  inflammation  takes  place  from  one  point  to  the  other. 
Occasionally,  the  parotitis  disappears  a  variable  time  before  the  onset  of 
the  metastatic  affection ;  then  the  interval  is  marked  by  grave  symptoms 
of  depression  and  cerebral  disturbance,  but  there  are  no  proofs  of  actual 
meningeal  involvement.  In  these  cases  there  is,  at  times,  an  excessive 
elevation  of  temperature,  which  may  account  for  the  brain  symptoms. 

The  most  constant  secondary  manifestation  is  swelling  of  the  testicle 
proper,  or  true  orchitis;  less  frequently  there  is  epididymitis,  and  with  it 
acute  hydrocele  and  oedema  of  the  scrotum.  The  orchitis  in  most  cases 
is  unilateral,  the  right  testicle  being  affected,  just  the  opposite  to  the  paro- 
tids, of  which  the  left  is  the  one  first  involved.  When  the  orchitis  is 
double,  both  testicles  do  not  become  swollen  at  once,  the  one  preceding 
the  other  by  an  interval  of  several  days. 

The  course  of  the  orchitis  is  very  similar  to  that  of  the  mumps,  the 
inflammation  increasing  gradually  for  from  three  to  six  days,  then  under- 
going rapid  resolution,  the  gland  returning  to  its  normal  condition  by  the 
end  of  two  weeks. 

The  local  symptoms  are  swelling,  the  testicle  being  enlarged  to  two  or 
three  times  its  natural  size,  dull  pain,  and  moderate  tenderness,  while  in 
very  severe  cases  there  is  burning  on  micturition  and  a  purulent  discharge 
from  the  urethra.  The  spermatic  cord  does  not  sympathize  in  the  inflam- 


624  PAROTITIS. 

mation,  and  neither  the  swelling,  pain,  nor  tenderness  is  so  great  as  in 
specific  orchitis. 

The  general  symptoms  are  confined  to  a  moderate  elevation  of  tempera- 
ture and  increase  in  the  frequency  of  the  pulse,  thirst,  and  loss  of  appe- 
tite. This  fever  is  separated  from  that  of  the  parotitis  by  an  interval  of 
two  or  three  days. 

The  course  of  bilateral  orchitis  is  longer  by  forty-eight  hours  than  that 
of  the  unilateral  form,  and  the  attending  fever  is  more  intense. 

The  rapid  return  of  the  testicle  to  its  natural  size  and  shape  shows 
that,  as  in  the  parotid  glands,  the  inflammation  does  not  extend  beyond 
the  stage  of  serous  exudation. 

THE  DIAGNOSIS  of  mumps  is  easy  after  the  disease  is  sufficiently  devel- 
oped to  produce  the  characteristic  alterations  in  the  facial  expression.  In 
the  earlier  stages  the  position  of  the  swelling,  immediately  beneath  and  in 
front  of  the  ear,  its  triangular  shape,  and  the  elevation  and  outward  dis- 
placement of  the  lobe  of  the  ear  of  the  affected  side,  distinguish  it  from 
the  enlargement  of  the  cervical  lymph-glands  so  liable  to  occur  in  stru- 
mous  subjects.  The  acute  onset  and  course  of  mumps  are  the  points  of 
distinction  between  it  and  morbid  growths,  or  the  very  rare  condition  of 
chronic  hypertrophy  of  the  parotid  gland.  The  metastatic  orchitis  cannot 
be  mistaken  for  gonorrhceal  orchitis  if  the  least  care  is  taken  to  investi- 
gate the  history  in  either  case. 

THE  PROGNOSIS  is  extremely  favorable,  there  being  no  record  of  a  fatal 
case  of  uncomplicated  mumps.  Suppuration  may  occur,  but  it  is  an 
exceedingly  rare  event.  In  scrofulous  children  the  course  may  be  pro- 
tracted for  several  weeks,  and  in  them  resolution  is  occasionally  imperfect, 
a  degree  of  enlargement  and  induration  of  one  or  both  parotids  remaining 
for  some  time. 

Metastatic  orchitis,  as  a  rule,  leaves  the  testicle  in  a  normal  condition, 
but,  according  to  Vogel,  in  some  epidemics  complete  atrophy  results. 

Dogrny  reports  an  epidemic  which  raged  in  a  garrison  of  Mount  Louis 
in  January,  1828.  Of  sixty-nine  bilateral  and  eighteen  unilateral  cases 
of  parotitis,  metastasis  to  both  testicles  occurred  in  four  cases,  all  of  which 
resulted  in  atrophy  of  the  affected  testicle. 

THE  TREATMENT  is  simple.  The  patient  should  be  kept  in  a  uniform 
temperature,  confined  to  one  room,  or,  better  still,  to  bed,  until  resolution 
is  well  established.  While  the  difficulty  in  swallowing  and  fever  continue 
the  food  should  consist  of  milk  and  beef-tea ;  later,  other  nutritious  articles 
of  diet  may  be  added  as  the  appetite  demands.  Water,  iced  carbonic  acid 
water,  or  lemonade  may  be  allowed  as  freely  as  the  patient  will  take 
them,  to  allay  the  thirst.  A  daily  evacuation  of  the  bowels  must  be 
secured  by  the  use  of  saline  laxatives.  During  the  early  stage,  if  the 
fever  be  high,  tincture  of  aconite-root  should  be  cautiously  administered ; 
afterward  liquor  potassii  citratis  will  sufficiently  fill  the  indications  for  a 
febrifuge.  Tonics  are  required  during  the  decline  of  the  disease;  of  this 
class  of  remedies,  syrup  of  the  iodide  of  iron,  bitter  wine  of  iron,  and 
ferrated  elixir  of  cinchona  are  most  useful. 

Special  symptoms  may  demand  attention.  For  example,  headache  and 
delirium  should  be  relieved  by  hot  mustard  foot-baths  and  moist  cold  to 
the  forehead ;  difficult  deglutition  from  enlargement  of  the  tonsils,  by  the 
frequent  swallowing  of  bits  of  ice,  or,  if  possible,  by  the  application  of 


SYMPTOMATIC  OB  METASTATIO  PAROTITIS.  625 

astringent  lotions,  as  tannic  acid  and  glycerine  (one  drachm  to  the  ounce) ; 
sleeplessness,  by  the  administration  of  bromide  of  potassium,  with  01 
without  small  doses  of  hydrate  of  chloral  in  children  and  of  some 
preparation  of  opium  in  adults. 

In  the  way  of  local  treatment  the  best  results  and  greatest  relief  to 
suffering  will  be  obtained  by  gently  rubbing  the  swollen  glands  with  a 
mixture  of  tincture  of  opium  and  sweet  oil  (one  drachm  to  the  ounce), 
three  times  daily,  and  in  the  mean  while  keeping  the  parts  enveloped  with 
a  moderately  thick  layer  of  cotton  wadding  covered  by  oiled  silk.  Water 
dressings  or  light  poultices  may  be  used  with  advantage.  When  resolu- 
tion begins  a  more  stimulating  lotion  will  hasten  the  disappearance  of  the 
swelling. 

In  the  exceptional  instances  in  which  the  skin  covering  the  tumor 
becomes  tense  and  red,  and  suppuration  is  threatened,  two  or  three 
leeches  may  be  applied  behind  the  ear  of  the  affected  side.  When 
suppuration  has  actually  taken  place  the  abscess  should  be  immediately 
opened  to  prevent  further  destruction  of  the  gland-tissue  and  perforation 
into  the  external  auditory  meatus. 

If,  particularly  in  strumous  subjects,  resolution  be  incomplete  and 
glandular  enlargement  and  induration  remain  after  the  cessation  of  the 
acute  symptoms,  cod-liver  oil  and  iodide  of  iron  are  demanded  for 
internal  administration  and  the  compound  ointment  of  iodine  for  external 
application.  It  is  well  to  dilute  the  latter  sufficiently  to  prevent  its 
causing  irritation  of  the  skin,  and  to  apply  it  twice  daily. 

When  metastasis  occurs,  the  return  of  fever  calls  for  the  same  general 
treatment  as  in  the  early  stage  of  parotitis.  In  addition,  an  emetic  should 
be  given,  as  this  often  cuts  short  the  fever  or  causes  it  to  disappear  more 
rapidly.  The  patient  must  be  kept  at  perfect  rest  in  bed,  with  the 
scrotum  elevated  by  a  cushion  and  covered  with  warm  anodyne  lotions. 
Salines  must  be  administered  sufficiently  often  to  secure  regular  and  free 
action  of  the  bowels. 

When  the  mammae  or  ovaries  are  secondarily  attacked,  the  seat  for 
local  treatment  is  of  course  different,  but  in  all  other  respects  the  manage- 
ment must  be  the  same. 

For  the  uncommon  cases  in  which  the  transference  of  the  inflamma- 
tion is  attended  with  depression  stimulants  are  required,  and  for  those  in 
which  meningitis  is  threatened  cutting  off  the  hair  and  the  application  of 
cold  to  the  head,  hot  mustard  foot-baths,  local  and  general  venesection, 
drastics,  and  irritants  to  the  cutaneous  surface,  are  necessary. 


IE.  Symptomatic  or  Metastatic  Parotitis. 

Symptomatic,  metastatic,  malignant,  or  suppurative  parotitis,  as  the 
condition  is  variously  designated,  is  an  inflammation  of  the  parotid  gland 
which  occurs  during  the  course  of  different  grave  acute  diseases,  is 
usually  unilateral,  and  terminates  in  suppuration,  or  much  more  rarely 
in  gangrene,  of  the  gland  involved. 

ETIOLOGY. — It  may  occur  in  association  with  typhus,  typhoid,  relaps- 
ing, puerperal,  and  scarlet  fevers,  or  with  the  plague,  measles,  dysentery, 
cholera,  and  pyaemia,  springing  into  notice  at  different  periods  of  the 

VOL.  I.— 40 


626  PAROTITIS. 

course  of  these  affections,  which  may  be  regarded  as  predisposing  causes. 
The  exciting  cause  is  perhaps  mechanical  in  nature — namely,  the  exces- 
sive dryness  of  the  mucous  membrane  of  the  mouth  so  common  in  the 
severe  fevers.  This  dryuess  may  lead  to  an  occlusion  of  the  orifice  of  the 
parotid  duct,  with  retention  of  the  saliva,  which  fluid,  undergoing 
decomposition,  may  act  as  an  irritant,  producing  inflammation,  and 
finally  suppuration,  of  the  glandular  tissue.  This  is  a  likely  enough 
explanation  of  the  causation  in  some  cases,  but  dryness  of  the  mouth  is 
such  a  uniform  symptom  in  fever,  and  suppurative  parotitis  such  a  com- 
paratively rare  complication,  that  it  cannot  be  a  very  active  or  common 
cause.  Nevertheless,  it  is  impossible  to  fix  upon  any  other  direct  cause, 
though  the  altered  condition  of  the  blood  in  the  conditions  mentioned 
must  not  be  lost  sight  of  as  an  important  etiological  factor. 

ANATOMICAL  APPEAKANCES. — The  character  of  the  pathological 
lesions  have  been  well  established,  owing  to  the  frequent  opportunities 
that  arise  of  examining  the  diseased  gland  at  different  stages  of  the 
inflammatory  process.  When  the  inflammation  has  lasted  a  short  time, 
a  day  or  two,  the  tubes  and  acini  of  the  gland  are  seen  on  section  to  be 
swollen  and  reddened,  and  the  connective  tissue  infiltrated  with  serum 
and  yellowish-red  in  color ;  a  fluid,  either  viscid,  ropy,  grayish  in  color, 
or  more  purulent  in  character,  fills  the  duct,  and  may  he  forced  out  into 
the  mouth  by  stroking  it  in  the  direction  of  the  orifice.  If  of  several 
days'  longer  duration,  purulent  softening  will  be  noticed  in  the  centre  of 
the  acini;  this  gradually  extends  until  each  acinus  is  converted  into  a 
little  sac  of  pus.  Then  the  inter-acinous  connective  tissue  breaks  down, 
and  the  multiple,  minute,  purulent  collections  become  converted  into  a 
single  large  abscess  or  into  two  or  more  smaller  ones.  Next,  the  pus 
seeks  an  outlet.  The  position  of  pointing  may  be  on  the  cheek  or  in  the 
external  auditory  meatus — a  very  common  location ;  again,  the  abscess 
may  break  into  the  mouth,  the  pharynx,  the  oesophagus,  or  into  the 
anterior  mediastinum,  the  pus  burrowing  its  way  along  the  sheath  of  the 
sterno-cleido-mastoid  muscle. 

While  the  parotid  abscess  is  forming,  suppurative  inflammation  is  apt 
to  be  set  up  in  the  masseter,  pterygoid,  and  temporal  muscles,  and  from 
these  positions  the  pus  forces  its  way  upward  to  the  temporal  or  zygo- 
matic  fossae.  The  periosteum  of  the  neighboring  bones,  and  even  the 
bones  themselves,  may  become  involved,  and  sometimes  the  cranial  bones 
are  partially  destroyed,  and  there  is  an  extension  of  the  inflammation  to 
the  brain  or  its  membranes.  The  middle  ear  may  participate  in  the  gen- 
eral destruction,  and  the  patient  is  left  permanently  deaf,  if  indeed  he 
escape  with  his  life. 

The  lymphatics,  veins,  and  nerves  traversing  the  parotid  are  affected 
by  the  suppuration  in  the  gland.  Irritation  of  the  lymph-vessels  results 
in  swelling,  tenderness,  and  suppuration  of  the  lymph-glands.  Thrombi 
form  in  the  jugular  vein  and  its  branches,  and  by  breaking  down  lead  to 
septicaemia  and  ichorization  of  the  sinuses  of  the  dura  mater.  The 
nerves  resist  for  a  long  time,  but  seem  to  act  as  paths  of  conduction  of 
the  inflammation,  the  facial  nerve  leading  it  to  the  ear,  and  the  branches 
of  the  trifacial  to  the  brain.  When  gangrene  of  the  gland  takes  place, 
the  traversing  nerves  as  well  as  the  gland  elements  are  rapidly  destroyed. 

SYMPTOMS. — Symptomatic   parotitis,  occurring  during  the  course  of 


SYMPTOMATIC  OB  METASTATIC  PAROTITIS.  627 

any  of  the  diseases  already  named,  produces  no  change  in  the  general 
symptoms ;  if,  on  the  other  hand,  it  occurs  during  convalescence,  the 
onset  is  marked  by  a  moderate  elevation  of  temperature  and  increase  in 
the  frequency  of  the  pulse,  by  thirst,  loss  of  appetite,  and  sluggish 
bowels.  The  tumor,  which  occupies  the  same  position  and  thrusts  out- 
ward the  ear-lobe  as  in  mumps,  is  hard,  dense,  well  denned,  and  the  seat 
of  considerable  pain  until  suppuration  takes  place,  when  the  latter  sub- 
sides greatly.  The  skin  over  it  is  red,  hot,  and  tense,  and  there  is  much 
tenderness  and  little  or  no  pitting  on  pressure.  After  the  abscess  has 
formed  there  is  well-defined  fluctuation  on  palpation,  and  at  the  position 
of  pointing  the  skin  becomes  very  thin  and  assumes  a  bluish-red  hue. 
Gangrene  of  the  gland  is  manifested  by  the  cadaverous  odor,  blackening 
of  the  skin,  the  formation  of  a  cavity,  and  the  discharge  of  ichor  and 
shreds  of  tissue.  The  alteration  in  the  expression,  the  pain  in  the  ear, 
the  difficulty  in  moving  the  jaw  and  in  swallowing,  are  as  constantly 
present  here  as  in  idiopathic  mumps.  It  must  not  be  forgotten,  though, 
that  when  the  disease  arises  during  the  course  of  any  of  the  severe  infec- 
tious diseases,  the  brain  may  be  so  overcome  that  the  subjective  symptoms 
are  frequently  not  complained  of. 

The  course  is  usually  rapid,  the  abscess  pointing  on  the  fourth  or  fifth 
day  after  the  appearance  of  the  parotid  tumor ;  occasionally,  however, 
the  inflammatory  process  is  much  slower,  extending  over  a  period  of 
several  weeks.  The  course  is  also  much  protracted  when  secondary 
abscesses  form  in  other  parts  of  the  gland  or  in  the  surrounding  tissues, 
when  the  abscess  is  transformed  into  an  ichorous  cavity,  and  when  gan- 
grene sets  in.  Ordinarily,  where  the  pus  is  evacuated  by  spontaneous 
rupture  or  by  incision  the  abscess  heals  quickly  by  granulation,  leaving 
the  gland  enlarged  and  indurated  for  some  time. 

THE  PROGNOSIS  depends  upon  the  gravity  of  the  original  disease,  the 
period  of  the  disease  at  which  the  complication  occurs,  and  whether  or 
no  mortification  sets  in.  When  the  vital  processes  are  greatly  impaired 
by  the  primary  disease,  the  onset  of  the  parotitis,  trifling  in  itself,  may 
prove  sufficient  to  determine  a  fatal  result.  The  danger  of  such  a  result 
is  much  increased,  too,  if  the  inflammation  begins  in  the  earlier  stages 
or  during  the  height  of  the  disease  which  it  complicates,  while  if  it  com- 
mences during  convalescence  by  far  the  most  frequent  result  is  recovery. 
Gangrene  of  the  gland  involves  great  risk  of  life — a  risk  which  increases 
in  proportion  to  the  early  date  of  its  onset  in  the  course  of  the  original 
disease.  Even  when  the  gangrenous  process  ends  in  recovery,  the  face  is 
much  distorted,  the  hearing  is  lost  in  the  ear,  and  the  facial  muscles  are 
paralyzed  on  the  affected  side.  Bilateral  symptomatic  parotitis  has  natu- 
rally a  graver  prognosis  than  the  unilateral  form. 

DIAGNOSIS. — The  disease  is  readily  distinguished  from  idiopathic 
mumps  by  the  history,  the  less  marked  degree  of  the  enlargement  and 
surrounding  oedema,  the  greater  degree  of  pain  and  tenderness,  the  hard- 
ness of  the  tumor,  the  red  discoloration  of  the  skin  covering  it,  and  the 
termination  in  suppuration.  Further,  it  never  displays  an  epidemic  tend- 
ency. 

TREATMENT. — The  general  treatment  of  this  form  does  not  differ  from 
that  of  the  disease  it  complicates,  though  the  employment  of  stimulant? 
in  increased  quantities  may  be  indicated. 


628  PAROTITIS. 

Before  the  first  appearance  of  tumefaction  of  the  parotid  the  introduc- 
tion of  a  probe  or  cauula  into  the  duct  of  Steno,  associated  with  pressure 
on  the  gland  from  the  outside,  may,  by  forcing  from  the  duct  a  collection 
of  mucus  or  muco-pus,  abort  the  inflammation.  If  this  is  unsuccessful, 
a  poultice  should  be  applied  over  the  gland  to  encourage  suppuration  and 
pointing  externally.  As  soon  as  the  abscess  points  the  pus  must  be 
evacuated  by  an  incision,  and,  as  this  has  a  tendency  to  close  again,  a 
piece  of  lint  must  be  kept  between  the  lips  of  the  wound. 

The  enlargement  and  induration  left  after  the  healing  of  the  abscess 
require  the  application  of  tincture  of  iodine  or  of  compound  iodine  oint- 
ment to  the  surface. 

When  gangrene  occurs  it  demands  the  same  treatment,  both  local  and 
general,  as  when  it  is  seated  elsewhere. 


ERYSIPELAS. 

BY  JAMES    NEVINS    HYDE,  M.  D. 


DEFINITION. — Erysipelas  is  an  acute  disorder,  characterized  by  the 
systemic  symptoms  common  to  the  febrile  state,  and  by  an  involvement 
of  the  integument  and  deeper  parts,  the  affected  surface  being  tumid, 
hot,  reddened,  painful,  and  often  the  seat  of  well-defined  bullse,  the  pro- 
cess terminating  either  in  complete  resolution  after  cutaneous  desquama- 
tion  or  in  a  fatal  result  commonly  due  to  complications  of  the  malady. 

SYNONYMS. — Eng.  St.  Anthony's  Fire ;  Fr.  firysipele ;  Germ.  Koth- 
lauf ;  Ital.  Risipolo. 

CLASSIFICATION. — Erysipelas  is  properly  recognized  as  one  of  the 
acute  infectious  diseases.  Though  by  its  symptoms  and  career  it  would 
seem  to  be  properly  assigned  to  the  category  of  the  exanthemata,  it  is 
yet  by  most  authors  set  apart  from  the  latter — first,  because  its  career  is 
less  specifically  defined ;  second,  because  its  contagiousness  is  less  demon- 
strable in  every  case ;  third,  because  one  attack  is  not  known  to  confer 
upon  its  victims  immunity  against  a  second ;  fourth,  because  the  occa- 
sional prevalence  of  the  disease  in  apparently  epidemic  form  is  evidently 
due  to  extrinsic  causes,  and  does  not  depend  exclusively  upon  its  sudden 
appearance  among  the  unprotected ;  fifth,  because  no  definite  period  of 
incubation  precedes  its  earliest  manifestations;  and,  sixth,  because  at 
times  it  appears  in  local  manifestations  apparently  unaccompanied  by 
systemic  phenomena. 

HISTORY. — The  earliest  writers  on  medicine  bear  witness  to  the  fact 
that  the  disease  was  recognized  at  the  date  when  men  first  made  record 
of  human  ailments.  It  has  occurred  in  all  parts  of  the  world  and  at  all 
seasons  of  the  year,  sparing  neither  age  nor  sex  in  its  development. 
Zuelzer1  refers  to  epidemic  occurrences  of  the  disorder,  described  by 
Rayer,  as  visiting  the' Paris  hospitals  in  1828 ;  by  Schonlein,  as  existing 
in  Zurich  in  1836;  by  Gintrac,  as  spreading  in  Bordeaux  in  1844—45; 
and  by  Trousseau,  as  prevailing  in  the  Maternity  in  Paris  in  1858. 

ETIOLOGY. — Authors  have  in  general  assigned  different  causes  to  the 
forms  of  erysipelas  hitherto  regarded  as  either  idiopathic  (or  medical)  or 
traumatic  (or  surgical).  The  modern  view,  however,  is  that  which 
regards  all  cases  as  alike  produced  by  the  absorption  of  the  toxic  agent 
capable  of  exciting  this  peculiar  inflammation  of  the  skin.  The  pecu- 
liarly well-characterized  symptoms  of  the  disease — for  example,  when  it 
affects  the  head  and  face — were  long  regarded  as  etiologically  distinct 
from  the  affection  which  complicates  surgical  injuries  and  wounds.  But 
1  Cyclop,  of  the  Prac.  of  Med.,  Ziemssen,  vol.  iv.  p.  424. 

629 


630  ERYSIPELAS. 

a  closer  study  of  many  of  the  cases  first  named  has  again  and  again  dis- 
closed the  fact  that  they  originated  in  such  traumatism,  for  example,  as 
the  piercing  of  the  lobule  of  the  ear  for  the  insertion  of  an  ear-ring,  a 
carious  tooth,  an  alveolar  abscess,  or  a  pathological  product  in  the  autrum 
of  Highmore. 

The  disease  is  equally  common — apart  from  the  puerperal  state — in 
both  sexes  and  at  all  ages,  and  occurs  under  favorable  circumstances  in 
all  seasons  of  the  year.  It  is  unquestionably  at  times  spread  by  direct 
contagion,  either  from  the  living  or  dead  body  affected  with  the  disease. 
Such  contagion  may  occur  mediately  or  immediately.  It  is,  however, 
not  readily  shown  to  be  producible  by  the  media  of  clothing  and  other 
articles  which  have  been  in  contact  with  a  diseased  surface.  The  con- 
tents of  the  bullous  lesions  which  appear  upon  the  erysipelatous  surface 
are  iuoculable ;  and  the  disease  has  in  this  way  been  transferred  not  only 
to  men,  but  also,  by  Orth  and  others,  to  the  lower  animals,  and  even  from 
one  of  the  latter  to  another  of  the  same  species. 

Certain  it  is,  however,  that  the  disease  does  occur,  characterized  by 
symptoms  indistinguishable  from  those  to  be  recognized  in  the  contagious 
type  of  the  malady,  where  the  most  careful  investigation  wholly  fails  to 
reveal  the  cause,  and  where  the  disorder  rapidly  spreads  if  the  conditions 
for  its  extension  are  favorable.  Under  these  circumstances  it  is  wisest  at 
present  to  admit  that  the  exact  etiology  of  erysipelas  is  unknown.  Its 
relative  frequency  in  the  puerperal  state  is  unquestionably  to  be  explained 
by  the  favorable  local  conditions  which  at  such  times  exist  in  the  female 
for  the  development  of  all  septic  disorders. 

As  regards  the  circumstances  which  might  be  supposed  to  specially 
favor  its  development,  these  the  capriciousness  of  the  disease,  which  is 
its  striking  characteristic,  often  quite  disregards.  Thus,  on  the  one  hand, 
it  may  and  often  does  prevail,  year  after  year,  in  certain  hospitals,  and 
even  in  certain  wards  of  a  single  hospital,  especially  where  these  are 
crowded  with  patients.  But  it  may  also  repeatedly  spare  masses  of  men 
affected  with  disease  of  a  different  type  when  the  latter  are  gathered 
together  in  prisons  or  camps,  and  indeed  even  may  appear  among  such 
individuals  and  fail  to  spread  to  others  who  are  in  close  proximity  to 
them. 

With  respect  to  the  propagation  of  erysipelas  from  infected  to  sound 
individuals,  a  contrast  is  exhibited  when  the  transmission  of  variola,  for 
example,  is  compared  with  it.  Thus,  it  is  well  known  that  the  mildest 
cases  of  varioloid  may  be  sources  of  malignant  forms  of  variola  to  the 
unprotected,  while  those  who  are  partially  protected  and  exposed  to  the 
virus  of  confluent  forms  of  the  disease  may  exhibit  the  mildest  symptoms 
of  varioloid.  In  erysipelas,  however,  it  is  tolerably  certain  that  there 
are  different  degrees  of  virulence  to  be  recognized  in  different  cases,  and 
that  the  disease  at  times  is  transmitted  in  its  different  types.  Thus,  trau- 
matic erysipelas  is  much  more  closely  related  to  childbed  fever  than  the 
varieties  of  the  disease  appearing  upon  the  head  and  face,  which  cannot 
be  attributed  to  traumatism,  surgical  accidents,  dental  abscesses,  or  local 
injuries  of  the  antrnm  of  Highmore.  Parturient  women  frequently 
escape  infection  when  the  erysipelatous  disorder  is  of  the  so-called 
medical  type.  Per  contra,  it  is  to  be  noted  that  women  who  are  prone 
to  the  relapsing  and  so-called  chronic  forms  of  erysipelas  are  particu- 


S  YMPTOMA  TOLOG  Y.  63 1 

larly  apt  to  suifer  from  that  involvement  of  the  genital  organs,  perito- 
neum, spleen,  and  febrile  movement  whose  sudden  occurrence  after  con- 
finement is  so  portentous. 

SYMPTOMATOLOGY. — The  disease  is  usually  announced  by  the  occur- 
rence of  a  chill,  which  may  precede  by  a  day  or  but  a  few  hours  the 
appearance  of  the  cutaneous  disorder.  The  rigor  may  be  severe  or  mild 
in  grade,  so  that  ^it  ^may  even  be  forgotten  by  the  patient  till  his 
attention  reverts  to  it  in  connection  with  the  resulting  symptoms.  There 
may  be  simultaneously  some  gastric  distress,  rarely  of  severe  character. 
These  symptoms  are  commonly  followed  by  a  febrile  reaction.  In  other 
cases  the  first  recognized  symptoms  of  the  malady  occur  in  the  skin,  the 
patient  scarcely  recalling  the  fact  of  a  slight  preceding  malaise. 

The  cutaneous  lesions  appear  in  the  form  of  a  circumscribed  oedema 
and  redness  of  the  surface,  often  preceded  and  usually  accompanied  by  a 
sensation  of  tension,  heat,  and  burning  pain.  This  macule,  plaque,  or 
patch  of  diseased  integument  is  in  its  typical  features  characteristic.  It  is 
distinctly  or  irregularly  circumscribed ;  its  cedematous  condition  elevates 
its  level  decidedly  above  that  of  the  adjacent  integument,  so  that  there  is  a 
somewhat  sudden  descent  from  the  former  to  the  latter  for  a  space  of  from 
one  to  two  or  more  lines.  The  redness  is  also  of  a  bright  crimson  hue, 
and  the  reddened  surface  has  a  sheen  or  glossy  appearance  uniformly 
displayed  over  its  area.  It  disappears  under  the  pressure  of  the  finger, 
leaving  a  yellowish-white  color  in  the  region  of  impact,  the  erysip- 
elatous  blush  rapidly  returning  when  the  circulation  at  the  surface  is 
restored.  This  smooth  and  shining  condition  of  the  reddened  patch  is  so 
characteristic  of  erysipelas  that  it  arrests  the  attention  of  the  diagnostician 
as  soon  as  he  observes  it.  According  to  Zuelzer,  it  is  caused  simply  by 
the  tension  of  the  epidermis.  When  first  observed  it  may  occur  in  the 
form  of  circular,  small  or  large  coin-sized  patches,  or  in  streaks,  striae, 
and  radiations,  or  as  very  irregularly  disposed,  rosy,  and  shining  mar- 
blings  or  mottlings  of  an  oedeinatous  surface. 

The  skin  thus  affected  is  hot  to  the  touch,  tender,  firm,  and  smooth. 
It  is  occasionally  the  seat  of  pruritic  sensations,  more  commonly  of  a 
peculiar  sensation  of  heat  and  burning. 

In  the  course  of  two  or  three  days  the  involved  area  spreads  uni- 
formly or  irregularly  and  centrifugally  from  the  point  first  involved, 
after  which  time,  in  mild  cases,  the  disease  persists  without  apparent 
change  for  a  few  days  more,  prior  to  its  decadence  by  resolution.  This 
final  stage  of  the  malady  is  characterized  by  a  progressively  diminishing 
fever,  moderate  desquamatiou,  gradual  disappearance  of  the  oedema,  and 
a  color-change  to  the  darker  shades  of  bluish-red  or  to  a  light  brown. 
In  this  form  of  the  disease  the  erysipelatous  patch,  after  being  fully 
developed,  does  not  tend  to  spread  from  the  affected  to  the  unaffectec] 
surfaces ;  and,  as  a  consequence,  the  affection  may  complete  its  entire 
career  in  less  than  a  fortnight. 

In  other  cases,  however,  a  remarkable  tendency  is  developed  to  the  pro- 
gressive spreading  of  the  inflammation  from  one  point  or  surface  of  the 
body  to  another,  the  parts  first  affected  paling  as  the  disease  passes  on  to 
involve  those  in  the  vicinity,  or  being  yet  deeply  involved  while  the  pro- 
cess of  peripheral  extension  is  in  progress.  In  yet  other  cases  the  red 
blush  sweeps  away  from  its  first  position  in  tongue-like  projections  over  a- 


632  ERYSIPELAS. 

tumid  and  painful  skin,  while  the  region  first  invaded  becomes  paler, 
though  still  preserving  its  cedematous  features.  In  still  another  class  of 
cases  the  advancing  ribbon  or  band  of  elevated  and  reddened  integument 
passes  over  to  a  new  area,  leaving  the  regions  it  has  traversed  tumid, 
painful,  and  here  and  there  streaked  with  rosy  lines,  patches,  or  irregular 
gyrations. 

In  yet  severer  types  of  the  malady  the  intensity  of  the  inflammatory 
process  is  such  that  the  epidermis  is  raised  from  the  tissues  below  by  the 
free  exudation  of  the  serum  of  the  blood.  In  this  way  vesicles,  or,  more 
commonly,  bullse,  develop  upon  the  surface.  Bullse  thus  formed  may  be 
typically  perfect,  but  are  often  exceedingly  irregular  in  contour,  having  an 
appearance  which  is  suggestive  of  the  blistering  of  a  surface  by  boiling  water. 
The  bullae  may  be  well  distended  and  filled  with  a  perfectly  limpid  serum. 
This  fluid  may,  however,  in  the  course  of  a  few  days  become  purulent, 
the  contents  in  such  case  drying  into  crusts.  In  the  severest  types  of  the 
disease  gangrene  results  from  the  intensity  of  the  dermatitis,  and  the  loss 
of  tissue  which  thus  occurs  is  repaired  by  the  processes  of  granulation  and 
cicatrization. 

The  migration  of  erysipelas  from  one  part  to  another  of  the  surface  is 
sometimes  so  extensive  as  to  invade  from  time  to  time  the  larger  part  of 
the  superficies  of  the  body.  Erysipelas  of  this  ambulant  character  may 
also,  after  invading  the  entire  surface  of  the  body,  be  relighted  at  the 
point  where  it  first  appeared.  In  other  cases  this  phenomenon  of  recur- 
rence or  reawakening  on  patches  of  skin  traversed  by  the  disease  may  be 
noticed  only  after  moderate  extension  from  a  given  point.  Reddish  or 
rosy-colored  islets  then  appear  as  new  centres  of  a  fresh  extension-process 
upon  an  integument  whose  swollen  tissues  still  exhibit  the  evidences  of 
the  prior  invasion.  In  still  other  cases  similar  islands  of  fresh  disease  are 
recognized  in  advance  of  the  elevated  edge  and  tongue-like  prolongations 
which  mark  the  onward  progress  of  the  erysipelatous  inflammation  over 
areas  previously  unaffected. 

The  swelling  of  the  involved  tissues  is  one  of  the  most  characteristic 
features  of  erysipelas.  By  this  is  meant  not  the  tumefaction  simply  of 
the  superficial  portions  of  the  integument,  nor  the  tumefaction  which  may 
be  measured  by  the  height  of  the  affected  above  the  level  of  the  unaffected 
skin  at  the  edge  of  the  involved  area,  but  a  swelling  much  more  than 
this,  involving  the  entire  skin,  and  often  indeed  the  subcutaneous  tissues, 
differing,  of  course,  in  the  extent  to  which  it  advances  in  different  cases. 
In  those  of  severe  grade  the  swelling  is  enormous,  an  affected  limb  assum- 
ing the  elephantiasic  aspect,  while  the  deformity  thus  induced  in  the  head 
is  fully  as  great  as  that  seen  in  the  height  of  confluent  variola.  In  such 
cases  the  neighboring  ganglia  are,  as  a  rule,  enlarged  and  often  painful. 

It  is  indeed  this  swelling  which  gives  to  erysipelas  of  the  head  and  face 
its  peculiar  physiognomy.  The  disorder  is  apt  to  find  its  starting-point 
in  the  ear,  the  side  or  point  of  the  nose,  or  one  cheek.  At  this  moment 
it  may  be  possible  to  recognize  the  fact  that  the  adjacent  mucous  mem- 
brane is  also  involved.  Thence  the  disease  progresses  over  the  face,  and 
possibly  over  the  scalp  also,  the  resulting  tumefaction  being  occasionally, 
as  already  stated,  enormous.  Thus  the  eyes  are  usually  closed  and  sealed 
by  the  swollen  lids  and  the  orbital  depressions  are  effaced.  The  lips, 
enormously  pouting  and  reddened,  project  from  the  swollen  visage  to  as 


SYMPTOMATOLOGY.  633 

great  an  extent  as  the  tumid  ears,  which,  for  similar  reasons,  depart  from 
the  usual  plane.  The  mouth,  nares,  and  eyes  alike  are  covered  with 
mucous  secretions,  possibly  commingled  with  the  contents  of  bullse  which 
have  formed  and  broken.  Crusts  may  thus  collect  near  the  mucous  outlets. 
The  tongue  is  dry,  parched,  and  cracked,  and  exhibits  a  reddish-brown 
hue.  In  less  severe  cases  it  may  be  seen  to  be  covered  uniformly  with  a 
thick  yellowish  or  yellowish-white  paste.  The  fauces  and  buccal  mem- 
brane are  reddish  in  color,  glazed,  and  dry. 

The  patient  having  this  serious  form  of  the  malady  is  indeed  in  a 
critical  condition.  There  is  usually  a  coincident  coma  or  delirium.  The 
pulse  is  either  greatly  accelerated  and  full,  or  thready,  fluttering,  and 
destitute  of  rhythm.  The  temperature  rises  to  105°  F.,  and  even 
higher.  In  this  condition  a  fatal  issue  may  be  heralded  by  collapse,  with 
decadence  of  the  external  evidences  of  the  disease,  or  by  the  occurrence 
of  blood-filled  blebs,  or  indeed  by  larger  or  smaller  areas  of  the  surface 
falling  into  gangrene.  This  latter  accident  may  also  involve  the  mucous 
surfaces,  large  patches  of  the  buccal  membrane,  the  gums,  and  even  the 
palate,  losing  their  vitality  and  showing  as  greenish-black,  insensitive 
tracts,  quite  firmly  attached  to  the  healthy  tissue.  These  accidents  may 
be  of  very  rapid  occurrence,  more  particularly  in  the  case  of  individuals 
prone  to  exhibit  the  severest  forms  of  the  malady,  such  as  very  young 
infants  and  those  enfeebled  by  advanced  age,  by  alcoholism,  or  by  any 
of  the  cachexise. 

Other  types  of  erysipelas,  chiefly  noticeable  by  reason  of  their  loca- 
tion, are  those  spreading  from  the  umbilicus,  the  genital  region,  the  sites 
of  vaccination,  of  varices  of  the  lower  extremities,  and  the  surfaces  near 
the  seat  of  surgical  accidents  and  operations. 

The  various  names  which  have  been,  especially  by  older  writers,  given 
to  the  several  expressions  of  this  disorder  relate  almost  exclusively  to 
their  external  characteristics.  Among  these  may  be  mentioned — E. 
ambulans,  e.  erythematosum,  e.  bullosum,  e.  glabrum,  e.  levigatum,  e. 
miliare,  e.  oadematosum,  e.  pemphigoides,  e.  phlyctenulosum,  e.  puerperale, 
e.  vaccinale,  e.  variegatum,  e.  verrucosum,  and  e.  vesiculosum. 

The  resolution  of  erysipelas  in  favorably  terminating  cases  is  accom- 
plished by  very  gradual  amelioration  of  symptoms.  The  swelling  begins 
to  subside,  usually  between  the  third  and  sixth  days.  The  blebs  that 
have  formed  then  disappear  by  absorption,  bursting,  desiccation,  or  crust- 
ing, and  subsequent  exfoliation.  Desquamation  of  the  involved  surface 
may  be  a  prominent  or  a  very  insignificant  feature.  When  the  patient 
with  erysipelas  capitis  enjoys  a  favorable  crisis  in  his  disease,  there  is 
occasionally  noted  a  very  rapid  amelioration  of  the  symptoms.  The 
tumefaction  speedily  subsides,  the  features  become  recognizable,  and 
defervescence  is  complete.  Throughout  the  course  of  all  attacks  the 
febrile  process  and  the  erysipelatous  blush  proceed  pari  passu  with 
but  little  deviation  of  the  severity  of  the  one  from  the  intensity  of 
the  other. 

The  complications  and  sequelae  of  the  disease  are  less  numerous  than 
they  are  grave.  In  erysipelas  of  the  head  there  is  usually  a  rapid 
shedding  of  the  hair,  though  in  convalescence  the  growth  of  the 
hair  may  be  restored.  An  obstinate  seborrhoaa  sicca  may,  as  after 
variola,  linger  long  afterward  upon  the  scalp;  here  also,  as  in  other 


634  ERYSIPELAS. 

portions  of  the  body,  one  or  many  abscesses  may  form  in  the  subcuta- 
neous tissue  after  the  resolution  of  the  dermatitis ;  while  in  phlegmouous 
erysipelas  these  abscesses  may  accompany  the  disease  at  its  height. 

Lymphangitis  and  adenopathy  are  common  complications  of  erysipelas, 
the  former  betrayed  in  thickened  and  often  knotted  cords,  which  may  be 
felt  radiating  from  involved  areas  to  neighboring  glands.  A  singular 
modification  is  often  undergone  by  the  integument  affected  with  erysipelas 
which  has  also  been  the  seat  of  other  cutaneous  disorders.  In  this  way 
lupus,  psoriasis,  chronic  eczema,  and  some  of  the  syphilodermata  have 
been  relieved. 

Besides  the  surfaces  of  the  nasal,  pharyngeal,  and  buccal  mucous  mem- 
branes which  have  been  indicated  as  at  times  involved  by  the  disease, 
the  inflammatory  redness  and  swelling  may  extend  to  the  epiglottis,  the 
larynx,  and  the  trachea.  Croupous  and  other  forms  of  pneumonia,  pul- 
monary oedema,  and  pleuritis  have  been  not  rarely  noted.  In  erysipelas 
of  the  head  the  membranes  of  the  brain  may  inflame  and  serous  effiisions 
distend  the  ventricles. 

The  joints  may  be  inflamed  either  by  sympathy  or  by  direct  extension 
of  the  erysipelatous  inflammation  to  the  periarticular  tissues,  or  yet  by 
the  occurrence,  in  or  about  them,  of  metastatic  abscesses  in  septicsemic 
conditions. 

The  peritoneum  may  be  also  acutely  or  subacutely  inflamed  in  ery- 
sipelas, though  it  is  doubtful  whether  the  accident  occurs  in  consequence 
of  the  extension  of  the  disease  to  this  membrane  from  the  skin  of  the 
abdominal  wall.  The  same  may  be  said  of  the  endocarditis  and  peri- 
carditis noted  by  several  authors.  Of  all  other  complications,  it  may  be 
said  that  they  can  usually  be  assigned  to  the  occurrence  of  either  septicae- 
mia, or  pyaemia,  or  to  the  development  of  metastatic  abscesses. 

With  respect  to  the  eyes,  a  distinction  should  be  drawn  between  those 
attacks  originating  in  deep  or  superficial  affections  of  the  globes  and  those 
in  which  the  visual  organs  are  merely  involved  as  by  accident  in  the 
extension  of  the  disease.  In  the  former  case  deep  orbital  abscesses  or 
inflammatory  affections  of  the  iris  and  retina  may  be  followed  by  ery- 
sipelas of  the  lids  or  neighboring  parts,  while  in  the  latter  event  the 
issue  is  more  commonly  a  transitory  conjunctivitis,  lachrymation,  and 
photophobia,  which  soon  disappear  when  the  disease  has  declined.  The 
cornea,  being  unmacerated  with  pus  as  in  severe  variola,  commonly  escapes 
perforation. 

Erysipelas  is  a  disorder  which,  without  question,  produces  in  a  certain 
proportion  of  patients  a  susceptibility  to  recurrent  attacks.  This  suscep- 
tibility, however,  is  less  a  systemic  tendency  to  the  development  of  the 
disease  than  a  peculiar  liability  to  recrudescence  originated  by  chronic 
local  ailments.  Thus  catarrhal,  ulcerative,  and  other  affections  of  the 
nasal  mucous  membrane  are  particularly  apt  to  originate  repeated  erysipe- 
latous attacks  in  the  integument  covering  the  nose,  and  the  same  is  true 
of  the  skin  in  the  vicinity  of  the  orifices  of  fistulous  sinuses  and  varicose 
veins. 

The  forms  of  disease  which  are  often  described  as  instances  of  chronic 
erysipelas  belong  to  several  classes.  There  are,  first,  those  in  which  are 
observed  recurrent  attacks  of  true  erysipelas.  Second,  those  in  which  a 
chronic  eczema  or  dermatitis  produces  a  circumscribed  patch  of  infiltration 


PATHOLOGY  AND  MOBS  ID  ANATOMY.— DIAGNOSIS.         635 

in  a  skin  having  a  lurid  reddish  hue,  which  is  also  the  seat  of  marked 
subjective  sensations,  chiefly  itching.  The  well-known  forms  of  chronic 
eczema  erythematosum  of  the  face  in  middle  years  or  advanced  life  are 
commonly,  and  erroneously,  regarded  as  erysipelatous  in  character. 
Third,  there  is  a  peculiar  dermatitis,  of  the  cheeks  chiefly,  with  regard  to 
whose  identity  as  an  erysipelatous  affection  there  is  much  doubt.  The 
skin  is  infiltrated  in  a  circumscribed  patch,  and  has  a  peculiarly  glossy 
red  hue.  It  is  essentially  a  chronic  disorder,  the  affected  patch  remaining 
unchanged  for  months  at  a  time,  and  then  exhibiting  aggravation  in  con- 
sequence of  accidental  exposure  to  heat  or  traumatism.  These  patches 
may  be  relics  of  relapsing  forms  of  erysipelas ;  and  in  my  experience 
are  more  commonly  encountered  in  the  subjects  of  chronic  alcoholism. 

PATHOLOGY  AND  MORBID  ANATOMY. — The  pathological  changes 
exhibited  in  the  erysipelatous  skin  are  those  of  an  exudative  process 
involving  the  cutaneous  and  subcutaneous  tissues.  Nothing  specially 
different  from  the  phenomena  observed  in  a  simple  dermatitis  can  be 
recognized  by  the  microscope  alone.  Biesiadecki's  careful  investigations1 
certainly  do  not  disclose  any  such  specificity.  The  epithelia  are  swollen 
with  serous  fluid,  and  the  exudate,  though  largely  serous,  contains  also  the 
corpuscles  recognized  in  plastic  lymph.  It  is  this  serum,  rapidly  invited 
to  the  surface  by  the  acuity  of  the  exudative  process,  which  raises  the 
epidermis  into  the  bullse  described  above.  The  nuclei  of  the  bodies 
recognized  in  the  exudate  are  evidently  in  a  state  of  division  and  conse- 
quent multiplication.  The  epithelia  of  the  rete  mucosum  are  swollen  and 
stretched.  The  connective-tissue  elements  in  the  derma  are  also  swollen, 
and  exhibit  reversion  to  the  embryonal  state.  There  is  within  each  a 
relative  increase  of  protoplasm,  as  a  consequence  of  which  they  undergo 
a  species  of  liquefaction.  The  blood-  and  lymph-vessels  enlarge  and  are 
crowded  with  corpuscles.  The  subcutaneous  tissue  participates  in  this 
process,  its  elements  being  filled  with  finely  granular  cells  disseminated  or 
in  aggregated  masses.  The  chief  peculiarity  of  this  exudation,  and  of 
these  changes  in  the  tissue-elements  where  it  recurs,  is  the  rapidity  with 
which,  wheu  involution  is  in  progress,  the  fluid  is  absorbed  and  the 
inflammatory  elements  disappear.  When  abscess  or  gangrene  complicates 
the  erysipelatous  inflammation  the  changes  are  not  different  from  those 
recognized  in  dermatitis  calorica. 

The  changes  noted  in  the  viscera  are  also  of  a  congestive  and  inflamma- 
tory type.  According  to  Poufick,2  there  is  at  times  a  parenchymatous 
degeneration  of  the  muscular  tissues  of  the  large  vessels,  and  of  the  ex- 
tremities, as  well  as  of  the  kidneys,  liver,  and  spleen,  the  latter  organ  occa- 
sionally undergoing  softening.  The  mucous  surfaces  of  the  mouth,  larynx, 
lungs,  and  alimentary  canal  have  also  been  found  affected  with  oedema,  con- 
gestion, and  infiltration,  rarely  terminating  in  ulcerative  changes. 

DIAGNOSIS. — The  diagnosis  of  a  typical  case  of  erysipelas  is  so  simple 
that  the  nature  of  the  malady  is  often  recognized  by  those  unskilled  in 
such  matters.  It  is  difficult  to  mistake  for  any  other  affection  the  circum- 
scribed, swollen,  shining,  and  rosy-reddish  patch  of  skin,  accompanied  by 
fever  or  marked  malaise,  with  adenopathy  of  near  glands,  and  often  with 
a  history  of  traumatism  to  which  the  origin  of  the  disorder  may  be 
readily  referred. 

1  Sitzungsber.  d.  L  Acad.  der  Wusen.,  Wien,  ii.,  1867.         '  Deutsch.  klin.,  No.  20,  1868. 


636  EBYSIPHLAS. 

It  is  to  be  distinguished  from  dermatitis  in  its  various  forms  (venenata, 
niedicamentosa,  phlegmonosa,  suppurativa)  by  its  characteristic  features, 
and  by  the  frequent  absence  in  these  inflammations  of  a  febrile  reaction 
and  of  a  shining,  rosy-red  hue  of  the  skin,  and  by  the  peculiarities 
described  above  of  the  elevated  margin  of  the  erysipelatous  area. 

Eczema,  especially  in  its  chronic  erythematous  forms,  exhibited  in  the 
face  of  adults  in  middle  and  later  life,  is  of  much  slower  development,  is 
uroductive  of  itching,  is  ill-defined  in  contour,  and  is  not  accompanied  by 
fever. 

Erythema  in  all  its  varieties  is  a  purely  hyperaemic  affection  and  unac- 
companied by  fever.  In  erythema  multiforme  there  is  an  exudative  pro- 
cess by  reason  of  which  various  papules,  nodosities,  and  at  times  even 
bullse,  appear  upon  the  surface.  None  of  them,  however,  are  accompa- 
nied by  a  diffused  area  of  redness  spreading  at  the  periphery.  All  of  its 
lesions  are  circumscribed,  and  rarely  affect  the  face. 

Pemphigus  could  only  be  mistaken  for  the  form  of  erysipelas  bullae, 
but  its  lesions  do  not  rise  from  a  broadly  inflamed  area ;  they  rather  have 
attended  with  each  a  distinct  individual  halo  when  the  integument  from 
which  they  spring  is  at  all  congested.  They  are  also  rarely  accompanied 
by  a  febrile  process. 

Scarlatina,  though  a  febrile  affection,  is  readily  distinguished  from  ery- 
sipelas by  the  appearance  of  its  exanthem,  symmetrically  and  generally 
developed  over  the  entire  surface  of  the  body,  or  progressively  and  sym- 
metrically from  the  upper  to  the  lower  segment  of  it.  The  exanthem  has 
also  a  dull  scarlet  color  or  the  boiled  lobster  hue,  differing  thus  from  the 
rosy-red  and  shining  patch  of  erysipelas. 

Urticaria  also  is  often  of  symmetrical  development,  is  rarely  accompa- 
nied by  fever,  and  is  characterized  by  typical  wheals,  which,  however 
closely  packed  together,  never  have  the  smoothness  of  the  surface  affected 
with  erysipelas. 

PROGNOSIS. — The  prognosis  of  a  simple  case  of  uncomplicated  erysipe- 
las occurring  in  an  individual  in  fair  health  and  possessed  of  a  reasonable 
degree  of  vigor  may  be  regarded  as  favorable.  Even  in  the  weakness  of 
infancy  a  large  area  may  be  involved  in  the  disease  and  a  high  degree  of 
fever  be  aroused  without  alarming  results. 

Erysipelas  should,  however,  always  be  regarded  as  a  serious  disease  or 
a  serious  complication  of  any  existing  malady.  It  is  often  a  grave  fea- 
ture in  surgical  injuries.  Erysipelas  involving  the  entire  surface  of  the 
face  and  head  is  always  a  formidable  affection.  In  the  puerperal  state  it 
is  dreaded  by  every  accoucheur. 

All  these  circumstances  are  rendered  more  portentous  by  the  existence 
of  the  disorder  as  a  complication  of  any  other  grave  malady,  or  by  its 
occurrence  among  the  subjects  of  alcoholism,  struma,  phthisis,  or  various 
other  cachexias,  and  among  the  aged.  Occurring  in  epidemic  form  among 
the  inmates  of  prisons,  camps,  and  hospitals,  the  mortality  of  the  disease 
may  be  increased  tenfold. 

TREATMENT. — The  prophylaxis  of  erysipelas  is  that  of  all  contagious 
diseases.  It  involves  isolation  of  the  affected  individual,  disinfection  of 
body-  and  bed-clothing  before  the  latter  are  again  employed  upon  the  per- 
sons of  others,  and  destruction  by  fire  of  all  dressings  which  have  been  in 
contact  with  the  integument. 


TREATMENT.  637 

The  hygienic  management  of  the  patient  is  not  to  be  neglected.  The 
complete  ventilation  of  the  sick  chamber  is  to  be  secured,  and  its  tempera- 
ture uniformly  sustained  at  a  point  between  65°  and  70°  F. 

The  general  treatment  of  the  sufferer  need  not  greatly  differ  from  that 
commonly  pursued  in  the  febrile  state  by  modern  therapeutists.  There  is 
but  little  confidence  to-day  in  the  methods  by  venesection  and  purgation, 
upon  which  at  one  time  reliance  was  placed.  Cool  or  cold  water  may  be 
freely  employed  when  there  is  hyperpyrexia,  either  by  general  bathing  or 
by  wrapping  the  patient  in  sheets  dipped  in  and  wrung  out  of  the  same 
fluid.  The  results  are  favorable  as  regards  the  bodily  temperature,  and 
are  not  productive  of  danger,  though  water  thus  applied  has  no  effect 
upon  the  local  disorder  of  the  skin.  Iced  or  cool  water,  by  the  ice-bag 
or  compresses,  is  specially  indicated  as  a  topical  application  for  the  head 
when  there  is  delirium  or  other  indication  of  disturbance  of  the  cephalic 
centres,  irrespective  of  the  invasion  of  the  scalp  and  face  by  the  erysipe- 
latous  inflammation.  The  sulphate  of  quinia  in  full  doses  is  indicated 
especially  when  there  is  any  tendency  to  remittence  in  the  febrile  accessions, 
but  is  not  known  to  possess  any  power  to  cut  short  the  disease.  In  many 
cases  of  erysipelas  the  febrile  condition  is  readily  managed  by  the  admin- 
istration of  the  simpler  remedies  found  grateful  to  the  palate  of  the  suf- 
ferer, such  as  iced,  acidulated,  and  effervescing  draughts,  with  perhaps 
the  employment  of  the  spiritus  Mindereri  or  the  spirit  of  nitrous  ether. 
In  other  cases  the  mineral  acids  can  be  substituted  with  advantage  for  the 
latter.  With  many  American  physicians  it  is  customary  to  add  to  these 
remedies  the  tincture  of  the  root  of  aconite,  with  a  view  to  its  effect  upon 
the  pulse. 

Few  internal  remedies,  however,  have  in  this  country  enjoyed  as  much 
popularity  with  the  profession  in  the  treatment  of  erysipelas  as  the 
muriated  tincture  of  iron  in  full  doses.     Its  use,  first  suggested  for  this 
purpose  by  Bell  in  1851,  has  here  steadily  gained  in  favor  since  its 
general  adoption.     It  is  well  to  give  it  in  doses  of  not  less  than  20  or 
30  drops,  repeated  every  two  or  three  hours,  diluted  with  water.     When 
there  is  high  fever,  and  especially  if  the  secretion  of  urine  is  scanty,  the 
following  formula  will  be  found  valuable : 
Tr.  Fern  Chloridi ; 
Sp.  Athens  Nitrosi ; 
Glycerinae  da  f  si.     M. 

S.  A  teaspoonful  in  water  every  three  hours. 

This  preparation  of  iron  certainly  seems,  in  many  cases,  to  shorten  the 
disease,  but,  per  contra,  it  is  to  be  remembered — first,  that  in  many  other 
cases  it  has  been  found  to  exercise  no  control. whatever  over  the  severest 
manifestations  of  the  disease ;  second,  that  in  other  countries,  especially 
in  Germany,  where  it  is  rarely  employed,  the  mortality  from  the  disease 
is  no  greater  than  elsewhere. 

The  widest  difference  in  practice  has  obtained  relative  to  the  local 
treatment  of  the  affection.  They  who  have  had  the  fortitude  to  content 
themselves  with  watching  the  evolution  of  the  specific  dermatitis,  merely 
protecting  the  skin  by  dusting  over  it  a  simple  powder  or  leaving  it 
covered  with  a  cold  compress,  have  certainly  no  worse  results  to  tabulate 
than  those  who  entertain  a  belief  in  the  efficacy  of  the  abortive  treatment 
of  the  local  disorder. 


638  ERYSIPELAS. 

No  remedies,  locally  applied,  can  be  recognized  as  certainly  possessing 
the  power  to  cut  short  the  inflammation.  Those  which  enjoy  the  highest 
reputation  for  topical  employment  are  saturated  solutions,  hot  and  cold, 
of  the  hyposulphite  of  sodium,  of  boracic  acid,  and  of  the  bicarbonate  of 
sodium ;  salicylic  acid ;  iodoform  in  powder ;  and,  quite  lately,  resorcin. 
Hot  fomentations  of  the  erysipelatous  patch  are  in  general  most  grateful 
to  the  patient,  and  with  these  an  opiate  and  astringent  effect  can  be 
obtained,  as  by  a  hot  lead  and  opium  wash  or  by  solutions  of  the 
sulphate  of  iron  or  of  alum  and  tannin.  Useful  methods  of  applying 
these  are  by  the  medium  of  borated  cotton,  oakum,  tow,  or  spongio- 
piline,  covered  with  oiled  silk  or  the  Lister  protective  material. 

Other  medicaments  which  have  enjoyed  favor  in  the  topical  treatment 
of  the  disease  are  lime-water  and  linseed  oil  (carron  oil),  sulphur  in 
powder,  carbolic  acid,  camphor,  the  oil  of  turpentine,  collodium,  cata- 
plasms and  ointments  containing  mercury,  lead,  zinc,  tar,  and  tannin. 

Respecting  the  measures  adopted  with  a  view  to  checking  the  exten- 
sion of  the  disease  at  the  periphery  of  the  patch,  the  belief  in  such  a 
possibility  has  been  wellnigh  abandoned.  For  this  purpose  the  nitrate 
of  silver,  caustic  potash,  tincture  of  iodine,  and  similar  substances  have 
been  boldly  and  broadly  applied,  alike  over  the  sound  and  affected  integ- 
ument, with  the  production  of  an  artificial  dermatitis  intended  to  supplant 
that  which  was  previously  in  progress.  Again  and  again  has  the  local 
inflammation  transgressed  these  artificial  limits;  and  when  they  have 
been  by  it  apparently  respected  there  has  been  little  ground  for  believing 
that  the  result  was  due  to  the  treatment  pursued.  Inasmuch  as  the 
disease  is  often  self-limited  and  distinctly  limited  in  its  progression  over 
the  surface,  it  is  manifestly  difficult  to  determine  that  its  limitation  in 
any  given  case  is  the  result  of  topical  agencies.  These  agencies  have, 
moreover,  the  marked  disadvantage  of  adding  their  irritative  effects  to 
those  incidental  to  the  dermatitis. 

The  surgical  treatment  of  erysipelas  invading  special  regions  of  the 
body  or  the  deeper  tissues  is  a  matter  of  importance.  Free  incisions  are 
requisite  for  the  liberation  of  pus,  and  all  abscess  cavities  should  be 
treated  antiseptically  and  stuffed  with  iodoform  or  resorcin.  Great  ten- 
sion of  the  lids  demands  free  incisions  in  the  long  diameter  of  either,  and 
the  same  surgical  procedures  are  often  demanded  in  erysipelas  of  the 
scrotum  or  of  the  labia  in  the  female.  Gangrene  and  sloughing  are  to 
be  treated  in  accordance  with  the  principles  recognized  as  important  in 
the  management  of  these  accidents  in  general. 

The  mouth  when  involved  may  be  benefited  by  gargles  containing  the 
chlorate  of  potassium,  alum,  tannin,  the  compound  tincture  of  cinchona,  or 
by  the  use  of  the  spray  with  a  saturated  solution  of  boracic  acid  in  rose- 
water.  Kaposi  lays  stress,  in  all  cases  of  erysipelas  of  the  face,  upon 
the  importance  of  searching  for  and  evacuating  all  dental  abscesses  and 
pustules  seated  upon  the  Schneiderian  membrane.  Crusts  in  the  nasal 
cavity  are  to  be  soaked  with  vaseline  and  removed  by  washing,  their 
re-formation  being  prevented  by  the  insertion  of  small  tampons  smeared 
with  a  bland  ointment  or  oily  fluid.  Abscesses  in  other  portions  of  the 
body,  not  suspected  as  being  etiologically  significant,  are  to  be  carefully 
searched  for  and  emptied,  whether  occurring  about  the  anus,  the  genitals, 
or  the  legs. 


TREATMENT.  639 

Subcutaneous  injections  of  carbolic  acid  and  other  antiseptic  solutions 
have  not  been  rewarded  by  such  results  as  to  establish  in  any  deerree  their 

•     1       £C 

special  emcacy. 

In  all  ordinary  cases  the  expectant  treatment  recommended  by  Zuelzer 
is  abundantly  to  be  commended.  The  inflamed  tissue  is  to  be  dusted 
with  finely-powdered  starch,  and  protected  by  a  layer  of  soft  cotton-wool 
which  exercises  a  moderate  degree  of  pressure  upon  it.  Antiseptically, 
the  highest  ends  are  thus  reached. 

The  diet  of  the  patient  should  consist  of  animal  broths,  soups,  milk, 
and  eggs,  with  a  view  to  the  reparation  of  the  waste  incidental  to  the 
febrile  process.  Stimulants  are  to  be  freely  used  in  all  asthenic  con- 
ditions. In  convalescence  the  warm  water  and  soap  bath  is.  to  be 
employed,  followed  by  dusting  of  the  surface  with  starch  powder  or 
hv  inunction  with  vaseline. 


YELLOW  FEVER. 

BY   S.    M.    BEMISS,  M.D. 


YELLOW  FEVER  is  a  specific,  infectious,  and  communicable  disease  of 
cue  febrile  paroxysm. 

This  definition  includes  some  of  the  most  prominent  characteristics  of 
the  disease.  The  malady,  however,  derives  its  name  from  a  symptom 
not  mentioned  in  the  definition.  The  yellow  color  of  the  skin  and 
scleroticae  which  appears  in  advanced  stages  of  grave  cases  of  yellow  fever, 
and  which  becomes  especially  marked  in  the  cadaver,  has  ruled  its  no- 
menclature. "Whatever  objections  may  be  urged  against  the  term  "  yellow 
fever  "  as  being  founded  upon  a  symptom  of  the  disease  not  always  present, 
it  is  too  strongly  fixed  in  both  medical  literature  and  popular  usage  to 
justify  efforts  to  change  it. 

Neither  is  it  liable  to  beget  confusion  as  long  as  it  is  understood  that  it 
is  to  be  restricted  in  its  application  to  a  specific  fever  induced  by  a  specific 
poison,  and  that  as  an  incident  of  its  morbid  processs  it  produces  yellow 
coloration  of  the  surface  so  frequently  as  to  suggest  the  prefix  yellow  to 
its  title. 

ETIOLOGY  AND  SYMPTOMATOLOGY. — In  this  day  of  almost  general 
belief  in  the  theory  which  holds  that  each  specific  disease  has  its  own 
specific  poison  or  morbific  germ,  it  is  scarcely  expedient  to  occupy  much 
space  in  discussing  the  propriety  of  classing  yellow  fever  among  the  spe- 
cific maladies. 

Whether  we  rest  the  decision  of  this  question  upon  the  uniformity  of 
those  circumstances  and  conditions  which  originate  and  develop  epidemics 
of  yellow  fever,  or  upon  the  sameness  of  its  symptomatic  phenomena 
wherever  observed,  we  find  very  nearly  as  substantial  claims  to  a  specific 
individualization  of  the  disease  as  any  one  of  the  eruptive  fevers  pos- 
sesses. Not  only  are  its  morbid  phenomena  so  characteristic  that  even 
non-professional  observers  designate  it  by  such  epithets  as  Bronze  John, 
Yellow  Jack,  Vomito  Prieto,  etc.,  but  it  is  inconvertible  with  other 
specific  affections.  This  inconvertibility  of  yellow  fever  with  other  dis- 
eases is  absolute,  and  affords  irrefrangible  evidence  of  the  specificity  of 
that  germ  or  poisonous  principle  which  produces  it. 

The  study  of  yellow-fever  poison  after  the  objective  method  has  hitherto 
been  unproductive  of  definite  results.  When  such  experienced  and  truth- 
ful observers  as  Sternberg,  Woodward,  and  Schmidt,  working  with  the 
most  approved  microscopes,  have  failed  to  identify  any  organism  or  object 
peculiar  to  the  products  from  the  bodies  of  yellow-fever  subjects  or  to 
the  circumfusa  of  the  sick,  this  declaration  is  sufficiently  supported. 

640 


ETIOLOGY  AND  SYMPTOMATOLOGY.  641 

But  when  we  turn  to  a  subjective  method  of  investigating  that  toxic 
agent  which  causes  yellow  fever,  it  is  found  to  possess  sufficiently  well- 
marked  characteristics  to  justify  practically  valuable  conclusions.  Some 
of  these  characteristics  or  modes  of  behavior  merit  notice. 

1st.  The  human  system  is  a  field  of  reproduction  and  multiplication  of 
yellow-fever  poison.  This  is  sufficiently  established  by  two  facts  : 

(a)  A  person  in  the  incubative  stage  of  yellow-fever  intoxication  may 
be  divested  of  all  fomites  and  yet  originate  other  cases  after  a  developed 
attack. 

(6)  The  infection  is  intensified  by  aggregation  of  the  sick. 

These  propositions  are  indisputably  true. 

2d.  The  poison  or  infection  undergoes  some  change  after  leaving  the 
human  system.  This  appears  to  be  susceptible  of  proof,  because  com- 
munication of  the  disease  from  person  to  person  is  not  a  common  event. 
When  this  does  apparently  occur,  there  is  often  very  strong  reason  for  a 
belief  that  the  contagion  was  resident  in  some  fomites  connected  with  the 
patient's  bed  or  clothing. 

3d.  There  are  no  sustained  observations  which  prove  that  yellow-fever 
poison  is  ever  created  de  novo. 

The  autochthonous  birthplace  of  the  poison  is  unknown.  The  sugges- 
tion of  Niebuhr,  that  yellow  fever  may  have  been  one  of  the  causes  of 
death  during  the  plagues  of  Athens,  can  not  be  authoritatively  denied. 
It  may  have  been  called  into  existence  at  the  moment  when  all  things 
else  were  created  which  were  to  perpetuate  each  its  kind. 

4th.  Some  of  those  conditions  and  circumstances  which  favor  or  retard 
the  development  or  maturation  of  yellow-fever  poison  outside  the  human 
body  are  quite  well  understood.  Warm,  damp  weather  is  most  prominent 
among  those  climatic  conditions  which  are  favorable  to  the  growth  of 
yellow-fever  epidemics. 

5th.  A  freezing  temperature  ordinarily  destroys  the  contagium  of  yellow 
fever.  A  high  degree  of  artificial  heat  produces  a  similar  result.  It  is 
highly  probable  that  certain  chemical  agents  would  also  effect  its  destruc- 
tion if  brought  in  contact  with  it. 

6th.  If  yellow-fever  fomites  are  hermetically  enclosed  in  situations  pro- 
tected from  cold  or  other  agents  which  are  destructive  to  their  infection, 
its  vitality  may  be  preserved  for  an  undetermined  length  of  time,  and  its 
toxic  qualities  again  made  manifest  when  unacclimated  persons  are  ex- 
posed to  it. 

7th.  Yellow-fever  poison  possesses  ponderability.  This  cliaracteristic 
is  so  distinctly  marked  that  it  has  been  frequently  termed  a  "  low-lying 
poison." 

8th.  It  is  incapable  of  being  air-borne  through  any  great  distance,  at 
least  without  being  deprived  of  its  toxic  effects. 

9th.  It  is  transportable  in  fomites  through  great  distances,  either  on 
sea  or  land,  and  as  often  as  its  toxic  effects  are  manifested  after  these 
portations  they  are  so  uniform  as  to  be  promptly  recognizable. 

A  great  number  of  different  materials  in  common  use  may  act  as 
fomites,  such  as  loose  wool,  cotton,  or  hair,  or  textile  fabrics  of  various 
descriptions. 

The  following  facts,  which  illustrate  how  yellow-fever  infection  may 
be  conveyed  in  the  most  unsuspecting  and  innocent  manner,  are  well 

VOL.  I.— 41 


642  YELLOW  FEVER. 

authenticated.  There  can  be  no  ground  for  accusation  of  error  except  in 
the  hypothesis  that  the  infection  was  encountered  simultaneously  in  some 
unexplained  manner.  The  facts  are  furnished  by  Dr.  Shannon  of  Ocean 
Springs,  Mississippi:  "On  the  14th  of  October,  1883,  Maj.  J.  B.  B. 
died  of  yellow  fever  in  Ocean  Springs,  Miss.  I  moved  the  family  at 
once  to  the  healthy  locality  where  you  saw  Miss  B.,  not  allowing  them  to 
take  any  article  from  the  room  where  the  husband  and  father  had  died. 
The  children  applied  to  me  for  a  lock  of  their  father's  hair,  which  I 
refused,  but  the  oldest  daughter,  now  dead,  prevailed  upon  the  nurse 
to  give  it  her.  She  placed  it  in  an  old  envelope  that  had  been  torn 
open  at  the  end  and  carefully  folded  the  torn  end  down,  thus  practi- 
cally sealing  it,  and  laid  it  away  among  other  old  letters.  On  Sunday, 
the  4th  of  November,  at  12.30  P.  M.,  she  brought  this  envelope  out 
upon  the  open  gallery,  and  opened  it  for  the  first  time  to  examine  the  lock 
of  hair  and  show  it  to  her  aunt,  Miss  S.,  who  was  visiting  her,  and  upon 
inhaling  the  concentrated  poison  confined  in  the  envelope  and  emanating 
from  the  hair,  exclaimed,  '  Oh,  what  a  peculiar  smell !'  She  then  handed 
the  envelope  to  her  aunt,  Miss  S.,  who,  unconscious  of  danger,  also  in- 
haled the  '  messenger  of  death '  with  a  similar  exclamation,  when  Mrs.  B., 
who  was  standing  near,  reached  out  her  hand  for  the  envelope,  but  was 
prevented  from  getting  it  by  the  entreaties  of  a  fretful  child  to  be  taken  up 
in  her  arms.  This  gave  time  for  sufficient  reflection,  and  she  admonished 
the  young  ladies  of  the  possible  danger.  The  envelope  was  then  carefully 
folded,  and  with  its  fatal  contents  replaced  in  the  drawer  where  it  had 
been  since  the  14th  of  October.  This  drawer  had  been  almost  daily 
opened.  On  the  following  Saturday  night,  Nov.  10th,  at  9  P.  M.,  Miss  S. 
was  taken  sick  with  a  chill,  and  Miss  B.  at  about  2  A.  M.,  some  five  hours 
later,  the  period  of  incubation  being  less  than  seven  days  in  both  cases. 
No  other  person  handled  the  fatal  envelope  or  in  any  way  came  in  con- 
tact with  it,  and  there  is,  after  the  most  careful  inquiry,  no  suspicion  of 
any  other  source  of  infection  in  these  two  cases.  Miss  S.  died  on  Oct. 
14th,  Miss  B.  on  Oct.  16th."/ 

10th.  These  qualities  of  yellow-fever  infection,  and  especially  its  faculty 
of  reproduction  (which  only  organisms  possess),  furnish  almost  conclusive 
evidence  that  yellow  fever  is  a  germ  disease  produced  by  a  specific  con- 
tagium  vivum. 

Many  facts  are  patent  which  sustain  the  generally  accepted  opinion  that 
yellow-fever  poison  gains  admission  to  the  system  through  the  medium 
of  atmospheric  air.  •  On  the  other  hand,  I  know  of  no  observations  which 
prove  that  the  disease  is  ever  communicated  by  food  or  drinks,  or  through 
any  other  vehicle  than  atmospheric  air. 

In  respect  to  atmospheric  infection  by  yellow  fever,  localizations  of 
aerial  impregnation  are  often  observable,  not  common  in  other  air-infect- 
ing diseases.  A  certain  district  of  a  large  and  populous  city  may  become 
the  seat  of  a  sweeping  and  fatal  epidemic,  and  yet  no  case  occur  outside 
of  this  area  of  prevalence.  It  is  customary  to  speak  of  these  points  of 
epidemic  prevalence  as  infected  localities.  If  unprotected  persons  visit 
such  infected  places,  even  for  a  short  period  of  time,  they  are  liable  to 
attacks  of  yellow  fever,  although  they  may  take  neither  food  nor  drink 
within  the  limits  of  infection  and  bring  no  fomites  away  with  them. 
Under  these  circumstances  atmospheric  impregnation  is  conclusive. 


ETIOLOGY  AND  SYMPTOMATOLOGY.  643 

Bat  it  is  difficult  to  determine  how  this  infection  of  a  locality  has  been 
produced  in  the  first  place,  and  how,  in  the  second  place,  it  is  maintained 
sometimes  for  periods  of  from  one  to  three  months,  with  so  little  apparent 
diminution  or  change  in  the  liability  to  communicate  yellow  fever  to  un- 
protected visitors  within  the  limits  of  infection. 

It  seems  highly  probable  that  yellow-fever  poison,  after  its  exit  from 
the  human  body,  attaches  itself  to  various  solid  surfaces  in  proximity  to 
the  sick,  where,  under  suitable  climatic  conditions,  it  undergoes  more  or 
less  speedy  processes  of  maturation  in  toxic  qualities.  The  poison  thus 
matured  is  capable  of  being  preserved  with  but  little  change  for  the 
periods  indicated  above,  and  is  communicable  through  the  atmosphere  for 
short  distances.  It  is  also  capable,  by  virtue  of  some  unexplained  pro- 
cess or  quality,  of  spontaneously  extending  its  area  of  infection.  But 
this  is  at  all  times  slow,  and  is  readily  interrupted  by  streams  of  water, 
high  walls,  or  even  by  much-travelled  thoroughfares. 

There  are  no  instances  in  which  the  water-supply  of  cities  has  been 
shown  to  have  distributed  yellow  fever. 

The  periods  of  time  which  may  intervene  between  exposure  to  yellow- 
fever  poison  and  attacks  of  the  disease  are  extremely  variable.  The  short- 
est period  of  incubation  which  has  come  under  my  observation  was  about 
twenty  hours.  In  three  cases  in  which  I  was  able  to  fix  the  hours  of 
first  exposure  with  precision  attacks  followed  in  72  hours,  83  hours,  and 
101  hours,  respectively.  Of  55  unacclimated  physicians  who  exposed 
themselves  at  Memphis  during  the  epidemic  of  1878,  54  suffered  attacks 
of  yellow-feyer.  In  these  cases  the  periods  of  incubation  varied  from  one 
to  twenty-five  days,  the  average  duration  being  ten  days.  These  physi- 
cians all  remained  steadfastly  at  their  posts  of  duty ;  consequently,  the 
attack  which  occurred  on  the  twenty-fifth  day  was  postponed  for  that 
length  of  time  during  constant  exposure  in  a  locality  most  intensely  in- 
fected. 

It  must  be  true  that  many  cases  of  individual  resistance  to  the  effects 
of  yellow-fever  infection  depend  upon  states  of  the  system  or  idiosyncra- 
sies which  diminish  liability  to  the  action  of  the  poison.  In  other  words, 
their  personal  receptivity  to  it  is  lessened  by  certain  constitutional  states. 

That  this  position  is  correctly  taken  is  proved  by  the  fact  that  many 
circumstances  which  violently  disturb  the  system  determine  attacks  in 
persons  who  may  have  for  a  long  time  enjoyed  immunity  from  them. 
Anxiety,  grief,  fright,  fatigue,  or  exposure  to  sudden  wettings  or  cold 
may  precipitate  attacks,  either  by  disturbing  vital  processes  by  which  the 
system  is  ridding  itself  of  the  poison — so  far,  at  least,  as  to  prevent  an 
accumulation  great  enough  to  occasion  attacks — or  by  lowering  powers  of 
resistance  through  enfeeblement  of  nerve-force. 

But  it  can  be  affirmed  in  regard  to  yellow-fever  poison  that  it  is  not 
more  capricious  or  eccentric  in  its  behavior  as  an  infection  than  that  of 
scarlet  fever.  Each  of  these  diseases  may  appear  in  a  large  family  of  un- 
protected persons  with  a  degree  of  violence  which  results  in  death  in  every 
instance,  and  suddenly  cease,  leaving  a  greater  or  less  number  of  the 
household  without  attacks,  though  equally  exposed  with  those  who  have 
died. 

One  attack  of  yellow  fever  confers  immunity  from  the  disease  during 
after  life.  A  person  who  has  suffered  an  attack  is  said  to  be  acclimated 


644  YELLOW  FEVER. 

or  protected.  Neither  of  these  terms  should  be  applied  to  those  who 
have  not  suffered  attacks,  however  long  they  may  have  withstood  ex- 
posure during  epidemics.  It  often  occurs  that  persons  who  have  escaped 
attacks  through  many  years  of  renewed  exposure  at  last  succumb  to  the 
disease.  On  the  other  hand,  I  know  of  three  well-authenticated  instances 
of  immunity  in  a  sweeping  epidemic  of  persons  whose  mothers  had  suf- 
fered attacks  during  the  gestations  which  respectively  resulted  in  their 
births. 

While  negroes  are  susceptible  to  yellow-fever  infection,  attacks  are  far 
less  fatal  than  among  whites. 

SYMPTOMS  IN  MILD  OK  SIMPLE  CASES. — Yellow  fever  is  usually 
sudden  in  its  onset.  Persons  are  liable  to  be  seized  while  pursuing  their 
ordinary  avocations,  or,  as  often  occurs,  the  attack  may  begin  during  the 
night.  The  initial  symptoms  are  chilliness  or  cold  sensations,  seldom 
amounting  to  a  decided  rigor.  Reaction  is  usually  prompt  and  decided, 
the  temperature  reaching  within  a  few  hours  102°  to  105°  F.  Yellow 
fever  is  not  a  disease  in  which  it  is  very  common  to  observe  excessive 
body  heat. 

As  the  fever  is  established,  the  countenance  becomes  flushed  and  the 
eyes  injected  and  glistening.  Frontal  headache  and  lumbar  pain  are 
experienced  very  early  in  the  attack,  and  are  liable  to  become  more  intense 
during  the  progress  of  the  fever.  Muscular  neuralgias,  especially  in  the 
lower  extremities,  are  not  uncommon. 

During  the  early  period  of  the  attack  the  tongue  is  indifferent 
as  a  symptom.  It  is  generally  moist  and  free  from  any  coating.  In 
cases  attended  by  much  furring  of  the  tongue  careful  investigation  is 
pretty  sure  to  disclose  the  fact  that  it  has  been  brought  about  by  some 
pre-existing  state  of  disease. 

The  bowels  are  generally  inactive,  though  naturally  impressible  to 
cathartic  drugs.  The  stomach  is  querulous  from  the  inception  of  the 
attack  to  its  conclusion.  Vomiting  may  not  occur  spontaneously, 
but  it  is  easily  provoked  by  repletion  of  the  stomach  with  any  descrip- 
tion of  ingesta  or  by  harsh  or  disgusting  medicines.  The  acts  of  emesis 
are  sudden  and  short  in  duration.  Bile  is  a  very  uncommon  constituent 
of  the  matters  ejected.  Whether  vomiting  has  occurred  or  not,  patients 
nearly  always  express  repugnance  to  the  weight  of  the  physician's  hand 
over  the  epigastrium.  In  the  very  mildest  cases  is  seems  to  excite  gastric 
distress  and  a  tendency  to  emesis.  The  stomach  and  bowels  are  liable  to 
distension  by  flatus,  sometimes  to  the  extent  of  producing  colicky  pains. 
Gaseous  eructations  are  common. 

During  and  shortly  succeeding  the  cold  stage  the  urine  may  be  some- 
what increased  in  amount,  but  after  the  fever  is  established  both  the 
quantity  and  the  specific  gravity  are  notably  lessened.  Albumen  seldom 
appears  in  the  urine  during  the  first  twenty-four  hours  of  an  attack.  In 
very  mild  cases  it  is  altogether  absent  throughout. 

Delirium  is  not  unusual  during  the  fever.  Among  children  attacks 
are  often  ushered  in  by  convulsions.  In  such  cases  delirium  may  be 
persistent  and  alarming  in  violence. 

The  pulse  in  the  early  stage  of  yellow  fever  is  slower  in  proportion  to  the 
temperature  than  in  most  other  acute  diseases.  This  is  more  especially  true 
in  respect  to  mild  cases.  Another  characteristic  feature  of  the  pulse  in 


SYMPTOMS  IN  MILD   OR  SIMPLE  CASES.  645 

yellow  fever  is  that  it  declines  in  frequency  before  the  fever  has  reached 
its  maximum.  In  the  mildest  forms  of  the  disease  the  temperature  will 
attain  its  highest  record  within  twelve  hours.  It  then  rapidly  defervesces, 
never  to  return  again.  But  in  some  cases  of  a  moderately  mild  form  the 
body  heat  does  not  reach  its  acme  of  intensity  until  the  second  day,  occa- 
sionally not  until  the  third  or  fourth  day.  In  these  cases  also  the  pulse 
is  apt  to  decline  in  frequency  before  the  fever  has  culminated.  There  are 
therefore  no  fixed  laws  which  govern  the  duration  of  the  hot  stage  of 
yellow  fever.  Those  which  relate  to  the  pulse  are  more  uniform. 

The  following  clinical  reports  of  two  cases  support  this  statement.  The 
detailed  account  of  the  symptoms  establishing  their  diagnosis  as  mild 
cases  of  yellow  fever  is  omitted. 

Susie  W ,  white,  aged  seventeen  years,  was  admitted  to  Charity 

Hospital  on  August  28,  1878.  First  observation,  nine  hours  after  the 
beginning  of  the  attack,  pulse  100,  temperature  104.6°.  Morning 
of  29th,  pulse  94,  temperature  102.8°;  evening,  pulse  80,  temperature 
101.5°.  Sanguineous  discharge  from  vagina  began  on  29th;  patient  sup- 
posed it  to  be  her  proper  period.  Aug.  30th,  pulse  80,  temperature 
99.2°;  convalescent  and  dismissed  from  further  observations.  In  this 
case  the  urine  presented  a  trace  of  albumen  early  on  the  second  day,  but 
as  the  menses  appeared  shortly  after  the  urine  was  obtained,  the  presence 
of  albumen  may  be  in  that  manner  accounted  for. 

Bessie   L ,  white,  age   twenty-seven   years,  admitted   to  Charity 

Hospital  on  August  28,  1878.  First  observation,  twelve  hours  after 
beginning  of  attack,  pulse  100,  temperature  100.6°.  29th,  pulse  76, 
temperature  102.3°.  30th,  pulse  64,  temperature  101.5°.  Sanguineous 
discharge  from  vagina  began  on  30th  and  continued  until  Sept.  4th ;  this 
was  two  weeks  before  the  patient's  regular  period.  The  urine  showed 
traces  of  albumen  at  date  of  admission.  Discharged,  cured,  Aug.  31st. 
It  may  also  be  stated  of  the  pulse  of  yellow  fever  that  it  is  easily  com- 
pressible and  often  gaseous  in  character. 

Perspiration  is  probably  an  incident  in  the  natural  clinical  history  of  a 
case  of  yellow  fever.  It  occurs  spontaneously  if  the.  patient's  surface  is 
protected  from  those  influences  which  conflict  with  its  appearance.  It  is 
not  critical  in  any  sense  of  the  word,  and  may  coexist  with  high  tempera- 
ture. 

Yellow  fever  is  considered  to  have  two  clinical  stages.  The  first  is  the 
paroxysm.  This  is  made  to  include  the  cold  stage  and  succeeding  fever. 
The  cold  stage  is  often  almost  or  quite  inappreciable,  and  when  this  is  not 
the  fact  it  is  in  simple  cases  a  very  unimportant  event.  It  is  therefore 
quite  convenient  to  include  it  with  the  fever  under  the  term  paroxysm. 
The  paroxysm  of  a  simple  case  is  terminated  by  a  subsidence  of  the  fever 
to  nearly  or  quite  a  normal  temperature.  Sometimes  the  temperature 
falls  below  the  normal  standard. 

The  neuralgias  and  subjective  sufferings  are  greatly  mitigated  or  cease 
altogether.  Thirst  and  restlessness  are  relieved,  and  the  patient  sees 
before  him  a  delicious,  but  too  often  treacherous,  mirage  of  restoration  to 
perfect  health.  This  is  termed  the  stage  of  calm,  perhaps  because  it  often 
precedes  a  tempest  of  fatal  symptoms. 

In  mild  cases  convalescence  begins  at  the  termination  of  the  paroxysm, 
and  may  proceed  without  interruption  until  complete  re-establishment  of 


646 


YELLOW  FEVER. 


health  has  been  accomplished.  But  in  the  very  mildest  cases  the  process 
of  recovery  is  easily  interrupted. 

In  these  simple  forms  the  tendency  to  hemorrhage  first  manifests  itself 
in  the  calm  stage.  The  gums  become  red,  tumid,  and  spongy,  the  tongue 
pointed  and  red  at  the  tip.  Epistaxis  is  liable  to  occur.  The  eyes  and 
skin  may  be  slightly  yellow,  and  the  urine  may  show  traces  of  albu- 
men. However  mild  the  other  symptoms  may  appear,  the  tendency  to 
hemorrhage,  to  albuminous  urine,  and  to  jaundice  in  the  calm  stage 
bears  a  direct  relation  in  frequency  of  occurrence  and  in  degree  to  the 
blood-stasis,  or  sluggish  capillary  circulation,  of  the  first  stage. 

The  foregoing  is  a  recital  of  the  clinical  phenomena  of  typical  and 
simple  forms  of  yellow  fever.  The  departures  from  type  have  been 
divided  by  different  writers  into  a  variety  of  forms.  The  most  important 
of  these  will  be  referred  to  in  connection  with  suggestions  as  to  treatment. 

PROGNOSIS. — Prognosis  is  variable  in  different  epidemics,  this  observ- 
ation being  understood  to  apply  to  the  same  localities.  Some  of  those 
circumstances  which  affect  epidemic  force,  so  as  to  increase  the  mortality- 
rate,  are  appreciable.  If  an  epidemic  invades  a  population  after  an 
interval  of  exemption  sufficiently  long  to  allow  a  large  number  of  unpro- 
tected persons  to  have  accumulated  in  its  midst,  the  crowding  of  the  sick 
will  increase  the  death-rate.  We  may  naturally  assume  that  this  is 
attributable,  first,  to  sheer  multiplication  of  the  infection ;  second,  to 
lack  of  proper  attention  to  the  sick,  and  to  fright,  grief,  exhaustion,  etc. 

Tabulated  Abstract  of  Practice  in  Yellow-Fever  Epidemic  of  1878,  New 
Orleans  Charity  Hospital. 


AGES. 

July. 

August. 

September. 

October. 

Total. 

Per  cent. 

White. 

1 

i 

I 

i 

1 

d 

fc 

I 
1 

•6 

3 
£ 

i 

•3 
3 

i 

T3 

• 

I 

O 
K 

| 
1 

73 

! 

d 
iz; 

•3 

3 

d 

K 

Under  5  

7 
2 
26 
246 
75 
7 

3 
1 

7 
141 
45 
6 

3 

1 
25 
175 
83 
5 

1 

1 

6 
91 
45 
1 

7 
61 

18 

1 

24 
10 
1 

10 
3 
66 
500 
185 
15 

4 
2 
16 
265 
106 
10 

40.0 
66.66 
24.2 
53.0 
57.3 
60.66 

5  to  10  

10  to  20  

8 
18 
9 
2 

3 
9 
6 
2 

20  to  40  

4u  to  60  

60  to  80  

Total  

37 

20 

363 

203 

292 

145 

87 

35 

779 

403 

51.7 

Black. 

10  to  20  

2 
11 

2 

3 

1 

5 
8 
1 

1 
1 

1 
5 
3 

1 
1 

8 
24 
6 

5 
3 

20.8 
50.0 

20  to  40  

40  to  60  

Total  

15 

4 

14 

2 

9 

2 

38 

8 

21.0 

•Grand  t 

otal  

817 

411 

50.3 

PROGNOSIS. 


647 


Prognosis  is  especially  bad  in  hospital  practice.  The  foregoing  statis- 
tics of  cases  admitted  to  the  Charity  Hospital  of  New  Orleans  during 
the  greater  part  of  the  epidemic  of  1878  illustrate  the  usual  results  of 
hospital  practice. 

Many  of  these  patients  were  conveyed  to  the  hospital  in  extreme  con- 
ditions ;  occasionally  they  were  moribund  on  admission.  It  is  hazardous 
to  the  life  of  a  yellow-fever  patient  to  transfer  him  over  the  rough  streets 
of  a  city,  often  for  two  or  three  miles,  unless  this  is  done  in  the  very 
earliest  hours  of  the  attack. 

Prognosis  is  seriously  influenced  by  the  condition  of  the  patient  at  the 
moment  of  attack.  If  pregnancy  exists  or  delivery  has  just  occurred,  it 
is,  under  most  circumstances,  extremely  unfavorable.  Fatigue,  anxiety, 
despair,  or  grief,  all  render  prognosis  more  gloomy. 

The  march  of  temperature  is  also  important  in  determining  fatal 
results. 

The  following  statistics  show  the  influence  of  temperature  in  relation 
to  mortality  from  yellow  fever  : 


First 
day. 

Died. 

Second 
day. 

Died. 

Third 
day. 

Died. 

Fourth 
day. 

Died. 

Fifth 
day. 

Died. 

106° 

3 

2 

1 

1 

2 

2 

105° 

9 

3 

5 

4 

2 

5 

2 

2 

2 

2 

104° 

18 

10 

23 

13 

8 

3 

2 

2 

3 

2 

103° 

14 

4 

11 

8 

2 

2 

3 

1 

2 

It  will  be  seen  from  this  table  that  the  danger  line  of  temperature  in 
yellow  fever  descends  as  the  case  progresses. 

It  may  again  be  stated  that  yellow  fever,  like  scarlet  fever,  exhibits 
such  striking  contrasts  in  its  mortality-rate  that  it  is  hardly  possible  to 
assert  any  average  standard.  It  is  true  that  in  this  disease,  as  in  all 
others,  statistical  accumulations  tend  to  correct  their  own  errors  in  exact 
proportion  to  the  magnitude  of  the  collections. 

In  1878  some  36,000  cases  occurred  in  Louisiana,  of  which  number 
not  less  than  6000  were  fatal,  a  percentage  of  16.66.  The  results  of  pri- 
vate practice  in  New  Orleans  are  exhibited  in  the  following  statistics : 
Four  of  the  principal  practitioners  in  the  city  treated  in  private  practice 
975  patients — 909  white  and  66  colored.  Of  the  former,  92,  or  10.11 
per  cent.,  died ;  of  the  colored  only  2  died.  The  cases  and  deaths  among 
the  whites,  classified  by  age,  were  as  follows : 


AGE. 

Cases. 

Deaths. 

Per  Cent. 

206 
233 
183 
232 

47 
4 

26 
20 
9 
39 
6 
2 

12.67 
8.61 
4.9 
16.7 
12.7 
50 

lOto  20       "            u          

20  to  40       "            "  

40  tr»  fiO        "               u 

fiO  to  Kft         "               " 

The  physicians  above  quoted  lived  in  diiferent  parts  of  the  city.     All  of 
them  extended  their  visits  and  professional  services  to  the  sick  to  the 


648  YELLOW  FEVER. 

very  limits  of  physical  endurance,  and  consequently  included  in  the 
above  lists  some  patients  who  were  not  able  to  procure  the  comforts  and 
attention  necessary  to  the  sick.  Some  cases  also  were  included  to  which 
the  physician  was  only  brought  that  he  might  sign  the  death-certificate 
and  so  avoid  the  coroner's  inquest.  After  making  allowance  for  increase 
of  mortality  on  these  scores,  I  think  it  safe  to  assert  that  the  best  results 
obtained  in  private  practice  varied  from  7  to  10  per  cent,  of  mortality- 
rate. 

DIAGNOSIS. — While  there  is  no  one  symptom  pathognomonic  of  yellow 
fever  in  every  stage  of  the  disease,  its  differential  diagnosis  is  nearly 
always  possible.  The  morbid  action  of  its  special  poison  produces  phe- 
nomena sufficiently  characteristic  to  prove  its  presence.  The  sudden 
attack,  the  slight  cold  stage,  the  frontal  and  lumbar  pain,  and  the  capil- 
lary congestion  are  important  diagnostic  symptoms. 

Even  in  mild  attacks  this  capillary  blood-stasis  is  usually  sufficient  to 
alter  the  patient's  countenance  to  such  a  degree  as  to  attract  attention.  A 
great  many  different  adjectives  are  used  in  description  of  the  countenances 
of  yellow-fever  patients.  While  no  one  among  them  is  constantly 
applicable,  the  presence  of  a  changed  facial  expression  should  enlist  the 
physician's  attention  and  incite  investigation.  If  this  altered  countenance 
be  associated  with  watery  or  glistening  injected  eyes,  the  probability  of 
yellow  fever  is  increased. 

The  slow  pulse  which  coexists  with  elevated  temperature  is  a  point 
of  much  diagnostic  value.  But  it  must  be  remembered  that  this  symptom 
is  not  peculiar  to  yellow  fever.  I  have  noted  this  lack  of  correlation  of 
of  pulse  and  temperature  in  several  cases  of  dengue.  It  is  also  not 
infrequently  found  in  ordinary  cases  of  jaundice.  The  slow  pulse  of 
yellow  fever  must  be  attributable  to  the  special  action  of  the  poison 
upon  the  nervous  system.  The  heart's  action  may  be  slowed  by  influ- 
ences exerted  directly  or  through  the  retrograde  effects  of  the  delay  of 
blood-currents  in  the  capillary  distribution. 

Albuminous  urine  is  a  symptom  of  much  diagnostic  importance. 

A  tendency  to  hemorrhage  may  be  safely  stated  to  exist  in  all  cases  of 
yellow  fever.  In  the  mildest  cases  hemorrhage  may  not  actually  take  place 
unless  the  patients  be  non-gravid  females  within  the  ovulating  limits  of 
life.  These  patients  seldom  pass  through  yellow-fever  attacks  without  san- 
guineous vaginal  discharges.  But  even  in  the  mildest  cases  yellow  fever 
establishes  the  hernorrhagic  diathesis  to  an  extent  sufficient  to  render 
the 'occurrence  of  hemorrhage  an  imminent  event.  This  fact  is  shown 
first,  by  the  congested  and  tumid  gums,  from  which  blood  can  be  readily 
pressed,  and  also  by  the  still  more  important  circumstance  that  medical  or 
hygienic  mismanagement  is  so  quickly  and  certainly  followed  by  black 
vomit  or  by  hemorrhages  from  other  parts  of  the  system.  Capillary  conges- 
tion is  undoubtedly  an  important  factor  in  the  production  of  hemorrhages 
in  yellow  fever,  since  we  cannot  otherwise  account  for  the  liability  to 
hemorrhage  which  is  so  general  in  this  disease. 

The  yellow  color  of  the  skin  and  eyes  during  life,  and  of  the  tissues 
and  serum  of  the  cadaver,  is  probably  due  to  the  coincident  influence  of 
two  causes :  first,  to  the  coloring  matter  of  the  red  corpuscles  diffused  in 
the  serum  of  the  blood ;  second,  to  an  accumulation  of  secondary  blood- 
poisons.  The  occurrence  of  the  yellow  color  and  its  intensity  bear  a 


TREATMENT.  649 

direct  relation  to  the  sluggishness  of  capillary  circulation  during  the  par- 
oxysm. It  appears  likely,  therefore,  that  the  yellowness  is  principally 
ascribable  to  coloring  principles  derived  from  dissolution  of  the  blood,  to 
which  capillary  obstruction  would  so  strongly  predispose  this  fluid. 

Schmidt  has  made  a  very  careful  resumS  of  the  pathological  changes 
found  after  death  from  yellow  fever.  The  most  important  and  uniform 
of  these  affected  the  nervous  system,  liver,  and  kidneys.  They  consisted 
for  the  most  part  of  hypersemic  conditions,  not  infrequently  attended  by 
points  of  extravasation  and  of  degenerative  changes.  The  latter  are 
principally  found  in  the  liver,  and  bear  some  relation  to  the  duration  of 
the  case,  and  it  may  be  also  to  the  degree  and  persistence  of  the  pyrexia. 
When  the  liver  is  the  seat  of  fatty  degeneration,  it  is  yellowish  in  color 
in  whole  or  in  parts.  It  is  then  sometimes  spoken  of  as  the  cafe  au 
lait  or  the  box-wood  liver. 

In  cases  which  run  a  very  rapid  course  these  changes  are  not  observed, 
but  only  those  which  indicate  congestion  are  found,  and  often  hemorrhagic 
puncta.  In  these  instances  the  depending  portions  of  the  body  have  dark 
or  livid  ecchymoses. 

TREATMENT. — There  are  two  propositions  to  which  due  attention 
should  be  given  before  formulating  rules  for  the  treatment  of  yellow 
fever.  The  first  of  these  is,  that  yellow  fever  is  strictly  a  self-limited 
disease,  and  therefore  is  insusceptible  of  jugulation.  Both  clauses  of  this 
proposition  are  indisputably  true.  Cases  have  been  observed  in  which 
mitigation  of  symptoms  and  abridgment  in  duration  appeared  to  follow 
spontaneous  diarrhoea.  Such  events  must  be  extremely  uncommon,  since 
in  my  large  experience  I  know  of  but  one  such  instance  supported  by 
good  testimony. 

Efforts  to  abort  the  disease  by  purgatives,  bleedings,  cold  baths,  qui- 
nia,  etc.  have  all  signally  failed.  Among  the  possibilities  of  the  future 
is  the  discovery  that  some  drug  or  combination  of  drugs  is  capable  of 
meeting  yellow-fever  poison  in  the  field  of  the  circulation  and  antago- 
nizing it  sufficiently  to  rescue  the  victim  from  its  fatal  toxic  effects. 

The  second  proposition  is,  that  the  formative  stages  of  the  disease — 
that  is,  the  early  hours  of  the  paroxysm — afford  the  most  precious  moments 
for  instituting  such  medication  as  may  be  considered  proper.  This  prop- 
osition applies  no  doubt  to  a  number  of  other  acute  affections,  but  in  no 
one  among  them  all  is  it  so  important  to  be  regarded  as  in  yellow  fever. 
The  primary  effects  of  the  poison  are  so  boldly  outlined  that  it  appears 
highly  probable  that  the  damage  it  exerts  upon  the  economy  is  chiefly 
inflicted  during  the  paroxysm.  This  affords  an  additional  reason  why 
efforts  at  medication  should  be  principally  restricted  to  the  paroxysm  and 
to  the  earliest  periods  of  that  stage. 

It  is  probable  that  during  an  attack  of  yellow  fever  the  patient's  hold 
upon  life  is  more  or  less  secure  in  direct  ratio  to  the  number  of  functions 
which  retain  their  physiological  integrity  fairly  well.  The  suggestion  of 
such  a  fact  should  exclude  all  scholastic  or  routine  rules  of  treatment. 

In  simple  forms  of  yellow  fever  the  first  desideratum  of  the  practi- 
tioner is  to  become  acquainted  with  the  patient's  condition  at  the  moment 
of  attack.  If  this  has  occurred  after  eating  indigestible  food  or  after  a 
hearty  meal  of  any  description,  the  stomach  should  be  emptied.  Ipecac- 
uanha may  be  given  in  warm  water  or  chamomile  infusion  until  this  result 


650  YELLOW  FEVER. 

has  been  accomplished.  After  emesis,  provided  this  should  have  been 
considered  necessary  or  as  a  first  step  of  treatment  under  other  circum- 
stances, a  purgative  is  usually  given.  The  benefits  of  purgation  are,  in 
my  opinion,  limited  to  the  act  of  ridding  the  bowels  of  any  fecal  accumu- 
lations present.  For  this  purpose  those  purgatives  which  combine  a  due 
degree  of  efficiency  with  inoifensiveness  in  operation  have  appeared  to  me 
to  be  the  best.  Castor  oil  is  at  the  head  of  this  class.  An  ounce  may  be 
given  to  an  adult  in  some  acceptable  vehicle.  This  may  be  followed  by 
an  enema  of  tepid  water  when  required.  Salines  are  more  agreeable  to 
the  palate,  but  far  too  unmanageable  in  their  cathartic  effects  to  be 
adopted  generally. 

Some  very  good  practitioners  believe  that  a  mercurial  purge  at  the 
onset  of  the  attack  impresses  the  subsequent  career  of  the  case  in 
some  favorable  manner.  I  do  not  share  in  this  opinion,  but  I  do  select 
calomel  as  the  preliminary  purgative  in  cases  where  much  gastric  irrita- 
bility attends  the  early  periods  of  the  attack.  I  exhibit  it  also  in  those 
cases  in  which  previous  indisposition  had  occasioned  coating  of  the 
tongue,  or  in  which  other  conditions  of  systemic  derangement  existed  for 
which  calomel  is  usually  prescribed. 

In  many  cases  it  is  desirable  to  avoid  the  disgust  at  taking  a  purgative 
or  the  perturbation  it  may  occasion  by  its  action.  Enemas  of  tepid 
infusion  of  linseed  or  of  milk  and  water  may  be  substituted,  with  the 
addition  of  castor  oil  when  necessary. 

In  the  early  hours  of  the  attack  warm  pediluvia  are  always  grateful 
and  proper.  They  are  to  be  given  by  placing  a  basin  of  warm  water 
near  the  foot  of  the  bed,  beneath  the  covering  of  a  light  blanket  or  sheet, 
and  allowing  the  patient's  feet  to  remain  immersed  for  ten  or  fifteen 
minutes.  If  the  feet  are  cold,  mustard  should  be  added.  During  the 
foot-bath  the  patient  usually  falls  into  a  perspiration  which  is  sometimes 
profuse  and  general. 

Perspiration  is  a  desirable  event  during  the  paroxysm,  although  it  is 
not,  like  the  sweatings  of  the  malarial  fevers,  critical,  in  the  sense 
of  being  accompanied  by  a  marked  decline  in  temperature.  The  idea 
that  sweating  is  beneficial  is  so  strongly  and  generally  prevalent  as 
to  give  countenance  to  the  erroneous  practice  of  resting  the  cure  of  the 
disease  upon  its  production  and  maintenance.  I  have  seen  valuable  lives 
sacrificed  by  obstinate  persistence  in  measures  to  promote  diaphoresis, 
more  especially  in  the  later  hours  of  the  paroxysm  or  in  the  succeeding  or 
calm  stage.  It  is  quite  sufficient  to  encourage  the  perspiration  by  the 
pediluvia  and  by  a  moderate  allowance  of  cool,  palatable  drinks.  Much 
value  is  attached  by  non-professional  persons  to  a  warm  infusion  of 
orange-leaves  or  some  other  warm  and  grateful  beverage.  When  agree- 
able to  patients  I  permit  them  in  moderate  amounts,  but  do  not  regard 
them  as  especially  valuable. 

Jaborandi  has  been  used  in  yellow  fever.  Strong  hopes  were  quite 
naturally  based  upon  the  action  of  this  drug  in  exciting  excretory  func- 
tions, especially  diaphoresis,  but  the  observations  of  my  friend  Dr. 
Thomas  Layton  and  of  others  show  that  it  possesses  no  special  value, 
while  it  frequently  increases  the  vomiting  and  has  to  be  discontinued. 

After  the  bowels  have  been  relieved  of  fecal  accumulations  it  is  good 
practice  to  exhibit  a  scruple  of  quinia  in  solution  with  ten  to  thirty 


TREATMENT.  651 

drops  of  tincture  of  opium,  by  rectal  injection.  Infusion  of  linseed  or 
mucilage  of  elm-bark  or  gum-arabic  are  the  best  vehicles. 

The  combined  action  of  the  quinia  and  opium  mitigates  the  patient's 
headache  and  lumbar  pains.  But  the  influence  of  these  drugs  is  not  lim- 
ited to  their  effect  on  the  nerves  of  sensation.  In  quite  a  proportion  of 
cases  reaction  is  not  so  prompt  or  complete  as  usual ;  or  reaction  may  be 
quite  pronounced,  and  still  the  surface  may  alternate  between  a  dry  and  a 
perspiring  state.  These  oscillations  of  function  of  the  organic  nerves  are 
also  often  corrected  by  this  prescription.  In  the  great  majority  of  simple 
cases  no  other  medication  than  this  is  requisite  or  proper,  for  no  medica- 
tion is  proper  in  yellow  fever  unless  it  is  requisite. 

When  the  neuralgias  are  excessively  violent,  opium  may  be  again 
administered,  preferably  by  enema,  and  in  combination  with  bromide  of 
potassium  or  chloral  hydrate.  But  the  eifects  of  opium  in  limiting  excre- 
tory function  must  always  be  borne  in  mind  and  carefully  avoided. 

External  applications  are  very  efficacious  in  relieving  the  neuralgias. 
In  the  southern  part  of  this  country  the  "  eau  sedative"  of  Raspail  is 
greatly  used.  This  is  a  mixture  of  ammonia,  camphor,  and  common  salt  in 
solution,  and  may  be  prepared  extemporaneously.  The  applications  may 
be  made  hot  or  cold,  but  if  used  cold  they  must  be  continuously  kept  up. 
It  is  therefore  better  to  use  them  warm  if  sufficiently  effective.  Stimu- 
lating embrocations  of  turpentine  or  mustard,  or  dry  or  wet  cups,  are 
sometimes  resorted  to  for  relief  of  pain. 

Excessive  temperature  demands  attention  and  antagonistic  treatment  in 
direct  measure  with  its  persistence,  its  degree,  and  its  occurrence  in 
advanced  periods  of  an  attack. 

In  the  epidemic  of  1867,  I  used  gelsemium  as  an  antipyretic  in  fifty 
cases  or  more,  but  the  results  were  so  unsatisfactory  that  I  have  quite 
abandoned  its  exhibition.  I  have  given  quinia  as  an  antipyretic,  but 
never  in  doses  of  more  than  a  scruple.  In  these  doses  it  has  failed  to 
accomplish  the  desired  result  in  the  great  majority  of  the  cases.  Perhaps 
its  antipyretic  effects  are  limited  to  those  cases  in  which  malaria  is  a 
known  or  an  unknown  complication. 

I  have  exhibited  small  doses  of  digitalis  with  apparent  benefit,  but 
aconite  and  veratrum  viride  I  have  long  since  discarded.  The  physician 
cannot  afford  to  sacrifice  gastric  quietude  and  competency  of  function  to 
the  use  of  remedies  whose  value  as  antipyretics  is,  to  say  the  most,  quite 
doubtful. 

Cold  has  for  a  long  period  of  time  been  brought  into  use  as  an  anti- 
pyretic in  yellow  fever.  Its  positive  value  and  instantaneous  action 
should  be  constantly  borne  in  mind,  and  in  the  hyperpyrexia  of  yellow- 
fever  it  constitutes  by  far  the  most  reliable  remedy,  though  its  mode  of 
application  must  be  carefully  adapted  to  the  degree  of  fever  present  and 
to  the  susceptibilities  of  the  patient.  Cold  drinks  in  limited  quantities, 
but  frequently  repeated ;  cold  spongings  of  the  surface,  or  the  use  of  the 
cold  pack,  especially  in  very  high  degrees  of  body  heat;  large  injections 
of  cold  water  per  rectum,  which  may  be  passed  off  and  repeated  once  in 
two  to  four  hours, — form  safe  and  effective  modes  of  treatment. 

Hemorrhages  are  a  constant  source  of  anxiety  in  yellow  fever.  It  is 
very  true  that  persons  do  not  often  die  from  actual  loss  of  blood.  I  do 
not  know  that  I  have  ever  witnessed  such  an  event  except  when  the 


652  YELLOW  FEVER. 

blood  was  poured  out  from  a  recently-emptied  uterus.  But  the  chances 
of  recovery  are  lessened,  because  the  hemorrhagic  state  indicates  a  degree 
of  spoliation  of  both  the  fluids  and  solids  of  the  system  incompatible 
with  maintenance  of  life.  When  this  condition  of  constitution  is  once 
established,  the  stomach  rarely  escapes,  and  in  a  majority  of  instances  it 
is  the  first,  and  sometimes  the  only,  bleeding  surface.  The  treatment 
should  be  directed,  first,  to  the  great  indication  of  correcting  the  hem- 
orrhagic diathesis;  secondly,  to  quiet  gastric  irritability,  in  order  that 
vomiting  shall  not  cause  rupture  of  capillaries.  To  meet  the  first  indi- 
cation I  regard  nutrition  and  stimulants  as  the  most  important  measures 
of  treatment.  The  mode  of  administration  will  be  specially  referred  to 
under  the  head  of  alimentation. 

Haemostatic  remedies,  given  as  specific  treatment,  generally  fail  in 
accomplishing  the  purpose  for  which  they  are  administered.  It  has 
always  appeared  to  me  that  those  therapeutic  agents  which  are  capable 
of  controlling  hemorrhage  where  yellow  fever  is  not  present  are  com- 
pletely neutralized  by  the  effects  of  its  toxic  agent  upon  the  vaso-motor 
nerves.  Consequently,  while  ergot,  turpentine,  gallic  acid,  and  other 
like  remedies  may  be  resorted  to,  too  much  hope  should  not  be  enter- 
tained as  to  their  good  effects. 

Some  excellent  practitioners  rely  greatly  on  preparations  of  iron.  The 
tincture  of  the  chloride  is  undoubtedly  the  best.  This  may  be  given  in  water 
or  upon  shaved  ice  in  doses  of  five  or  ten  drops  every  half  hour.  To 
allay  the  gastric  irritability  pellets  of  ice  should  be  swallowed.  Effer- 
vescing drinks  may  be  given  with  benefit. 

T  have  often  used  with  good  results  the  following  prescription  : 
Tfy.  Sodii  Bicarb.  gr.  xx; 

MorphiaB  Sulph.  gr.  ss. 

Aquse  Lauro-Cerasi, 
Aquse  Menth.  Pip.     da  f^iv.     M. 
S.  Teaspoonful  after  every  act  of  emesis. 

Occasionally  I  have  given  the  following  prescription  : 

ty.  Creasoti  gtt.  viij  ; 

Tinct.  Opii  Deodorat.  gtt.  xl. 

Aquae  Menth.  Pip., 

Muc.  Acacife  da.  f siv. 

S.  Teaspoonful  after  every  act  of  emesis  in  iced  Seltzer  or  Apolh'uaris 
water,  or  in  champagne. 

Sometimes  a  few  drops  of  chloroform  in  a  spoonful  of  iced  mucilage  of 
acacia  act  favorably. 

In  cases  which  appear  utterly  hopeless  the  physician,  acting  desper- 
ately, is  sometimes  able  to  save  life  by  treatment  which  could  scarcely 
be  safely  recommended.  I  once  administered  a  fourth  of  a  grain  of 
morphia  to  a  child  of  seven  years,  who,  after  a  sleep  of  ten  hours,  ceased 
to  throw  up  black  vomit  and  recovered. 

External  applications  to  the  epigastrium  usually  afford  some  relief 
to  nausea  at  any  stage  of  yellow  fever.  Mustard  or  aromatic  cata- 
plasms may  at  all  times  be  used  with  hopes  of  favorable  effects.  Towels 
wrung  from  cold  water  are  very  efficacious.  Sometimes  a  drachm  01  two 
of  chloroform  dashed  over  them  increases  their  anti-emetic  action. 

Suppression    of   urine    is    generally   a    symptom    of    fatal    import. 


TREATMENT.  653 

Attempts  may  be  made  to  establish  the  secretion  by  dry  or  wet 
cups  in  the  lumbar  region,  by  warm  applications  around  the  loins,  or 
by  mustard  cataplasms  or  blisters.  If  the  condition  of  the  patient's 
stomach  is  such  as  to  permit  this  practice,  copious  diluent  drinks  and 
diuretics  should  be  given.  Lemonade  holding  bitartrate  of  potassium  in 
solution  is  generally  the  most  acceptable,  and  probably  the  most  efficient. 
Some  physicians  think  they  oftener  obtain  good  results  from  small  and 
frequently  repeated  doses  of  turpentine.  I  can  bear  testimony  to  the 
good  results  which  sometimes  follow  large  rectal  injections  of  warm  or 
cold  water,  the  latter  being  preferable  when  there  is  high  fever. 

In  certain  cases  of  yellow  fever  reaction  from  the  cold  stage  is  feeble 
and  imperfect,  or  perhaps  may  not  occur  at  all.  This  departure  from 
type  is  very  fatal.  The  patients  are  stupid,  sometimes  semi-comatose  and 
incoherent,  from  the  earliest  hours  of  the  attack.  The  face  is  listless, 
drunken,  or  idiotic  in  expression.  The  color  of  the  skin  is  dark  olive 
and  almost  livid.  The  print  of  a  hand  on  the  chest  is  very  slowly  eifaced. 
Sometimes  the  surface  is  covered  with  a  peculiarly  unctuous  perspiration. 
The  pulse  is  feeble  and  compressible  ;  the  temperature  seldom  more  than 
one  or  two  degrees  above  the  normal  standard.  Albuminous  urine  is 
found  during  the  first  day.  Death,  attended  by  convulsive  rigors,  gen- 
erally closes  the  scene  within  seventy-two  hours  from  the  moment  of 
seizure. 

Hot  mustard-baths  should  be  resorted  to.  Blood  may  be  drawn  by 
cups  or  leeches  from  the  back  of  the  neck  or  temples,  and  this  may  be 
followed  by  the  application  of  a  blister.  Morphia  and  atropia  may  be 
exhibited  subcutaneously  in  small  doses,  to  be  repeated  as  often  as  proper. 
Quinia  may  be  administered  per  rectum  or  by  the  hypodermic  method. 
Lastly,  pilocarpine  may  be  thrown  into  the  tissues  in  sufficient  doses  to 
procure  its  vigorous  physiological  action. 

Almost  in  precise  symptomatic  contrast  with  these  cases  of  failure  in 
reaction  is  another  form  of  attack,  in  which  violent  disturbances  of 
nerve-function  occurs ;  such  cases  often  being  characterized  as  congestive 
in  type.  The  most  typical  of  these  attacks  are  among  children  or  ado- 
lescents. If  attended  by  noticeable  chill,  it  is  ordinarily  slight.  Reac- 
tion is  quick  and  excessively  violent.  The  face  is  flushed,  the  eyes 
injected,  and  convulsions  with  delirium  are  liable  to  occur  as  early  symp- 
toms. I  have  watched  with  much  interest  the  alternate  flushings  and 
pallor  of  the  countenance  occurring  in  these  cases,  such  as  are  often 
observed  in  basilar  meningitis. 

The  treatment  in  this  type  of  attacks  should  include  chloroform  by 
inhalation  in  sufficient  amount  to  control  convulsions.  Chloral  hydrate 
may  be  administered  by  enema,  or  morphia  hvpodermically.  Cathartic 
doses  of  calomel  often  exert  a  beneficial  effect.  Leeches  or  cups,  to  }>e 
followed  by  cold  applications  or  by  blisters,  may  be  applied  about  the 
head  or  neck.  But  cupping  and  leeching  should  only  be  resorted  to  in 
the  treatment  of  grave  symptoms,  since  obstinate  hemorrhage  is  liable 
to  occur  from  any  and  every  point  from  which  the  cuticle  has  been 
removed. 

Yellow  fever  is  often  masked  during  the  paroxysm  by  some  pre-exist- 
ing disease.  Malarial  fevers,  the  febrile  states  of  pulmonary  consump- 
tion or  of  the  recently-delivered  female,  may  all  mask  the  early  clinical 


654  YELLOW  FEVER. 

phenomena  to  such  a  degree  that  the  most  experienced  and  vigilant 
practitioners  are  sometimes  astonished  to  find  black  vomit,  suppression 
of  urine,  and  all  those  symptoms  which  mark  the  last  stages  of  the  dis- 
ease, suddenly  developed. 

Walking  cases  should  be  classed  in  the  same  category  as  masked  forms. 
In  these  instances  the  early  symptoms  are  so  slight  as  to  be  overlooked  or 
neglected  by  their  subjects.  They  continue  to  prosecute  their  usual  pur- 
suits until,  by  sheer  exhaustion,  they  are  driven  to  beds  from  which  they 
seldom  arise. 

The  hygienic  and  dietetic  management  of  yellow-fever  patients  is 
extremely  important,  and  the  strictest  attention  must  be  paid  to  the 
condition  and  discipline  of  the  sick  chamber.  In  this  disease  those 
occurrences  and  circumstances  which  in  other  affections  would  be 
reckoned  as  unimportant  and  trivial  become  matters  of  serious  mag- 
nitude. 

The  physician,  by  a  composed  and  cheerful  demeanor,  often  decides 
which  end  of  the  balance  shall  go  down.  But  an  intelligent,  experienced, 
and  faithful  nurse  is  equally  as  important  as  the  excellent  physician. 

The  patient  should  be  confined  in  strictly  recumbent  positions,  and  all 
drinks  and  foods  must  be  given  through  tubes  or  from  pap-cups.  It 
frequently  occurs  that  patients  are  unable  to  void  the  bladder  in  such 
positions.  In  these  cases  the  catheter  should  be  used,  rather  than  suffer 
any  violation  of  the  rule  which  demands  a  maintenance  of  unbroken 
decubitus. 

The  sick  room  should  be  kept  freely  ventilated,  and  the  patient': 
bedding  should  be  changed,  when  requisite,  by  removing  him  to  one 
side  of  the  bed  while  the  other  is  renovated.  If  the  patient's  night- 
shirt becomes  soiled  and  disagreeable,  it  may  be  cut  so  as  to  remove  it, 
and  another,  cut  in  the  same  manner,  may  be  substituted  and  stitched 
together.  The  room  must  be  kept  quiet,  and  useless  visiting  entirely 
forbidden. 

Cool  and  grateful  drinks  may  be  given  in  any  stage  or  state  of  yellow 
fever  if  demanded  by  patients.  The  quantity  allowed  at  one  time  should 
be  small,  since  over-distension  of  the  stomach  almost  certainly  causes  vom- 
iting. Effervescing  drinks  are  nearly  always  grateful,  and  are  better  toler- 
ated than  others.  Seltzer-water  and  lemonade,  or  Seltzer  or  Apollinaris  on 
shaved  ice,  are  to  be  recommended.  Sometimes  patients  call  for  sparkling 
wines  or  beers.  I  never  refuse  them  or  any  other  alcoholic  drink  asked 
for  in  any  stage  of  the  disease.  Wine  surely  possesses  valuable  thera- 
peutic effects  in  yellow  fever. 

Alimentation  must  be  severely  controlled  by  the  physician,  and  the 
tolerance  and  effects  constantly  watched.  Even  to  the  most  experienced 
physician  the  kind  of  food  to  be  selected,  and  the  time  and  manner  of 
administration,  constitute  difficult  problems.  In  simple  forms  of  the 
di.sea.se  food  had  better  be  strictly  withheld  during  the  continuance  of  the 
paroxysm.  Even  after  the  stage  of  calm  has  been  reached,  sufficient  time 
should  be  allowed  to  elapse  to  enable  the  physician  to  form  some  estimate 
of  the  degree  of  damage  his  patient  has  suffered  and  his  competency  to 
retain  foods  and  be  nourished  by  them.  This  question  can  seldom  be 
answered  in  a  decided  manner,  except  through  a  cautious  trial  of  some 
bland  and  inoffensive  food. 


TREATMENT.  655 

On  the  third  or  fourth  day  of  sickness  a  single  tablespoonful  of  iced 
milk  may  be  given,  and  the  immediate  consequences  closely  watched.  If 
no  retching  or  gastric  uneasiness  should  ensue,  it  may  be  repeated  at  the 
end  of  thirty  minutes.  Some  physicians  prefer  to  begin  with  spoonful- 
ful  doses  of  equal  parts  of  sweet  milk  and  thin  barley-water.  In  my 
own  experience  chicken-water  has  proved  to  be  the  most  universally 
acceptable,  as  well  as  the  most  beneficial,  of  all  the  various  forms  of 
nutriment  to  be  chosen  as  a  first  venture.  I  have  frequently  combined 
this  with  barley-water  when  first  given.  In  this  cautious  and  tentative 
manner  even  the  most  experienced  physician  prefers  to  proceed,  rather 
than  to  attempt  to  prescribe  rules  of  diet  in  an  abstract  and  arbitrary 
manner. 

If  these  light  articles  of  diet  are  well  borne,  they  are  to  be  gradually  and 
watchfully  exchanged  for  beef-essences,  the  blood  of  a  rare  beefsteak,  and 
the  more  substantial  broths.  Solid  articles  of  food  should  not  be  allowed 
during  the  first  ten  days  after  an  attack,  and  for  still  longer  periods  patients 
should  be  admonished  against  excesses  in  eating,  and  especially  in  respect 
to  indigestible  articles.  Those  lesions  of  the  blood  and  of  the  stomach, 
and  those  grave  disorders  of  nerve-function  which  occasion  hiematemesis 
in  yellow  fever,  are  slowly  repaired.  Instances  are  reported  in  which 
black  vomit  and  death  have  followed  excessive  eating  and  drinking  ten 
or  twenty  days  after  dismissal  from  treatment. 

There  are,  however,  certain  conditions  which  are  liable  to  complicate 
yellow  fever  which  demand  a  course  of  dietetic  procedure  different  from 
that  which  I  have  recommended.  Thus,  children  cannot  bear  privation 
of  food  until  the  paroxysm  is  over  if  its  duration  is  long.  In  like  man- 
ner, a  more  supporting  course  is  required  in  most  of  those  cases  in  which 
yellow  fever  occurs  as  an  intercurrent  affection,  in  all  those  cases  which 
are  termed  typhoid  or  adyuamic  per  se,  and,  more  emphatically  still,  in 
every  case  in  which  hemorrhages  are  occurring.  A  failing  pulse  should 
in  all  instances  admonish  us  to  resort  to  nourishment  and  stimulants. 

It  is  a  fortunate  circumstance  that  in  yellow  fever  the  lower  bowel  is 

fenerally  in  a  state  favorable  for  the  retention  of  nutritious  enemas, 
n  the  most  trying  and  critical  hours  of  desperate  cases  I  have  seen 
patients  tided  through  by  the  use  of  skilfully  prepared  and  skilfully 
administered  injections  of  some  suitable  meat-essence.  When  insomnia 
exists,  chloral  hydrate  or  bromide  of  potassium  may  be  conveniently 
given  in  these  vehicles. 

It  is  evident  that  the  discussion  of  the  vastly  important  sanitary  ques- 
tions pertaining  to  the  prevention  of  yellow  fever  cannot  be  appropri- 
ately discussed  in  the  present  article. 


DIPHTHERIA. 

BY  A.  JACOBI,  M.  D. 


DEFINITION  ;  SYNONYMS  ;  HISTORY. — Diphtheria  is  a  specific,  infectious, 
and  contagious  disease,  characterized  principally  by  epithelial  changes  in. 
and  the  exudation  of  fibrin  on  and  into  mucous  membranes,  the  surface  of 
wounds,  and  the  rete  Malpighii,  thereby  constituting  the  so-called  pseudo- 
membrane.  Under  the  names  ulcus  syriacum,  ulcus  segyptiacum,  garotillo, 
morbus  suffocans,  morbus  suffocatorius,  affectus  suffocatorius,  pestilentis 
gutturis  affectio,  pedancho  maligna,  angina  maligna,  angina  passio,  mal 
de  gorge  gangr6neux,  ulc&re  gangr6neux,  angina  polyposa,  angine  couen- 
neuse,  cynanche,  croup,  diphtheritis,  and  diphtheria,  the  disease  has  been 
known  and  described  at  different  periods  by  the  writers  of  different 
nations.  The  Hippocratic  writings  and  some  remarks  in  the  Talmud 
allow  of  some  doubt  in  regard  to  their  explanation.  Whether  their 
authors  observed  or  recognized  diphtheria  cannot  be  proven.  There  is 
less  doubt  in  regard  to  Archigenes,  quoted  by  Oribasius.  Areta?us  of 
Cappadocia  is  notably  the  first,  if  we  except  Asclepiades  only,  who  is  said 
to  have  performed  laryngotomy.  The  description  of  the  pharyngeal  and 
laryngeal  manifestations  furnished  by  the  former,  however,  can  leave  no 
doubt  in  our  minds  that  he  knew  diphtheria  and  recognized  it.  Galen, 
in  his  remarks  on  the  Chironian  ulcer,  tells  us  that  the  pseudo-membrane 
was  gotten  rid  of  by  coughing  when  the  respiratory  passages  were  affected 
by  the  disease,  and  by  hawking  when  the  disease  was  in  the  pharynx. 
Caelius  Aurelianus  recognized  diphtheria  of  the  pharynx  and  larynx,  as 
well  as  the  diphtheritic  paralysis  of  the  soft  palate;  it  is  to  him  we  are 
indebted  for  the  information  that  Asclepiades  resorted  to  scarification  of 
the  tonsils,  and  even  to  laryngotomy.  Ae'tius  in  the  fifth  century  distin- 
guished white  and  grayish  patches  and  gangrenous  degeneration,  observed 
paralysis  of  the  soft  palate,  and  advised  against  energetic  local  treatment 
and  the  forcible  removal  of  the  deposits  before  they  were  in  a  condition  to 
fall  off  spontaneously.  The  Arabs  and  Arabists  contain  no  allusions  to 
the  subject,  but  early  chronicles  tell  of  an  epidemic  raging  in  St.  Denis 
in  580,  subsequent  to  a  great  inundation.  There  appear  to  have  been 
memorable  epidemics  in  Rome  in  856  and  1005,  in  Byzantium  in  1004. 
The  former  are  mentioned  by  Baronius,  the  latter  by  Cedrenus.1 

According  to  Morejon,  Gutierrez  wrote  his  Tradado  del  enfermedad  del 
garrotillo  in  the  second  half  of  the  fifteenth  century.  A  malignant  form 
of  angina  raged  in  1517  in  Switzerland,  along  the  Rhine,  and  in  the 
Netherlands;  in  1544  and  1545  in  Northern  Germany  and  on  the  Rhine; 

1Hae»er,  Lehrb.  a.  Oesch.  du  Med.  u.  d.  Epidem.  Krankh.,  3d  ed.,  vol.  Hi.,  p.  434. 
656 


HISTORY.  657 

in  1557  in  France,  Germany,  and  Holland;  to  the  latter  refer  the  reports  of 
Tetrus  Fosterus.  Antonio  Soglia,  quoted  by  Chomel,  describes  an  epi- 
demic in  Naples  and  Sicily  (1563),  which  spread  in  the  following  year  as 
far  as  Constantinople;  Joannes  Wierus,  epidemics  in  Dantzic,  Cologne, 
and  Augsburg  (1565);  Ballonius  (Baillon),  in  Paris  (1576).  At  the  same 
time  this  disease  was  frequent  in  Denmark.  From  Spain  there  are  reports 
on  severe  epidemics  between  the  years  1583  and  1618;  the  year  1613  was 
long  known  as  the  year  of  diphtheria  (anno  de  los  garrotillos). 

Mercado  (1608)  speaks  of  a  child  that  had  communicated  the  disease  to 
his  father  by  biting  his  finger.  Casealez  advised  gargles  containing  alum 
and  sulphate  of  copper.  Herrera  described  diphtheria  of  the  skin  and 
of  wounds,  and  looked  upon  the  pseudo-membrane  as  the  essential  cha- 
racteristic of  the  disease.  Heredia,  in  1690,  recognized  the  suffbcative  and 
astheuic  forms,  as  well  as  the  paralysis  of  the  soft  palate,  the  pharynx, 
and  the  limbs;  he  also  called  attention  to  the  occurrence  of  relapses, 
which  he  attributed  to  the  absorption  of  the  morbid  products,  and  endeav- 
ored to  prevent  by  cauterization. 

Naples  had  diphtheria  1610-45,  in  its  worse  form  1618-20,  together 
with  erysipelas,  and  diphtheritic  affection  amongst  cattle.  About  those 
times  tracheotomy  was  often  performed  by  Severino,  the  same  who  found 
pseudo-membrane  in  the  larynx  at  a  post-mortem  examination  made  in 
1642.  In  1620  the  disease  was  in  Portugal,  Sicily,  and  Malta;  in  1630 
in  Spain,  according  to  Fontechu,  Villa  Real,  and  Herrera.  It  was 
remarked  that  in  some  instances  no  membranes  were  perceived  in  the 
throat,  but  the  cases  were  liable  to  terminate  fatally  with  large  glandular 
swellings  round  the  neck  and  general  symptoms  of  adynamia.  Sicily  was 
again  invaded  in  1632,  Rome  in  1634,  Italy  from  1642  to  1650,  Spain  in 
1666.  The  Italian  reports  emphasize  the  marked  contagiousness  of  the 
disease  and  its  tendency  to  depress  the  vital  powers,  also  the  weakness 
of  the  mental  faculties  left  behind.  In  Germany  the  disease  was  described 
by  Wedel  in  1718.  The  epidemics  observed  by  him  were  not  very  instruc- 
tive, yet  they  sufficed  to  teach  the  importance  of  isolating  the  sick. 

In  the  New  England  States  diphtheria  appeared  in  the  seventeenth 
century.  Samuel  Danforth  lost  the  four  youngest  of  his  twelve  children 
by  the  "malady  of  bladders  in  the  windpipe"  within  a  fortnight  in 
December,  1659,  in  Roxbury,  Mass.  John  Josselyn  mentions  an  epi- 
demic in  New  England,  mainly  in  Maine,  which  lasted  at  least  until  the 
year  1671.  Mr.  Douglass  reports  another,  which  commenced  on  the  20th 
of  March,  1735,  in  Kingston  township,  about  fifty  miles  east  of  Boston, 
and  extended  all  over,  and  also  to  Boston,  where  it  was  mild  at  first.  But 
in  1738  it  was  very  severe,  and  remained  so  for  some  time.  Indeed,  it 
did  not  abate  for  a  long  time,  to  judge  from  a  letter  of  Cadwalader  Golden 
written  in  1753  to  Dr.  Fothergill,  and  the  two  letters  of  Dr.  Jacob  Ogden, 
written  in  1769  and  1774  to  Mr.  Hugh  Gaine  of  New  York;  as  also 
from  John  Archer's  "Inaugural  Dissertation  on  Cynanche  Trachealis, 
commonly  called  Croup  or  Hives,"  published  in  1798.1  In  1809  there 
was  a  severe  epidemic  in  Philadelphia;2  in  1816  in  Crete. 

1  For  extensive  quotations  from  these  and  other  writers  on  diphtheria  at  a  very  inter- 
esting period  of  our  medical  literature,  see  A.  Jacobi,  A    Treatise  on  Diphtheria,  New 
York,  1880. 

2  Caldwell,  in  ed.  of  Cullen's  First  Lines  of  the  Practice  of  Physic,  Philadelphia,  1816, 
1,  p.  260. 

VOL.  I.— 42 


658  DIPHTHERIA. 

The  reports  of  Le  Cat  concerning  epidemics  in  Rouen  in  1736  and 
1737  being  doubtful,  the  first  great  epidemic  must  be  set  down,  in 
France,  for  1745.  It  commenced  in  Paris,  and  invaded  the  provinces 
afterward.  Chomel  gave  an  accurate  description  of  the  diphtheritic 
paralysis  of  the  soft  palate,  and  reports  a  case  of  strabismus.  Epidemics 
are  reported  from  the  Netherlands  in  1745,  1746,  1769,  1770,  1778-86 ; 
from  Spain  in  1764-71;  from  England  in  1744-48  (by  Starr),  from 
Plymouth,  England,  in  1751-53  (Thurham)  and  1776.  Dropsy  and 
glandular  swellings  were  frequent;  emetics  and  pure  air  were  the  sheet- 
anchors  of  treatment.  The  Netherlands,  France,  and  the  West  Indies 
were  invaded  from  1770-80  by  the  disease,  which  was  found  often  com- 
plicated with  scarlatina;  Portugal  in  1786  and  1787;  France  again  in 
1787  and  1788 ;  Northern  Germany  in  1790.  At  that  time,  particularly 
in  France,  the  main  reliance  was  had  on  the  internal  administration  of 
cinchona  and  the  insufflation  into  the  throat  of  alum. 

Epidemics  have  been  described  since  from  different  localities  in  differ- 
ent years :  in  Glasgow,  1812  and  1819 ;  Switzerland,  1823-26 ;  Norway 
and  St.  Helena,  1824;  New  York  and  Kentucky,  1826  and  1828; 
French  provinces,  1834;  Paris,  1841;  several  parts  of  Europe  and 
North  America,  1845-56;  Paris,  1853-55;  England,  1854  and  1859, 
when  95  per  cent,  of  all  the  cases  of  nasal  diphtheria  proved  fatal ; 
Netherlands  and  Sweden,  1855  ;  all  Western  Europe,  1855-65,  up  to  the 
present  time,  and  all  Europe  since;  California,  1856  and  1857  ;  Portugal 
and  France,  1856;  Eastern  Prussia,  1850,  1852,  1856,  1857;  and  all 
the  countries  with  a  cold  or  moderate  climate  to  this  very  day. 

During  the  second  half  of  the  eighteenth  century  but  two  writers  are 
worthy  of  especial  notice — Home,  a  Scotchman,  1765,  and  Samuel  Bard, 
an  American,  1771. 

Home  deserves  credit  for  having  distinctly  drawn  the  line  between  the 
pseudo-membranous  and  the  gangrenous  affections.  He  also  endeavored 
to  prove  that  croup  and  angina  maligna  were  two  distinct  diseases,  not- 
withstanding all  that  had  been  said  since  the  time  of  Aretseus  in  favor  of 
their  identity.  The  false  membrane  of  croup  he  looked  upon  as  an  aggre- 
gation of  mucus.  He  sought  for  it  exclusively  in  the  respiratory  tract, 
and  disregarded  any  connection  between  it  and  the  false  membrane  found 
in  the  pharynx. 

Bard's  experience  was  very  extensive;  he  saw  membranous  pharyngitis, 
laryngitis,  and  pharyngo-laryngitis ;  he  speaks  of  the  membrane  as  met 
upon  the  skin,  of  paralysis  of  the  muscles  of  deglutition  and  of  the 
larynx,  and  likewise  of  paralysis  of  the  lower  extremities,  as  sequelae. 
He  looked  upon  the  morbific  process  as  the  same  whichever  were  the 
mucous  membranes  attacked,  and  made  a  distinction  only  according  to  the 
localization  of  the  disease.  The  influence  which  he  might  have  exercised 
in  shaping  the  professional  opinion  on  the  nature  of  the  disease  did  not 
make  itself  felt,  partly  because  of  his  classical  modesty,  and  partly 
because  of  his  remoteness  from  the  centres  of  European  learning.  Not 
before  1810  was  his  book  translated  into  French  (by  Iluette).  While  his 
style  is  classical  in  its  simplicity,  his  observation  is  astonishingly  correct, 
and  his  conclusions  as  to  the  actual  identity  of  all  the  diphtheritic  pro- 
cesses in  the  most  various  clinical  symptoms  unimpeachable  this  very  day. 
His  description  of  the  various  forms  of  pharyngeal  diphtheria  is  painfully 


HISTORY.  659 

good,  his  observations  on  cutaneous  diphtheria  very  accurate,  his  few  dis- 
sections well  recorded,  particularly  when  he  speaks  of  tracheal  and 
tracheo-laryngeal  diphtheria,  and  his  historical  reviews  very  judicious 
indeed.  "Upon  the  whole,  I  am  led  to  conclude  that  the  morbus 
strangulatorius  of  the  Italians,  the  croup  of  Home,  the  malignant 
ulcerous  sore  throat  of  Huxham  and  Fothergill,  and  the  disease  I  have 
described  and  that  first  described  by  Douglas  of  Boston,  however 
they  may  differ  in  symptoms,  do  all  bear  an  essential  affinity  and  relation 
to  each  other,  or  are  apt  to  run  into  each  other,  and,  in  fact,  arise  from 
the  same  leaven.  The  disease  I  have  described  appeared  evidently  to  be 
of  an  infectious  nature,  and,  being  drawn  in  by  the  breath  of  a  healthy 
child,  irritated  the  glands  of  the  throat  and  windpipe.  The  infection  did 
not  seem  to  depend  so  much  on  any  prevailing  disposition  of  the  air  as 
upon  effluvia  received  from  the  breath  of  infected  persons.  This  will 
account  why  the  disorder  sometimes  went  through  a  whole  family,  and 
yet  did  not  affect  the  next-door  neighbors.  Here  we  learn  a  useful 
lesson — viz.  to  remove  young  children  as  soon  as  any  one  of  them  is 
taken  with  the  disease,  by  which  many  lives  have  been  saved  and  may 
again  be  preserved." 

Jurine,  in  his  prize  essay  of  1807,  denies  the  gangrenous  nature  of 
angina  maligna  and  emphasizes  the  frequent  complication  of  membranous 
croup  with  membranous  pharyngitis.  It  was  reserved  for  Bretonneau  to 
enforce  attention  to  the  ideas  of  Bard  by  asserting  (though  he  did  not 
mention  either  his  monograph  or  its  French  translation  of  1810)  the 
identity  of  angina  maligna,  or  by  whatever  other  title  it  may  be  known, 
with  membranous  laryngitis,  and  by  inaugurating  his  theory  with  a  new 
name  for  the  disease  to  perpetuate  the  views  expressed  therein.  First  and 
foremost,  he  called  attention  to  the  continuity  of  the  membrane  (accord- 
ing to  him,  composed  of  coagulated  mucus  and  fibrin)  of  the  nose,  pha- 
rynx, and  respiratory  tract,  its  identity  with  certain  morbid  conditions  of 
the  skin,  and  promulgated  the  theory  that  "  diphtherite  " — the  name  dates 
from  that  time — is  a  specific  disease,  an  affection  sui  generis,  and  differs 
both  from  a  catarrhal  and  a  scarlatinous  inflammation. 

The  modern  history  of  diphtheria  may  be  dated  from  June  26,  1821, 
when  Bretonneau  read  his  first  essay  on  that  subject  before  the  French 
Academy  of  Medicine,  and  gave  to  the  disease  the  name  it  now  bears. 
His  second  and  third  (Nov.  25th)  papers  belong  to  the  same  year ;  his 
fourth  was  read  in  March,  1826  ;  his  fifth  appeared  in  the  Archives  g&n. 
of  January  and  September,  1855.  It  was  only  in  1826  that  the  material, 
previously  gathered,  was  summed  up  in  his  celebrated  monograph.1 
Before  this  time,  however,  the  separate  essays  had  received  prominence 
from  the  reports  and  commentaries  of  Guersant,  who  laid  particular  stress 
on  the  statement  that  diphtheria  was  a  non-gangrenous  affection,  identical, 
and  even  synchronous,  with  croup  in  the  majority  of  epidemics.  Since 
that  epoch  the  literature  on  the  subject  has  assumed  enormous  propor- 
tions. It  is  a  matter  of  regret  that  the  limited  space  allotted  to  this 
subject  should  exclude  much  historical  detail  of  the  etiology,  pathology, 
and  therapeutics  of  diphtheria.  If  the  history  of  any  disease  is  interest- 
ing,  and  the  neglect  of  its  study  has  ever  punished  itself,  it  is  diphtheria. 

1  P.  Bretonneau,  Des  Inflammations  speciales  du  tissu  muqueux,  et  en  particulier  de  la  Diph- 
thtrite,  etc.,  Paris,  1826. 


DIPHTHERIA. 

Particularly  would  the  treatment  have  been  more  successful  if  the  know- 
ledge of  former  times  had  been  available  and  more  heeded.  As  long 
ago  as  in  the  seventeenth  century  depletion  in  diphtheria  was  con- 
demned, and  in  the  seventeenth  and  eighteenth  centuries  the  local  treat- 
ment with  muriatic  acid  and  the  internal  administration  of  cinchona,  cam- 
phor, and  rolx>rant  diet  were  held  to  be  the  only  admissible  ones,  Bre- 
tonnean  urged  the  same  principles,  and  still  in  our  own  times,  for  want  of 
historical  knowledge,  we  had  to  learn  the  old  lesson  over  again.1 

The  following  is  a  brief  review  of  the  main  points  of  discussion  upon 
subjects  connected  with  the  symptomatology  and  pathology  of  diphtheria 
since  Bretonneau's  first  paper : 

Bourquoise  and  Brunet  express  their  belief  (1823)  in  the  contagious 
character  of  this  disease.  Desruelles  (1824)  sees  a  diagnostic  difference 
between  the  sporadic  and  the  epidemic  forms  in  the  participation  of  the 
brain  in  the  latter.  Louis  referred  a  number  of  cases  of  croup  in  adults 
to  pharyngeal  diphtheria  as  their  source.  Mackenzie  considers  that  croup 
has  its  origin  in  the  fauces,  and  urges  the  employment  of  lunar  caustic. 
Billard  (1826)  denies  the  specific  character  of  diphtheritic  inflammation. 
Hamilton  describes  cases  that  terminated  in  suppuration,  and  which  he 
therefore  distinguishes  from  Bretonneau's  cases.  He  describes  two  modes 
of  termination  of  the  disease— one  in  croup,  the  other  in  a  state  of 
debility  arising  from  the  effect  of  the  absorbed  secretion  on  the  respira- 
tory nerves.  Pretty  looks  upon  those  cases  of  croup  that  have  their 
original  seat  in  the  tonsils  as  contagious.  Bland  (1827)  explains  the  dif- 
ference between  croup  and  diphtheria.  Deslandes  declares  them  to  be 
identical.  Bretonneau  publishes  a  work  in  which  he  compares  diphtheria 
with  scarlatina  anginosa,  and  recommends  the  use  of  alum.  Emmangard 
is  the  first  one  of  the  physiological  school  who,  likening  diphtheria  to 
typhoid  and  claiming  its  origin  in  a  malarial  infection,  calls  it  angina 
gastro-enterica.  Abercrombie  is  in  favor  of  distinguishing  diphtheria 
from  croup,  but  reports  a  number  of  cases  of  diphtheria  of  the  pharynx 
that  terminated  fatally  by  stenosis  of  the  larynx.  Ribes,  who  encoun- 
tered the  disease  in  nine  members  of  a  single  family,  asserts  that  croup 
rarely  occurred  without  a  preceding  diphtheria  in  his  experience;  he 
advises  an  examination  of  the  throats  of  apparently  healthy  individuals. 
Fuchs  relates  the  history  of  epidemics  of  angina  maligna,  and  declares 
croup  to  be  a  genuine  angina  maligna  trachealis,  which  only  does  not  run 
through  all  the  stages.  Broussais  opposes  the  identity  of  croup  and  diph- 
theria (1829),  and  gives  a  report  of  cures  by  means  of  antiphlogistic  regi- 
men and  laryngotomy.  Diphtheria  and  gangrenous  angina  are  synony- 
mous with  him.  Gendron  expresses  a  belief  in  the  identity  of  diphtheria 
and  gangrenous  angina.  Roche  considers  the  membrane  rather  of  henior- 
rhagic  than  of  inflammatory  origin,  and  consisting  of  discolored  fibrin. 
About  the  same  time  Trousseau  is  endeavoring  to  clearly  establish  the 
diagnosis  between  diphtheria  and  scarlatinous  angina.  Shortly  after 
(1830),  he  reports  cases  of  diphtheria  which  originated  in  blistering 
wounds,  and  of  diphtheria  of  the  skin  giving  rise  to  throat  affections,  and 

1  See  history  and  bibliography  of  diphtheria  in  Chatto ;  Sanne,  Trade  de  la  Diphtherie 
Paris,  1874;  Jacobi,  in  Gerhnrcie*  Handb.fi.  Kinderk.,  vol.  ii.,  1877;  Seitz,  Diphtheric 
und  Croup  getch.  u.  Klin,  (largest,  Berlin,  1879  ;  fndex-Calalogue  of  the  Library  of  the  Sur* 
geon-GeneraCa  Office,  U.S.  A.,  vol.  iii.,  Washington,  1882. 


HISTORY.  661 

diphtheria  of  the  throat  followed  by  skin  disease.  T.  F.  Hoffmann  cites 
a  severe  case,  that  ultimately  recovered,  with  consecutive  paralysis  of  cer- 
tain cranial  nerves.  Cheyne  (1833)  makes  a  stand  against  the  "  confound- 
ing of  croup  and  cynanche  maligna  under  the  name  of  diphtheritis." 
Bourgeois  witnessed  an  epidemic  succeeding  mumps. 

Fricout  and  Burley  (1836)  declare  their  belief  in  the  contagiousness  of 
the  disease.  Bouillaud  attacks  the  theory  of  its  specific  character  on  the 
ground  that  abstraction  of  blood  produced  favorable  results.  Stokes 
makes  a  distinction  between  primary  and  secondary  croup  according  to 
the  original  seat  of  the  affection  (1837).  Kessler  advocates  (1841)  the 
view  of  its  contagious  nature,  and  Rilliet  and  Barthez  adduce  evidence 
of  the  occurrence  of  ulceration  and  gangrene  in  the  course  of  the  disease. 
Taupin,  like  Ribes,  enjoins  a  methodical  examination  of  the  throat  of 
every  patient  during  the  prevalence  of  an  epidemic  of  diphtheria,  what- 
soever be  the  disease  from  which  the  child  suffers.  Boudet  (1842)  opposes 
Bretonneau's  hypothesis  that  croup  is  a  descending  diphtheria,  and  holds 
to  the  identity  of  diphtheria  and  gangrenous  angina.  In  this  contest 
Durand  (1843)  also  takes  sides  against  Bretonneau,  and  lays  particular 
stress  on  the  point  that  the  diphtheritic  patient  succumbs  rather  from  the 
severity  of  the  constitutional  symptoms  than  from  suffocation.  Rilliet 
and  Barthez,  on  the  other  hand,  rally  to  the  support  of  the  attacked 
master,  asserting  that  the  usual  form  of  croup  and  that  resulting  from  a 
decending  diphtheritis  are  one  and  the  same,  while  they  claim  that  diph- 
theritis and  gangrenous  angina  are  distinct  affections. 

Meanwhile,  the  strife  regarding  the  nature  of  the  disease  continued. 
Guersant  and  Blache  (1844)  describe  the  stomatite  couenneuse  (nonia, 
stomacace,  according  to  them,  the  rarest  kind  of  gangrenous  angina)  as  a 
form  of  Bretonneau's  diphtheritis,  and  Landsberg  raises  the  question 
whether  a  nerve-inflammation,  present  in  a  certain  case,  was  to  be  looked 
upon  as  an  accidental  or  an  essential  feature  of  the  disease,  and  finally 
comes  to  the  conclusion,  with  Schonlein,  that  it  was  a  neurophlogosis 
dependent  on  the  disease.  Bouisson  (1847)  reports  a  case  of  diphtheritic 
conjunctivitis  resulting  in  loss  of  the  eye.  Robert  publishes  his  observa- 
tions on  diphtheria  of  the  skin  and  of  wounds,  which  he  attributes  to  an 
atmospheric  contamination  in  crowded  wards  of  hospitals,  and  looks  upon 
it,  with  Delpech  and  Eisenmann,  as  a  form  of  hospital  gangrene.  Vir- 
chow,  in  the  same  year,  distinguished  the  catarrhal,  croupous,  and  diph- 
theritic varieties  of  the  disease.  Meanwhile,  reports  of  paralysis  of  the 
soft  palate  after  diphtheria  came  from  Morisseau,  from  Trousseau  and 
Lasegue,  and  lastly  (1854-59)  from  Maingault.  The  subject  of  diph- 
theritic conjunctivitis  was  studied  by  A.  v.  Graefe((1854),  who  encoun- 
tered the  disease  as  a  complication  of  diphtheria  of  the  pharynx,  nose, 
and  skin,  and  hence  considered  it  a  part  of  the  general  disease  rather  than 
an  independent  local  affection.  Diphtheria,  in  its  effects  on  the  system, 
had  at  the  same  time  been  investigated  by  Trousseau,  who  sums  up  with 
the  statement  that  the  principal  source  of  danger  lies  in  the  invasion  of  the 
larynx,  and  that  the  large  majority  of  cases  of  croup  began  as  a  diph- 
theria of  the  pharynx,  but  that,  even  without  the  occurrence  of  a  laryn- 
geal  localization,  many  cases  terminate  fatally  owing  to  adynamia. 

Outside  of  France,  too,  the  subject  had  attracted  attention.  ^  West,  who 
had  never  seen  the  disease  occur  primarily,  describes  diphtheria  as  a  com- 


(562  DIPHTHERIA. 

plication  of  measles.  Bamberger  (1855)  divides  the  inflammations  of 
the  mouth  and  pharynx  into  the  catarrhal  and  croupous  forms,  and  con- 
siders croup  and  diphtheria  to  be  subdivisions  of  the  latter  form,  differ- 
ing only  in  degree.  The  paralysis  of  the  muscles  of  deglutition  is 
discussed  by  Dehsenne  (1857)  who  had  contracted  the  disease,  and  the 
paralysis  of  other  muscles  by  Faure.  A  case  of  diphtheria  of  the 
tonsils,  nipples,  and  vagina  in  a  woman  recently  confined,  followed  by 
infection  of  the  new-born  and  the  death  of  both,  is  reported  by  Ma- 
thieux ;  and  cases  of  diphtheritic  conjunctivitis  by  Grichard,  Warlomout, 
and  Testelin.  The  same  year  Isambert  published  a  work  in  which  he 
divided  the  diphtheritic  affections  into  three  forms — viz.  angine  couen- 
neuse,  scarlatinous  angina,  and  diphtheritic  angina.  The  last-mentioned 
is  further  subdivided  into  a  croupous-diphtheritic  angina,  in  which  croup 
of  the  larynx  plays  an  important  part,  and  into  that  form  in  which  death 
results  from  adynamia ;  in  the  latter  form  there  is  a  marked  swelling  of 
the  lymphatic  glands.  Apparently,  at  this  time  the  epidemic  in  Paris 
underwent  a  considerable  change,  for  the  croupous  form  does  not  occur 
by  far  so  frequently  as  Bretouueau  had  asserted,  and  croup  of  the  larynx 
without  a  preceding  diphtheria  of  the  pharynx  was  observed  more  fre- 
quently than  he  would  lead  us  to  believe. 

The  various  changes  in  the  symptoms  of  the  epidemics  of  diphtheria 
which  were  observed  in  different  places  and  countries,  and  at  different 
times,  explain  many  of  the  differences  of  opinions  in  regard  to  the  nature 
of  the  disease.  The  literature  of  that  subject  is  in  the  last  twenty-five 
years  simply  stupendous,  and  a  few  more  notes  must  suffice  for  the 
elucidation  of  the  drift  of  theories  and  observations.  Beale  was  the  first 
to  look  for  organic  beings  as  the  cause  of  the  disease,  without  finding  any. 
Laycock  sees  it  in  the  bacilli  and  spores  of  oidium  albicans;  Wilks, 
however,  found  the  same  parasite  in  other  affections.  Cammack  declares 
the  diphtheritic  membrane  to  be  herpetic.  Ferou  also  calls  Bretonueau's 
mild  form  of  the  disease  a  herpetic  angina  with  pseudo-membrane ;  so 
does  Gubler.  Bouchut  writes  against  the  identity  of  diphtheria,  croup, 
and  gangrene.  Condie  describes  the  disease  as  occurring  with  scarlatina. 
Litchfield  claims  that  it  is  a  concealed  scarlatina,  and  Hillier  that  it  has 
some  connection  with  it.  Millard  cites  one  case  in  the  course  of  which 
gangrene  occurred,  and  another  in  which  skin,  mouth,  pharynx,  respira- 
tory passages,  oasophagus,  and  vulva  were  affected  at  the  same  time. 
Harley  vainly  endeavored  to  inoculate  the  disease  in  animals.  Stephens 
declares  the  disease  to  be  infectious.  Sanderson  looks  upon  it  as  identical 
with  the  angina  maligna  of  the  aged.  Farr  considered  the  exhalations 
from  sewers  an  important  etiological  factor.  Sellerier,  Kingsford,  and 
Harley  (1859)  report  paralyses  as  sequelae.  Maugin  speaks  of  a  specific 
eruption ;  Ward,  of  an  accompanying  purpura.  Bouchut  and  Empis 
remarked  the  frequent  presence  of  and  danger  from  albuminuria  ;  so  did 
Wade.  Maugiu  calls  attention  to  the  fact  that,  when  present  in  diphtheria, 
it  occurs  early,  whereas  in  scarlatina  it  is  seen  during  the  period  of  des- 
quamation,  and  is  not  of  frequent  occurrence  even  then.  Gull  gives  an 
account  of  cases  in  which  death  resulted  from  asthenia,  and  speaks  of  a 
nerve-lesion  which  he  attributes  to  the  severity  of  the  local  inflammation. 
Hildige  describes  diphtheritic  conjunctivitis  as  seen  in  Graefe's  practice, 
and  looks  upon  it  as  contagious.  Magne  denies  its  contagious  or  infec- 


HISTORY.  663 

lious  character.  Mackenzie,  while  probably  having  seen  false  membrane 
appear  on  the  conjunctiva  when  in  a  state  of  inflammation,  yet  refuses  to 
recognize  diphtheritic  conjunctivitis  as  a  distinct  disease. 

In  the  same  degree  that  observations  of  cases  and  epidemics  increased 
in  number,  the  nature  of  the  disease  and  its  cause  commenced  to  be 
studied.  The  assumption  that  the  latter  was  a  chemical  poison  was  soon 
doubted,  and  the  parasitic  nature  of  diphtheria  considered  by  many  as 
proven. 

After  Henle  had  (1840)  expressed  his  belief  in  the  existence  of  a 
coutagium   animatum,  and   morbid  processes  had  for  some  time  been 
compared    with    the    phenomena    of    fermentation,   Schwann    demon- 
strated the  presence  of  lower  organisms  in  fermentation  and  putrefac- 
tion.    The  discovery  of  the  cause  of  the  silk-worm  disease  by  Bassis, 
of  the  achorion  by  Schonlein,  of  the  acarus  by  Simon,  of  bacteria  in 
malignant  pustule  by  Pollender,  Brauell,  and,  above  all,  by  Davaine, 
in  relapsing  fever  by  Obermeier,  the  teachings  of  Pasteur  concerning 
the  conditions  under  which  putrefaction  occurs, — all  tended  to  explain 
the  various  infectious  and  contagious  diseases  by  analogy  also,  and  to 
stimulate  the  search  for  a  vegetable  organism  in  diphtheria.     Buhl  was 
the  first  to  discover  schizomycetse  in  diphtheritic  membrane,  but  expressed 
no  opinion  as  to  the  part  they  played  in  the  process.     Hiiter  found  them 
in  the  gray  diphtheritic  covering  of  wounds,  in  the  surrounding  appar- 
ently healthy  tissues,  and  in  the  blood.     Hiiter  and  Tomasi  found  them 
in  the  diphtheritic  membranes  of  the  pharynx  and  larynx,  inoculated 
them  on  the  mucous  membranes  of  animals,  and  described  them  as  small, 
round  or  oval,  dark-colored,  active  little  bodies.     The  latter  observers 
look  upon  these  organisms  as  a  part  of  the  infectious  element.     Oertel 
found  them  in  diphtheritic  membrane  and  in  inflamed  mucous  membranes 
in  the  lymphatic  vessels,  lymphatic  glands,  kidneys,  and  other  organs ; 
he  considers  them  as  the  contagious  element  of  diphtheria.     Nassiloff, 
too,  after  inoculations  in  the  cornea  resulted  in  an  enormous  multiplica- 
tion of  the  microscopic  organisms  and  their  appearance  with  pus-cells  in 
the  lacteals  and  in  the  lymphatics  of  the  palate,  and  even  in  the  bones  and 
cartilages,  asserts  that  the  development  of  organisms  is  the  primary  step 
in  the  diphtheritic  process.     Eberth  made  successful  inoculations  in  living 
tissues ;   the  micro-organisms,  introduced   into  the  cornea,  proliferated 
actively  and  caused  an  inflammation  of  irritative  character  in  the  sur- 
rounding tissue.     He  asserts,  with  the  positiveness  of  an  evangelist,  that 
diphtheria  cannot  occur  without  bacteria.     Klebs  inoculated  the  micro- 
cocci  in  pigeons  and  dogs,  and  found  them  in  the  blood  of  the  animals 
after  death.     Orth  found  them  in  the  pleura,  lungs,  kidneys,  and  urinary 
bladder.     But  what  their  action  is,  whether  they  are  directly  pernicious, 
or  deprive  the  body  of  certain  elements  (as  of  oxygen  in  malignant  pus- 
tule, according  to  Bollinger),  or    injure  mechanically  by  acting  on  the 
coats  of  the  blood-vessels  (either  directly  or  by  means  of  altering  the 
blood),  thus  depriving  whole  territories  of  their  blood-vessels,  is  a  ques- 
tion upon  which  the  principal  advocates  of  the  parasitic  theory  have  not 
yet  agreed.     Even  Oertel  acknowledges  the  impossibility  of  explaining 
the  manner  in  which  bacteria  act  (Ziemsseu,  Handbuch,  ii.,  1,  p.  581,  2d 
ed.).     This  much  is  positive,  at  any  rate :  that  no  one  has  yet  proven  that 
the  vegetable  organisms  alone,  and  not  other,  free  or  fixed,  parts  of  the 


664  DIPHTHERIA. 

diphtheritic  membrane,  are  the  vehicles  of  the  infecting  elements  (Steu- 
dener) ;  and  even  now  the  question  has  not  been  decided  whether  the  bac- 
teria met  with  in  diphtheria  constitute  the  cause  of  the  disease,  or  are  a 
part  of  the  process,  or  co-effects  of  the  poisonous  action — whether  they 
are  the  carriers  of  the  poison  or  entirely  indifferent  entities. 

The  most  important  observations  made  by  those  who  deny  a  direct  etio- 
logical  connection  between  micro-organisms  and  septic  diseases  in  general, 
and  diphtheria  in  particular,  are  those  of  Hiller  and  Billroth.  The  latter 
has  proven  the  morphological  identity  of  the  various  kinds  of  bacteria, 
although  it  cannot  be  denied  that  the  apparent  similarity  may  mask  a  yet 
unknown  difference.  Hiller  calls  attention  to  the  fact  that  large  numbers 
of  micrococci  have  been  found  in  the  cadaver  where  death  has  not  been 
the  result  of  septic  disease,  and  also  that  septic  infection  is  not  always 
severest  where  the  bacteria  most  abound,  but  where  an  extensive  chemical 
decomposition  or  a  mass  of  putrefying  tissue  is  found.  This  would  indi- 
cate that  the  septic  process  is  rather  dependent  on  chemical  decomposition 
than  on  the  presence  of  bacteria. 

Panum,  Bergmann,  and  Schmiedeberg  have  isolated  poisons  that  con- 
tained no  bacteria.  Rawitsch  and  many  others  prove  that  septic  infection 
is  not  dependent  on  the  existence  of  bacteria.  Davaine  has  shown  that 
an  infinitely  small  amount  of  a  chemical  poison,  free  from  bacteria,  can 
kill  quickly. 

The  presence  of  cocco-bacteria  (Billroth)  in  the  blood  during  life  has 
not  once  been  proven,  not  even  in  pysemia  or  septicaemia.  Yet  their  being 
swept  into  the  lungs  with  the  atmospheric  air  is  indisputable.  It  would 
therefore  seem  as  though  living  blood  had  a  greater  tendency  to  destroy 
bacteria  than  to  allow  itself  to  be  decomposed  by  them.  Not  only,  how- 
ever, would  it  seem  so,  but  P.  Grawitz  (Virch.  Arch.,  vol.  Ixx.,  p.  546) 
proves  that  sporules  do  not  grow  in  the  (tissue  and)  blood,  but  that  they 
are  in  part  dissolved,  in  part  eliminated  through  the  kidneys,  and  that 
this  result  is  accomplished  through  the  combination  of  the  following  four 
factors — viz.  the  elasticity  of  the  blood,  its  constant  motion,  the  absence 
of  oxygen  in  sufficient  quantity  in  the  circulating  blood,  and  the  presence 
of  living  animal  cells.  All  of  these  factors  appear  to  be  of  great  import- 
ance. Thus  it  is  that,  where  the  constant  motion  of  the  blood  and  th<. 
animal  living  cells  are  not  present  (as  in  the  anterior  chamber  of  the  eye 
or  in  the  humor  vitreous)  a  rapid  proliferation  and  accumulation  of  bac- 
teria can  take  place.  They  are  also  known  to  increase  rapidly  and  emi- 
grate into  the  liver  when  deposited  in  the  abdominal  cavity. 

The  destruction  of  bacteria  in  the  circulating  blood,  into  which  they 
may  have  penetrated,  accounts  for  some  microscopical  facts  in  connection 
with  (actually  or  apparently  morbid)  blood.  Their  remnants  are  probably 
the  pale  and  dark  particles  which  are  discovered  in  the  blood  alongside 
the  red  and  white  blood-corpuscles.  They  could  not  be  identified  as 
micrococci,  while  in  the  tissue  they  are  more  recognizable.  In  autopsies 
they  have  been  found  in  the  urinary  tubules,  pressing  forward  and  pier- 
cing the  walls,  not  occupying  a  nidus  of  inflammation,  however,  and  prob- 
ably are  even  here  a  post-mortem  phenomenon.  A  direct  necrosis  or 
inflammation  by  the  inoculation  of  diphtheritic  elements  can  only  be  pro- 
duced in  the  cornea,  as  was  shown  by  Reckliughausen,  and  particularly 
Eberth.  Besides,  there  is  nothing  characteristic  in.  the  cocco-bacteria  of 


HISTORY.  665 

diphtheria,  with  the  exception,  perhaps,  of  their  browner  color,  to  justify 
their  being  looked  upon  as  a  distinct  variety,  certainly  not  as  another  spe- 
cies. It  is^  more  likely  that  a  difference  of  action  is  not  so  much  to  be 
sought  for  in  a  different  parasite  as  in  the  peculiarity  of  the  corneal  tissue. 
When  fluid  containing  cocco-bacteria  was  injected  into  ,the  eye  of  a  rabbit, 
in  twenty-four  hours  the  eye  was  destroyed.  If  injected  into  the  eye  of 
a  dog  or  guinea-pig,  only  a  slight  inflammation  resulted  (Billroth  and 
Ehrlich).  If  these  experiments  were  continued  on  a  larger  scale,  we 
might  eventually,  by  analogy,  infer,  and  even  prove,  that  the  immunity 
against  certain  diseases  enjoyed  by  some  animals  is  owing  to  peculiarities 
in  the  very  structure  of  their  own  tissues.  In  a  similar  manner  I  shall 
prove  hereafter  that  even  peculiarities  and  variations  in  the  tissue  and 
epithelium  of  the  human  body  give  rise  to  different  shades  and  variable 
clinical  symptoms  in  the  diphtheritic  processes. 

The  views  of  Curtis,  Satterthwaite,  and  Charlton  Bastian  fully  agree 
with  those  of  the  above  observers.  The  latter  is  rather  inclined  to  look 
upon  bacteria  as  an  effect  of  the  disease  than  as  a  cause.  Similar  views 
were  expressed  by  Burdon  Sanderson. 

Nor  are  the  researches  of  Weissgerber  and  Terls,  Lukomsky,  Weigert, 
Liicke,  any  more  conclusive;  and,  finally,  Fiirbringer,  in  his  most  recent 
and  careful  studies  of  diphtheritic  nephritis,  insists  upon  this,  that  it  is 
not  caused  by  immigration  of  fungi  into  the  kidneys,  that  the  very  best 
methods  employed  for  the  finding  of  parasites  result  in  the  absence  of 
micrococci  from  the  inflamed  organ,  and  that  the  renal  inflammation  fol- 
lowing diphtheria  is  the  result  of  a  chemical  process. 

H.  C.  Wood  and  Henry  F.  Formad,  in  Supplement  7  of  the  National 
Board  of  Health  Bulletin  (1880),  declare  it  altogether  improbable  that 
bacteria  have  any  direct  function  in  diphtheria — i.  e.  that  they  enter  the 
system  as  bacteria  and  develop  as  such  in  the  system,  and  cause  the 
symptoms.  It  is,  however,  possible  that  they  may  act  upon  the  exuda- 
tions of  the  trachea  as  the  yeast-plant  acts  upon  sugar,  and  cause  the 
production  of  a  septic  poison  which  differs  from  that  of  ordinary  putre- 
faction, and  bears  such  relations  to  the  system  as  to,  when  absorbed, 
cause  the  systemic  symptoms  of  diphtheria.  Now,  these  bacteria  may 
be  always  in  the  air,  but  not  in  sufficient  quantities  to  cause  tracheitis, 
but  enough  when  lodged  in  the  membrane  to  set  up  the  peculiar  fermen- 
tation ;  whilst  during  an  epidemic  they  may  be  sufficiently  numerous  to 
incite  an  inflammation  in  a  previously  healthy  throat. 

The  same  authors  publish  a  number  of  other  experiments  and  conclu- 
sions in  Suppl.  17  (Jan.,  1882):  "There  is  no  proof  as  yet  that  the 
micrococci  are  the  cause  of  the  disease.  Their  presence  in  the  exposed 
dead  tissue  is  no  evidence,  for  the  membrane  represents  but  the  necrotic 

mucous  lining Indeed,  when  the  healthy  mucous  membrane  of 

the  mouth  or  trachea  is  destroyed  by  caustics — for  instance,  ammonia — 
the  eschar  into  which  it  is  converted — really  a  pseudo-membrane — con- 
tains the  same  micrococci  as  are  found  in  true  diphtheria,  as  Wood  and 
Formad  have  learned.  Moreover,  in  the  scrapings  of  the  healthy  tongue 
the  same  micrococci  can  be  seen.  Of  more  significance  is  the  detection 
of  the  same  or  similar  micrococci  in  the  blood  of  the  living  patients 
during  severe  attacks.  But  since  these  parasites  were  found  only  in  the 
more  severe  cases,  and  not  in  all  instances  of  the  disease,  were  seen  also 


666  DIPHTHERIA. 

in  the  blood  of  other  septic  disorders,  and  since  no  cultures  have  been 
made  with  the  fresh  blood,  there  is  not  yet  enough  evidence  for  any 
decision.  In  the  internal  organs  bacteria  are  not  found  with  any  regu- 
larity in  diphtheria."1 

O.  Heubner,  while  studying  both  the  local  affection  and  the  general 
infection  of  diphtheria,  availed  himself  of  the  methods  of  Cohnheim 
and  Litten,  who  produced  diphtheritic  deposits  by  cutting  off  the  circu- 
lation of  the  blood.  He  ligated  the  neck  of  the  bladder  in  rabbits  for 
two  hours.  On  the  first  day  he  noticed  a  hemorrhagic  cedema  of  the 
mucous  membrane,  with  loosened  and  tumefied  epithelium  ;  on  the  second 
a  firm  and  coagulated  exudation  took  the  place  of  the  normal  tissue ;  on 
the  third  there  were  genuine  diphtheritic  spots  in  the  mucous  membrane. 
The  newly-formed  pseudo-membrane  exhibited  all  the  morphological 
elements  of  human  diphtheria  (genuine  or  scarlatinous)  and  epidemic 
dysentery.2  Thus  Heubner's  results  agree  with  the  definition  of  diph- 
theria as  the  compound  of  severe  inflammation  and  necrosis.  The  inoc- 
ulation of  his  diphtheritic  artefacts  he  found  sterile.  Animals,  however, 
which  were  inoculated  with  diphtheritic  masses  taken  from  the  diseased 
human  patient  fell  sick  with  tumor  of  the  spleen,  hemorrhages,  and 
general  sepsis,  besides  a  local  diphtheritic  affection.  Scarlatinal  diph- 
theria used  for  the  same  purpose  had  the  same  effect.  Bacilli  were 
developed,  but  they  were  not  found  in  the  blood-vessels  (differing  in  that 
respect  from  the  bacilli  of  anthrax),  in  spite  of  continued  examination. 
Thus,  Heubner  refuses  to  accept  the  bacilli  as  the  diphtheritic  poison ; 
they  are,  in  his  opinion,  the  result  of  the  morbid  process,  and  not  its 
cause.  Thus,  though  he  believes  the  diphtheria  poison  to  be  organic,  he 
concludes  that  its  nature  is  not  yet  explained  ;  contrary  to  the  assertions 
of  many  prolific  prophets  of  the  bacteria  literature,  who  now  and  then 
claim  for  this  year's  microscopic  revelations  the  same  infallibility  which 
was  claimed  for  last  year's  opposite  views.2 

E.  Bindfleisch 4  expresses  himself  as  follows :  "  The  microphytes  of 
diphtheria,  septicaemia,  and  pyaemia  have  not  been  isolated  and  cultivated 
as  yet.  But  experimenters  are  convinced  that  there  are  a  great  many 
species  of  microphytes  underlying  genuine  putrefaction.  In  producing 
septicaemic  conditions  in  animals  their  efficacy  differs.  Not  every  animal 
is  influenced  by  the  same  microphyte.  Thus  it  becomes  probable  that  the 
human  organism  is  endangered  by  a  certain  number  of  the  putrefaction 
microphytes.  Some  one  may  have  a  particular  predilection  for  granu- 
lating wounds  and  mucous  membranes,  and  thereby  produce  a  diphtheritic 
inflammation.  Another  may  enter  the  blood  from  a  recent  wound  and 
give  rise  to  a  septicsemic  fever  with  rapidly  fatal  termination.  The  third 
may  invade  the  body  by  means  of  a  phlegmonous  inflammation,  purulent 
infiltration,  thrombosis,  embolism,  and  metastatic  abscesses,  accompanied 
with  a  pyaemic  fever  of  a  remittent  type." 

After  all,  it  does  not  appear  to  me  that  the  bacteria  question  has  come 

1  H.  Gradle,  Bacteria  and  the  Germ  Theory  of  Disease,  Chicago,  1883,  p.  186. 

2  Die  Experimentellf  Diphtheric,  Leipzig,  1883. 

s  L.  Letzerich  recognized  in  former  years  the  specific  parasites  of  diphtheria,  whoop- 
ing cough,  and  typhoid  fever  as  if  they  were  labelled.     Then,  again  (Arch.  f.  Experim. 
Pathol.  u.  Pharmtir.oL),   he  admitted  the  great  difficulty  in  discriminating  the  specific 
Bchizomycetee  of  diphtheria,  croupous  pneumonia,  epidemic  influenza,  and  typhoid  fever. 
Die  Elemente  der  Pathologic,  Leipzig,  1883,  p.  301. 


SYMPTOMS.  667 

any  nearer  its  solution  in  the  last  few  years,  in  spite  of  the  most  eager 
researches  and  the  fact  that  some  of  the  best  medical  names  in  the  world 
of  medicine  take  the  parasitic  nature  of  diphtheria  for  granted.  For 
instance,  in  the  second  Congress  for  Internal  Medicine  (Wiesbaden,  1883) 
C.  Gerhardt  rises  in  its  favor.  He  makes  the  statement,  or  rather 
admits,  that  several  parasites  have  been  found  by  different  men,  that 
every  one  considers  his  the  genuine  one,  that  several  writers  assume  that 
there ^  are  several  diphtheria  parasites,  and  suggests  that,  in  his  opinion, 
the  disease  may  be  produced  by  different  varieties  of  bacteria.  At  the 
same  time,  he  contends  that  the  essence  of  the  disease  consists  in  the 
erosion  (and  change)  of  the  epithelium  and  the  emigration  of  leucocytes. 
If  that  be  the  case,  I  understand  less  than  ever  why  diphtheria  is,  or  is 
to  be  called,  a  parasitic  disease. 

Panum's  words  seem  still  to  be  the  soundest  expression  of  all  our 
knowledge  on  the  subject  when  he  says :  "  It  is  a  matter  of  rejoicing  that 
physicians  have  come  to  the  conclusion  that  certain  microscopic  organ- 
isms, be  they  considered  vegetable  or  animal,  and  designated  as  bacteria, 
fungi,  monads,  micrococci,  or  vibriones,  do  not  exist  merely  in  the  minds 
of  theorists  as  causes  of  disease,  but  are  in  reality  enemies  that  must  be 
combated  with  all  the  known  efficient  weapons  in  our  possession.  But, 
while  thus  rejoicing,  it  must  be  borne  in  mind  that  we  have  but  a  feeble 
insight  into  the  relation  between  these  organisms  and  diseases,  and  in 
order  to  effect  that  much-desired  advance  in  scientific  knowledge — a 
matter  of  considerable  importance  in  the  practice  of  medicine — it  is 
necessary  not  only  to  grasp  at  isolated  data,  but  carefully  and  deliberately 
to  observe  and  study  all  the  facts  before  us,  and  even  to  devote  some 
attention  to  those  which  would  tend  to  prove  that  there  are  bacteria  and 
fungi  which,  under  certain  circumstances,  are  perfectly  harmless,  and  that 
even  some  of  the  malignant  ones  among  them  do  not  commit  all  those 
outrages  with  which  they  are  charged,  directly  and  personally." 

SYMPTOMS. — In  the  majority  of  cases  the  disease  has  a  prodromal 
stage,  which  usually  lasts  a  day  or  two,  and  may  run  a  similar  course  to 
that  of  a  catarrhal  pharyngitis.  The  patient  feels  somewhat  indisposed, 
has  slight  fever,  is  dejected,  complains  of  painful  deglutition,  more 
marked  when  swallowing  fluids  than  solids  or  semi-solids,  has  headache 
and  occasionally  vomiting.  The  occurrence  of  the  latter,  however,  is 
very  much  less  frequent  than  in  the  outbreak  of  scarlatina.  In  very 
severe  cases  convulsions  have  been  observed,  chills  very  rarely ;  eleva- 
tions of  temperature  of  from  102.5°  to  104°  F.  are  frequent;  higher 
ones,  from  105°  to  107°,  rare.  At  this  time  it  is  often  difficult  or 
impossible  to  distinguish  a  catarrhal  angina  from  a  diphtheritic  by  the 
subjective  symptoms.  Slight  glandular  swellings  under  the  jaw  may 
occur  in  either.  The  characteristic  objective  symptom  of  the  latter 
disease  is  the  presence  of  membrane  on  the  reddened  mucous  membrane 
of  the  fauces,  which,  usually,  is  markedly  injected  over  all  or  part  of  the 
surface.  The  arches  of  the  palate  and  the  tonsils,  less  frequently  the 
posterior  wall  of  the  pharynx,  are  so  affected.  A  distinctly  localized  red- 
ness cannot  be  but  either  traumatic  or  diphtheritic.  Larger  or  smaller 
deposits  are  found  thereon,  lying  loose  on  the  surface  or  deeply  imbedded 
according  to  the  locality.  At  times  the  first  examination  reveals  their 
presence  in  large  numbers ;  at  other  times  but  a  single  one  can  be 


668  DIPHTHERIA. 

detected,  which  is  soon  followed  by  others,  however.  Within  a  certain 
period  of  time,  as  a  rule  twenty  to  twenty-four  hours,  the  single  deposits 
coalesce  and  form  a  membrane  of  greater  or  less  extent.  Mostly  in  the 
same  proportion  to  its  increase  in  size  it  increases  in  thickness.  On  the 
uvula,  soft  palate,  and  the  posterior  wall  of  the  pharynx  the  membrane 
is  located  superficially,  and  at  times  can  be  easily  removed ;  on  the  tonsils 
it  has  a  firmer  hold,  and  is  usually  amalgamated  with  their  uppermost 
tissues.  On  the  other  hand,  there  are  cases  in  which  no  actual  mem- 
branous formation  is  observed ;  in  such  cases  the  tissues  are  more  or  less 
swollen,  the  surrounding  portions  more  or  less  reddened,  and  the  grayish- 
white  discoloration  is  the  resuH  of  an  infiltration  of  the  tissues  them- 
selves, and  cannot  be  removed. 

There  are  still  other  cases  in  which  deposits  of  membrane  and  tissue 
infiltration  are  found  at  the  same  time,  and  where  both  history  and  evi- 
dence indicate  that  these  two  phenomena  are  the  result  of  one  and  the 
same  process.  When  the  uvula  takes  part  in  the  process  the  swelling  is, 
as  a  rule,  more  marked  than  when  the  remaining  parts  of  the  fauces  only 
are  implicated.  Its  circumference  is  very  considerable,  and  amounts 
sometimes  to  the  treble  or  quadruple  of  the  normal,  in  consequence  of 
the  cedematous  condition  of  the  entire  tissue. 

We  have  to  deal,  then,  with  three  different  manifestations  of  the 
diphtheritic  process :  first,  with  a  membrane  lying  on  the  mucous  mem- 
brane, and  removable  without  causing  much  injury  to  the  epithelium  or 
any  to  the  basement  membrane ;  such  membranes  were  given  by  some  the 
name  of  croupous  deposits  ;  secondly,  with  a  membrane  implicating  the 
epithelium  and  upper  layers  of  the  mucous  membrane ;  to  this  the  title 
of  diphtheritic  membrane  has  been  given  by  preference ;  thirdly,  with  a 
whitish  or  grayish  infiltration  of  the  surface  and  the  deeper  tissue,  which, 
if  abundant,  may  give  rise  to  a  necrotic  destruction  of  the  tissue. 

The  severity  of  the  disease  does  not  always  depend  on  the  predomi- 
nance of  one  of  these  three  forms,  for  any  of  them  may  accompany  a  mild 
or  a  severe  attack.  By  a  severe  attack  we  understand  one  attended  with 
chills,  temperatures  as  high  as  105°  and  107°  F.,  and  marked  nervous 
symptoms,  such  as  vomiting  and  convulsions.  It  is  characteristic  of 
such  cases  that  when  the  membrane  is  accidentally  or  forcibly  removed  it 
is  speedily  reproduced  ;  the  lymphatic  system,  in  addition,  takes  an  active 
part  in  the  process.  The  neighboring  glands  become  swollen ;  the  peri- 
glandular  tissue  does  likewise,  so  that  the  circumference  of  the  neck 
becomes  enormous,  and  the  space  between  the  lower  jaw  and  the  clavicle 
appears  one  immense  tumefaction.  These  are  the  cases  in  which,  as  a 
rule,  loss  of  strength  and  general  debility  speedily  ensue,  and  death  occurs 
from  exhaustion.  The  membrane  in  cases  of  this  description  frequently 
undergoes  changes  in  appearance ;  under  the  influence  of  the  atmosphere 
and  of  ^  foreign  substances,  and  by  admixture  of  blood,  its  color  becomes 
yellowish  or  brownish.  The  odor  of  the  membrane  and  surrounding 
parts  becomes  sweetish  and  musty,  and  occasionally  so  fetid  that  it  con- 
taminates the  atmosphere  of  the  "room,  and  the  air  in  its  transit  through 
the  nose  and^over  the  pharynx  becomes  by  inhalation  dangerous  to  the 
patient. ^  His  throat  becomes  more  swollen,  his  respiration  loud;  he 
keeps  his  mouth  open  constantly,  has  an  indifferent  expression  ;  the  saliva 
dribbles  continually,  the  color  of  the  skin  is  sallow  and  livid,  the  appe- 


SYMPTOMS.  669 

tite  very  poor,  and  pulse  both  frequent  and  small.  When  the  symptoms 
are  of  long  duration,  and  a  deep  infiltration  of  the  affected  parts  occurs, 
hemorrhages  not  infrequently  make  their  appearance.  These  may  be 
slight  although  frequent ;  occasionally,  however,  larger  blood-vessels  are 
encroached  upon  in  the  process  of  destruction,  and  dangerous,  nay  even 
fatal,  hemorrhages  may  be  the  result.  The  septic  forms  which  I  have 
here  described  are  more  dangerous  than  the  mild  ones  previously  men- 
tioned. Still,  even  in  the  latter  bad  results  may  ensue  from  a  direct 
absorption  into  the  blood  of  putrid  substances  and  by  the  penetration  of 
fetid  gases  to  the  lungs. 

Occasionally,  where  the  infiltration  has  been  extensive,  we  meet  with  a 
condition  that  can  only  be  considered  as  gangrene.  In  such  cases  we  see 
collections  of  a  grayish  pulpy  mass,  which  on  falling  off  leaves  a  con- 
siderable loss  of  tissue,  the  further  course  of  the  disease  being  either 
favorable,  or  dangerous  through  absorption  of  septic  material,  or  accom- 
panied by  local  hemorrhages.  When,  after  a  time,  health  is  completely 
restored,  marked  cicatrices  are  left  behind.  Such  loss  of  tissue  is  gener- 
ally seen  in  the  tonsils  only,  but  it  may  also  be  encountered  in  the  soft 
palate.  Its  cicatrices  on  the  soft  palate  are  always  a  source  of  inconveni- 
ence, partly  in  swallowing,  partly  in  speaking.  Actual  local  perforation 
of  the  soft  palate  I  have  seen  but  five  times  in  twenty-five  years,  slough- 
ing without  perforation  very  often. 

The  diphtheritic  membrane  not  infrequently  spreads  from  the  pharynx 
to  the  neighboring  organs.  From  the  posterior  aspect  of  the  soft  palate 
or  pharynx  the  disease  gradually  ascends  to  the  nasal  cavities ;  this  is 
particularly  apt  to  occur  when  the  uvula  is  the  seat  of  extensive  deposits, 
and  by  forced  inspiration  and  deglutition  its  posterior  surface  becomes 
affected.  In  such  cases  the  membrane  which  extends  thence  to  the  nasal 
cavities  is  very  dense,  and  capable  of  narrowing  the  capacity  of  the  nasal 
cavities  anteriorly,  and  occasionally  even  to  close  them  entirely ;  as  a  rule, 
however,  several  days  elapse  before  the  membrane  assumes  such  a  condi- 
tion. Usually,  when  this  form  of  nasal  diphtheria  is  in  its  incipient 
stage,  it  is  impossible  to  diagnosticate  it ;  the  most  important  sign  thereof, 
besides  a  more  nasal  articulation  and  sometimes  greater  difficulty  in  deglu- 
tition, and  the  result  of  close  ocular  examination  while  the  uvula  is 
turned  sideways  or  drawn  forward,  is  a  swelling  of  the  deep  facial  glands 
at  the  angle  of  the  lower  jaw ;  when  these  swell  rapidly  it  can  be  asserted 
positively  that  the  nasal  cavities  have  been  invaded.  There  is  little  or 
no  discharge  from  the  nostrils  under  these  circumstances. 

The  picture  is  a  very  different  one,  however,  when  the  nose  becomes 
primarily  affected.  This  usually  occurs  only  where  an  acute  catarrh  with 
but  little  secretion,  not  so  often  where  a  chronic  catarrh,  has  preceded 
infection.  When  the  secretion  is  thin  and  serous,  the  diphtheritic  infec- 
tion renders  it  no  thicker,  but  makes  it  slightly  flocculent,  and  it  may 
become  very  profuse.  This  form  is  frequently  attended  with  a  disagree- 
able odor,  equally  unpleasant  to  the  patient  and  to  those  around  him. 
During  the  prevalence  of  an  epidemic  one  must  always  be  prepared  to  see 
an  acute  nasal  catarrh  or  an  influenza,  or  even  a  chronic  nasal  catarrh, 
become  complicated  with  diphtheria  or  pass  into  it.  Schuller  reports^the 
case  of  a  five- weeks-old  male  child  who,  having  had  a  nasal  catarrh  since 
birth,  became  affected  with  diphtheria  of  the  nose.  The  glandular  swell- 


670  DIPHTHERIA. 

ing  of  which  I  spoke  above  is  a  very  important  diagnostic,  and  likewise 
a  decidedly  unpleasant  symptom,  which  becomes  very  marked  inside  of 
twenty-four  hours  ;  frequently  a  partial  swelling  remains  long  after  the 
disappearance  of  the  diphtheritic  membrane.  Such  glands  rarely  sup- 
purate or  undergo  a  necrotic  degeneration ;  sometimes  they  become  per- 
manently indurated.  This  induration  and  a  chronic  pharyngeal  and  nasal 
catarrh  are  very  serious  matters  in  many  instances.  Both  of  these  condi- 
tions are  starting-points  for  a  number  of  acute  or  subacute  attacks  of 
diphtheria  in  the  same  person.  It  is  they  which  constitute  the  liability 
of  persons  once  affected  to  be  taken  sick  again.  Not  only  are  they  liable 
to  be  affected  themselves,  but  they  are  a  constant  danger  to  all  around 
them.  Diphtheria,  in  a  large  family  of  children  living  in  one  of  the  best 
houses  of  the  city,  after  having  returned  half  a  dozen  times  in  the  course 
of  a  year,  disappeared  instantaneously,  not  to  return,  when  a  seamstress 
living  in  an  infected  neighborhood  and  suffering  from  occasional  sore 
throats  was  relieved  of  her  daily  work  in  the  house.  QEdematous  swell- 
ing of  the  mucous  membrane  and  submucous  tissue  is  often  observed  for 
a  long  period  to  come ;  elongated  uvulae,  enlarged  tonsils,  often  date  back 
to  such  an  acute  attack.  Thus  it  is  with  the  upper  portion  of  the  larynx 
about  the  posterior  insertion  of  the  vocal  cords  (see  below) ;  its  large 
amount  of  loose  submucous  tissue  is  liable  to  swell  considerably  in  acute 
attacks.  Frequent  spells  of  croupy  cough  and  a  certain  degree  of 
dyspnoea  are  often  observed  for  years  afterward.  Though  the  cases  of 
genuine  cicatrization  between  the  arytenoid  cartilages,  as  described  by 
Michael,1  be  rare,  with  their  result  of  permanent  paresis  of  the  thyro- 
arytenoid  interni  muscles,  when  they  do  occur  they  are  either  obstinate  or 
altogether  incurable. 

Diphtheritic  conjunctivitis  occurs  either  primaily  or  as  a  complication 
of  pharyngeal  or  nasal  diphtheria.  Fortunately,  it  is  not  of  frequent 
occurrence ;  the  cornea  may  become  destroyed  either  by  pressure  through 
the  considerable  swelling  of  the  eyelid  or  by  diphtheritic  keratitis. 
Usually  the  upper  eyelid  is  the  first  to  suffer ;  it  is  red,  rigid,  swollen. 
In  the  beginning  the  conjunctiva  palpebrse  is  smooth,  dry  and  pale,  while 
that  of  the  eye  is  chemosed ;  afterward  diphtheritic  deposits  take  place 
either  in  floccules  or  in  solid  masses.  Knapp  distinguishes  between  croup 
and  diphtheria  of  the  eyelid  according  to  the  facility  or  impossibility  of 
removing  the  deposit.  In  favorable  cases  the  membranes  begin  to 
macerate  and  the  eyelids  to  soften  after  a  few  days.  In  those  less 
favorable  perforation  of  the  cornea,  prolapse  of  the  iris,  or  total  destruc- 
tion of  the  eye  take  place. 

The  ear  is  but  rarely  the  primary  seat  of  diphtheria.  A  girl  of  throe 
years  died  of  laryngeal  diphtheria  on  Sept.  6,  1882,  after  an  illness  of 
four  days.  A  girl  of  seven  years  was  removed  from  the  house  on  Sept. 
6th  and  returned  on  Sept.  8th.  On  the  afternoon  of  the  10th  an  earring 
taken  from  the  corpse  was  attached  to  the  left  ear  of  the  sister,  after 
having  been  washed  with  soap  and  water  only.  About  noon  on  the  llth 
the  lobe  of  the  left  ear  reddened,  on  the  12th  it  exhibited  a  membrane 
and  became  swollen,  and  some  glands  enlarged  in  the  neighborhood.  On 
the  right  mastoid  process  the  skin  was  not  quite  healthy,  a  vesicatory 
having  been  applied  three  weeks  previously.  This  surface  became  diph- 
1  Deutsch.  Arch.f.  klin.  Med.,  1879,  xxiv.  p.  618. 


SYMPTOMS.  671 

theritic  on  the  12th,  without  consecutive  glandular  swelling.  On  the 
13th  the  membranes  _  grew  thicker;  on  the  14th  the  pharynx  was  also 
affected,  and  the  physician  called  in. 

Most  diphtheritic  affections  of  the  ear,  however,  are  secondary.  In 
pharyngeal  and  nasal  diphtheria  the  narrow  orifice  of  the  Eustachian 
tube  is  easily  obstructed  by  either  catarrhal  swelling  or  diphtheritic  deposit. 
The  disease  may  invade  the  middle  ear  and  the  drum  membrane  with 
perforation,  caries,  and  deafness  following. 

The  descent  of  the  diphtheritic  process  into  the  respiratory  organs 
may  give  rise  to  various  conditions.  The  membrane  is  not  always 
found  to  pass  uninterruptedly  from  the  mucous  membrane  of  the 
fauces  into  the  larynx;  not  infrequently  isolated  diphtheritic  spots 
are  found  in  the  pouches  on  either  side  of  the  attached  extremity  of 
the  epiglottis,  or  on  the  epiglottis,  or  in  the  larynx.  At  such 
times  the  epiglottis  is  moderately  swollen,  its  margins  hard  and  red- 
dened. Occasionally  the  redness  is  interrupted  by  small  diphtheritic 
deposits,  which  may  remain  isolated  for  a  considerable  time,  but  generally 
coalesce  so  as  to  coat  the  edges  of  the  epiglottis  with  a  continuous  mem- 
brane. As  a  rule,  the  upper  surface  of  the  epiglottis  is  not  completely 
covered  by  membrane,  while  only  now  and  then  diphtheritic  deposits  are 
found  on  its  under  surface. 

The  subjective  symptoms  accompanying  the  affection  of  the  epiglottis 
are  not  always  in  direct  proportion  to  the  extent  of  the  membranes. 
Dyspnoea  and  hoarseness  occasionally  occur  where  the  only  abnormal 
condition  is  a  marked  oedema  at  the  entrance  of  the  larynx,  particularly 
of  the  the  posterior  wall  near  the  arytenoid  cartilages  and  the  attachment 
of  the  vocal  cords.  The  oedematous  condition  causes  a  functional  paral- 
ysis of  the  vocal  cords,  together  with  marked  dyspnoea  on  inspiration. 
The  difficulty  of  breathing  may  become  so  excessive  that  the  clinical 
diagnosis  of  croup  is  unquestionable,  and  tracheotomy  resorted  to,  while 
expiration  is  comparatively  free  and  the  voice  not  markedly  affected. 
Furthermore,  cases  occur  in  which  there  is  no  marked  oedema,  but  merely 
a  general  catarrh  of  the  epiglottis  and  larynx ;  here,  too,  the  subjective 
symptoms  of  hoarseness  and  dyspnoea  may  become  severe  and  necessitate 
the  performance  of  tracheotomy.  Still,  bearing  this  in  mind,  I  have  on 
several  occasions  refrained  from  performing  this  operation  where  I  judged 
that,  aside  from  the  diphtheria  of  the  pharynx,  I  had  to  deal  with  a 
moderate  oedema  of  the  glottis  or  a  laryngeal  catarrh. 

Frequently,  however,  membranes  form  in  the  larynx  in  the  same  way 
as  in  the  pharynx  or  nose ;  then  inspiration  and  expiration  are  equally 
interfered  with,  and  hoarseness  is  a  more  constant  symptom  than  in  the 
above-mentioned  cases.  Fever  and  pain  are  not  necessarily  prominent 
symptoms;  in  fact,  they  are  frequently  unimportant,  but  in  proportion  as 
the  degree  of  narrowing  of  the  larynx  increases  the  respiration  becomes 
more  difficult,  long-drawn,  and  loud. 

It  may  happen  that  the  trachea  and  bronchi  may  become  affected, 
although  diphtheria  of  the  fauces  does  not  exist,  This  does  not  occur  as 
rarely  as  Henoch  and  Oertel  seem  to  believe.  They  think  that  diph- 
theritic tracheo-bronchitis  is  mistaken  for  the  primary  condition,  because 
the  throat  is  not  examined  early  enough. 

Oertel  is  of  the  opinion  that  the  membrane  in  the  fauces  is  over- 


672  DIPHTHERIA. 

looked  in  such  cases.  Steiner1,  too,  asserts  that  "the  tendency  of 
the  times  is  to  question,  nay,  rather  to  deny,  the  existence  of  croup 
extending  from  below  upward."  Now,  on  the  contrary,  repeated 
experience  enables  me  to  assert  with  positiveness  that  diphtheritic 
tracheo-bronchitis  may  occur  without  an  affection  of  the  pharynx  at 
the  same  time.  I  do  not  deny  that  it  may  last  for  days  without  giving 
rise  to  dangerous  symptoms.  I  know  it  does.  But  when  the  process 
reaches  the  larynx,  the  symptoms  of  suffocation  become  so  urgent  that 
tracheotomy  may  be  absolutely  required  at  once,  and,  in  spite  of  the 
operation,  death  soon  after  occurs. 

Of  course  these,  cases  are  exceptions ;  as  a  rule,  laryngeal  and  tracheal 
diphtheria  result  from  a  descent  of  the  disease  from  the  fauces.  More  or 
less  uncomplicated  cases  of  primary  laryngeal  diphtheria,  or  so-called 
sporadic  membranous  croup,  were,  however,  observed  before  tho  end  of 
the  sixth  decade  of  this  century.  They  were  then  almost  the  only  cases 
of  diphtheria,  and  linked  former  epidemics  and  the  present  one  together. 

Inflammatory  affections  of  the  lungs  may  occur  at  various  times  and  in 
various  forms  during  an  attack  of  diphtheria.  That  which  appears  after 
tracheotomy  is  usually  a  broncho-pneumonia,  and  results  from  rarefaction 
of  the  air  in  the  respiratory  passages  during  the  period  of  impeded  res- 
piration, with  consequent  collapse  of  pulmonary  tissue  and  dilatation  of 
the  blood-vessels,  and  hence  a  disturbance  of  the  circulation.  It  may 
not  fully  develop  until  after  tracheotomy,  and  is  a  frequent  cause  of 
death  on  the  second  or  third  day  after  the  operation.  Now  and  then  a 
case  of  lobular  pneumonia  will  result  from  the  aspiration  of  pieces  of 
membranes  into  the  smallest  bronchi.  It  can  be  easily  recognized  when 
the  trachea  is  opened,  but  previous  to  the  operation  the  auscultatory  signs 
are  of  little  or  no  value,  being  masked  by  the  laryngeal  rales.  Percus- 
sion is  equally  useless,  for  a  dulness  may  just  as  well  indicate  collapse  of 
the  lung  as  infiltration.  The  second  form  of  pneumonia  associated  with 
diphtheria  is  from  the  beginning  fibrinous  in  character.  Here,  too, 
auscultation  and  percussion  are  of  little  assistance  in  establishing  a 
diagnosis  when  there  is  a  laryngeal  diphtheria  at  the  same  time,  for 
the  above  reasons.  Where,  however,  the  dulness  on  percussion  is  accom- 
panied by  high  fever,  and  the  long-drawn  inspiration  is  replaced  by 
rapid  respiratory  movements,  the  diagnosis  of  pneumonic  complication  is 
justified. 

Diphtheria  of  the  mouth,  as  a  primary  affection,  is  not  of  very  fre- 
quent occurrence;  not  rarely,  however,  is  it  associated  with  diphtheria 
of  the  fauces  and  nose,  mainly  when  they  have  assumed  a  septic  or  gan- 
grenous character ;  it  appears  on  cheeks,  tongue,  angles  of  the  mouth  and 
gums,  and,  after  the  fetid  discharges  have  excoriated  the  skin,  on  the  lips 
also.  In  all  of  these  localities  it  appears  less  in  the  form  of  an  exten- 
sive, thick  membrance  than  an  infiltration  of  the  tissues.  It  is  most  apt 
to  occur  where,  from  the  start,  the  mucous  membrane  of  the  mouth  was 
eroded  or  ulcerated.  The  ulcerated  base  of  a  follicular  stomatitis  is  very 
frequently  the  starting-point  of  a  general  diphtheria  of  the  mouth.  It 
is  always  a  disagreeable  symptom,  points  to  a  long  duration  of  the  whole 
process,  and  threatens  septic  absorption. 

The  O3sophagus  and  the  cardiac  portion  of  the  stomach  are  the  seat 

1  Ziemssen's  Handb.,  iv.,  1,  126. 


SYMPTOMS.  673 

sometimes  of  very  massive  and  extensive,  mostly  fibrinous  exudations,  in 
typhoid  fever,  dysentery,  cholera,  measles,  and  scarlatina,  or  after  injuries 
following  contact  with  mineral  acids,  alkalies,  corrosive  sublimate,  or 
antimony.  When  the  normal  tissue  was  not  injured  I  never  saw  any 
that  were  not  superjacent  and  could  not  easily  be  peeled  off  (croupous). 
In  cases  of  extensive  pharyugeal  and  laryngeal  diphtheria  the  upper  part 
of  the  ^  oesophagus  is  often  covered  to  a" distance  of  half  an  inch  or  an 
inch  with  membrane,  the  lower  part  of  which  is  thinning  out  into  a  mere 
film.  A  case  of  local  diphtheritic  deposit  near  the  cardiac  portions  of  the 
oesophagus,  upon  the  seat  of  a  stricture,  I  have  described  in  my  Treatise, 
p.  83.^  Actual  diphtheria  of  the  stomach  is  rare.  So  is  that  of  the 
intestine,  which  is  much  more  liable  to  be  affected  in  animals  than  in 
man.  In  the  cow  intestinal  diphtheria  is  frequent  (Bollinger).  In  the 
gall-bladder,  resulting  from  the  irritation  produced  by  calculus,  it  was 
seen  by  Weisserfels.  The  diphtheritic  form  of  inflammation  of  the 
human  colon  and  rectum — dysentery — is  frequent  enough,  but  will  be 
the  subject  of  discussion  in  another  place.  But,  besides  this,  in  the 
lower  portion  of  the  small  intestines  and  in  the  colon  long,  tough,  cohe- 
rent membranes  are  sometimes  found  in  the  male  and  female  (not  in  the 
hysterical  female  only).  As  a  rule  they  are  not  diphtheritic,  but  consist 
mostly  of  nothing  but  mucus  hardened  and  flattened  down  by  protracted 
compression.  The  few  cases  of  intestinal  diphtheria  I  have  met  with 
gave  rise  to  the  usual  symptoms  of  enteritis,  and  were  diagnosticated  as 
such. 

Wounds  of  all  kinds  are  easily  and  rapidly  infected  by  diphtheria ;  for 
instance,  vaginal  abrasions  and  erosions  of  the  external  ear,  tongue,  and 
corners  of  the  mouth.  Scarification  or  removal  of  part  of  the  tonsils  is 
followed  in  half  a  day  or  a  day  by  a  deposit  of  diphtheritic  membrane 
on  the  wound.  The  wound  caused  by  tracheotomy  becomes  liable  to  be 
infected  with  diphtheria  within  twenty-four  hours.  Leech-bites,  skin 
denuded  by  vesicatories,  removal  of  the  cuticle  by  scratching  during 
cutaneous  eruptions,  all  furnish  a  resting-place  for  diphtheria  in  a  short 
time.  What  Billroth  has  described  under  the  name  of  muco-salivary 
diphtheritis,  as  it  occurs  after  the  extirpation  of  a  large  portion  of  the 
tongue  and  resection  of  the  lower  jaw,  belongs  to  this  class. 

At  times  immediately  at  the  beginning  of  an  invasion  of  diphtheria, 
at  other  times  only  on  the  second  or  third  day,  an  erythematous  eruption, 
more  or  less  general,  appears  on  the  skin.  Now  and  then  it  appears  on 
the  chest,  shoulders,  and  back  ;  at  other  times  it  covers  the  body,  and  has 
not  infrequently  led  to  its  being  confounded  with  scarlatina.  It  is  not 
always  accompanied  by  much  fever,  and  cannot  therefore  be  mistaken  for 
that  form  of  erythema  which  frequently  appears  in  children  with  delicate 
skins  during  high  fever  from  any  source.  I  cannot  say  that  I  have 
found  this  complication  to  give  a  more  malignant  character  to  the  disease, 
but  true  erysipelas  does.  I  am  not  prepared  to  prove  that  the  two  pro- 
cesses, erysipelas  and  diphtheria,  are  identical  under  some  circumstances, 
but  the  complication  of  the  two,  and  the  ferocity  with  which  they  com- 
bine, renders  a  close  relationship  probable.  I  have  seen  an  infant  dying 
from  an  erysipelas  added  to  a  post-auricular  diphtheria,  this^  being  due  to 
a  slight  abrasion  of  the  surface.  Erysipelas  originating  in  the  trache- 
otomy wound,  though  ever  so  carefully  disinfected  and  secured,  is  fre- 

VOL.  I.— 43 


674  DIPHTHERIA. 

quently  observed  after  two  or  three  clays,  and  is  a  very  ominous  symp- 
tom. Erysipelatous  surfaces,  denuded  of  their  epidermis  by  spontaneous 
vesicatiou  or  injured  by  ever  so  slight  a  trauma,  are  very  liable  to  be 
covered  with  diphtheritic  membranes. 

An  eruption  resembling  urticaria  in  the  beginning  is  as  innocent  as 
erythema,  but  purpura  in  the  latter  stage  is  a  symptom  of  mostly  omin- 
ous nature. 

On  the  vulva  and  vagina  of  little  girls  diphtheria  is  sometimes  met 
with ;  probably  in  every  case  it  is  due,  under  the  epidemic  influence,  to 
a  local  catarrh  or  erosion.  In  but  few  cases,  comparatively,  the  inguinal 
glands  are  swollen.  There  are  not  many  cases  of  vaginal  diphtheria 
which  are  followed  by  the  pharyngeal  affection.  Diphtheria  of  the 
vagina  in  puerperal*  women  is  liable  to  become  the  cause  of  general 
sepsis,  and  is  a  dangerous  disease ;  it  is  seldom  complicated,  but  uterus, 
Fallopian  tubes,  and  peritoneum  may  become  the  seat  of  inflammatory 
and  septic  disturbances.  In  the  bladder  it  may  occur  when  the  urine  is 
alkaline,  in  chronic  cystitis,  after  lithotomy,  urethotomy,  the  operation 
for  vesico- vaginal  fistula,  and  in  ectopia  vesica?.  This  form  has  a  marked 
tendency  toward  localization,  but  by  extension  of  the  phlegmon,  when  of 
putrid  character,  to  the  retro-peritoneal  cellular  tissue,  peritonitis  may 
ensue  and  terminate  fatally.  Sepsis  from  absorption  is  also  frequent. 
Vesical  diphtheria  is  sometimes  quite  unsuspected.  A  man  of  sixty  had 
urinary  trouble  a  long  time ;  his  urine  was  frequently  very  offensive,  con- 
taining blood  and  pus.  About  five  days  before  his  death  he  suddenly 
collapsed.  I  found  the  bladder  well  filled,  and  introduced  a  catheter,  but 
succeeded  in  removing  but  a  few  drops  of  fetid  liquid.  Assuming  the 
presence  of  a  malignant  tumor  at  the  neck  of  the  bladder,  I  attempted 
to  draw  off  the  urine  by  puncturing  above  the  symphisis  pubis ;  again 
without  success.  At  the  post-mortem  examination  a  thick  membranous 
lining  of  the  bladder  was  found  detached  in  the  form  of  a  sac  containing 
about  a  quart  of  urine.  During  life  the  beak  of  the  catheter  evidently 
passed  into  the  space  between  the  bladder  and  the  membranous  sac,  which 
accounts  for  the  unsuccessful  attempts  at  catheterization. 

Diphtheria  of  the  placenta  was  observed  by  Schiiller.  The  membrane 
was  between  uterus  and  placenta,  and  attached  to  the  latter.  It  resulted 
from  puerperal  sepsis.  Balano-posthitis  is  liable  to  result  in  local  and 
general  diphtheria;  so  are  circumcision  wounds.  They  are  apt  to  become 
affected  either  primarily,  without  apparent  cause,  or  when  other  members 
of  the  family  are  suffering  from  the  disease. 

The  kidneys  may  become  affected  in  various  ways.  Albuminuria  is 
not  always  of  significance,  as  it  occurs  in  severe  and  mild  cases  alike, 
both  before  and  after  tracheotomy,  and  therefore  is  not  connected  always 
either  with  the  height  of  the  fever  or  the  degree  of  dyspnoea ;  at  times 
it  disappears  in  a  few  days,  in  other  cases  it  is  of  longer  duration.  It  is 
not  invariably  complicated  with  changes  in  the  kidney,  neither  do  we 
always  discover  casts  or  degenerated  epithelial  cells  in  the  urine.  In 
other  respects  also  it  does  not  behave  like  albuminuria  in  scarlatina.  In 
the  latter  it  appears  seldom  before  the  second  week  of  the  process,  and 
frequently  later,  while  in  diphtheria  it  is  often  seen  early.  It  sometimes 
lasts  but  a  few  days,  particularly  in  many  cases  which  set  in  with  a  high 
fever,  which  rapidly  diminishes,  and  terminates  in  speedy  recovery.  In 


SYMPTOMS.  675 

these  occurrences  the  presence  of  albumen  appears  to  attend  the   rapid 
elimination  of  the  poison. 

Albuminuria  seldom  lasts  longer  than  a  week,  and  is  not  often  com- 
plicated with  oedema,  but  sometimes  it  is  but  a  symptom  of  a  local  or 
general  nephritis,  and  then  hyaline,  epithelial,  and  fibrin  casts  and  gran- 
ular cells  are  found  in  the  urine.  Nephritis  then  assumes  as  serious  a 
character  as  it  possesses  in  scarlatina.  Cases  of  nephritis, '  fortunately 
rare  in  a  very  early  period  of  diphtheria,  are  liable  to  run  a  rapid  and 
often  fatal  course. 

The  heart  and  blood  are  affected  in  various  ways  by  the  diphtheritic 
process.  Where  the  disease  runs  a  slow  course,  accompanied  by  high 
fever,  a  granular  degeneration  occurs,  similar  to  that  appearing  in  other 
acute  infectious  disorders — typhoid,  for  example.  In  diphtheria,  how- 
ever, it  would  seem  that  this  condition  may  arise  even  without  marked 
elevation  of  temperature.  The  pathological  changes  in  the  heart 
produced  by  diphtheria  are  not  always  the  same.  Ecchyrnoses, 
cellular  hypertrophy,  and  granular  degeneration  have  frequently  been 
noticed  after  death  where  the  symptoms  had  been  severe.  The 
result,  of  course,  is  considerable  weakness  of  its  muscular  tissue, 
evidenced  by  the  formation  of  local  (Beverly  Robinson)  thrombi,  general 
sluggishness  of  the  circulation,  dyspnoea,  muffled  heart-sounds,  a  cool 
and  pale  skin,  and  sudden  death,  preceded  by  a  very  feeble  and  frequent, 
sometimes,  however,  by  a  very  slow,  pulse.  Aside  from  this,  there  is 
actual  endocarditis  during  the  course  of  diphtheria  or  convalescence  there- 
from. It  affects  especially  the  valves,  and  among  them  particularly  the 
mitral.  It  is  characterized  by  high  fever,  precordial  pain,  attacks  of 
syncope,  and  a  systolic  murmur. 

The  rapid  decrease  of  red  blood-cells  and  a  moderate  increase  of  leuco- 
cytes were  demonstrated  by  Bouchut  and  Dubrisay,  but  the  disproportion 
was  not  such  as  to  necessitate  the  diagnosis  of  leucocythasmia.  Wunder- 
lich  reports  two  cases  of  Hodgkin's  disease,  the  pseudo-leukaamia  devel- 
oping during  diphtheria.  And  the  slowness  of  final  recovery  in  many 
cases,  even  of  but  short  duration  and  not  complicated  with  nervous  dis- 
orders, appears  to  point  to  a  serious  disintegration  of  the  elements  of  the 
blood.  The  dark  color  and  defective  coagulation  of  the  blood  in  autop- 
sies of  diphtheria  cases  have  often  been  remarked. 

The  direct  and  rapid  introduction  into  the  blood  of  a  foreign  substance 
has  amongst  its  earliest  symptoms  fever.  This  reaction  of  a  nervous 
system  depends  both  on  the  quantity  and  quality  of  the  substance  or 
poison  introduced,  and  on  the  susceptibility  of  the  patient.  High  tem- 
peratures are,  however,  not  the  only,  nor  are  they  the  most  dangerous, 
nervous  symptoms.  To  the  latter  belong  the  different  shades  of  paralysis 
met  with  during  or  subsequent  to  diphtheria. 

Sudden  and  unexpected  collapse  is  sometimes  observed,  not  infrequently 
in  the  earlier  part  of  the  disease.  The  changes  found  in  autopsies,  such 
as  a  dark  color  of  the  blood,  deficient  coagulability,  extravasations  into 
and  friability  and  granular  degenerations  of  the  tissues,  accumulations  of 
degenerated  cells,  and  granules  between  the  fibres,  degeneration  mainly  of 
the  heart-muscle,  the  presence  of  heart-clots,  thrombi  in  remote  veins,— 
they  all  show  to  what  extent  the  disease  can  destroy  life  in  the  shortest 
time  possible.  In  the  heart  either  the  pneumogastric  or  the  ganglionic 


676  DIPHTHERIA: 

nerves  may  be  affected,  aud  the  symptoms  will  vary  accordingly.  Paraly- 
sis of  the  former  will  accelerate  the  pulse,  degeneration  of  the  sympathetic 
will  diminish  its  frequency,  yet  death  may  ensue  in  either. 

The  usual  form  of  diphtheritic  paralysis  makes  its  appearance  during 
the  period  of  convalescence,  at  a  time  when  all  danger  seems  to  have 
passed  by.  As  a  rule,  the  soft  palate  and  the  muscles  of  deglutition  are 
the  first  to  be  attacked,  while  the  condition  of  these  organs  is  apparently 
normal  (and  no  longer  oedematous,  and  thereby  inactive,  as  in  the  first 
period  of  the  disease).  While  they  are  recovering,  or  before,  the  accom- 
modation muscles  of  the  eyes  become  paralyzed.  Sometimes,  however, 
these  are  the  first  to  be  affected.  Thia  paralysis  does  not,  as  a  rule,  follow 
severe  cases ;  on  the  contrary,  it  is  not  uncommon  to  observe  it  after  appa- 
rently mild  attacks  of  the  disease.  In  consequence  of  the  former  paraly- 
sis, deglutition  becomes  difficult;  fluids  are  expelled  through  the  nose  or 
enter  the  larynx  and  bronchi,  thereby  giving  rise  to  pneumonia ;  in  the 
latter  there  is  strabismus.  The  upper  and  lower  extremities  become  para- 
lyzed afterward.  As  a  rule,  a  number  of  muscles  are  affected  at  the  same 
time,  and  improvement  will  take  place  in  about  the  same  order  in  which 
the  individual  muscles  became  affected.  After  paralysis  has  become 
affected,  circulation  begins  to  suffer.  The  extremities  now  and  then 
become  bluish,  cool,  emaciated;  rarely  atrophy  and  fatty  degeneration 
have  been  observed.  The  muscles  of  the  neck  also  become  paralyzed ; 
the  head  cannot  be  carried,  or  with  difficulty  only.  The  fingers  are  but 
seldom  affected.  The  same  holds  good  of  the  bladder  and  intestines. 
The  respiratory  muscles  are  not  frequently  attacked.  Their  paralysis  is 
very  ominous,  and  may  prove  fatal  in  a  short  time  from  apnoea. 

Not  only  motory  but  sensory  paralyses  may  occur.  Anaesthesia,  amau- 
rosis,  deafness  have  been  observed ;  a  number  of  cases  of  locomotor  ataxia 
are  on  record,  and  but  lately  Hadthagen l  publishes  a  case  which  he  claims 
as  disseminated  sclerosis. 

Sometimes  the  nervous  affection  in  diphtheria  is  localized  in  a  peculiar 
manner;  it  seems  as  if  there  is  a  predisposition  on  the  part  of  a  certain 
nerve  to  become  diseased.  The  case  of  a  boy,  active  and  healthy,  in  the 
practice  of  H.  Guleke,  is  very  interesting.  In  the  course  of  three 
years  he  had  three  attacks  of  diphtheria.  In  the  very  beginning  of  the 
disease  he  always  became  soporous  with  an  almost  normal  temperature 
and  a  slow  but  regular  pulse.  Probably  the  heart's  ganglia  are  the  first 
to  submit  to  the  influence  of  the  poison  and  exhibit  symptoms  of  flagging 
function.  In  most  of  the  cases  of  diphtheritic  paralysis  the  prognosis  is 
good ;  the  large  majority  will  run  a  favorable  course  in  from  six  to  ten 
weeks. 

INVASION. — Is  diphtheria,  primarily",  a  local  or  a  constitutional  disease? 
Mercado's  well-known  case  of  diphtheria,  engendered  by  the  biting  of  a 
finger,  has  been  alluded  to.  I  know  of  one  case  in  which  the  vagina 
became  first  affected,  and  later  the  pharynx.  Bayles  saw  denuded  por- 
tions of  skin  assume  a  membranous  character,  and  general  diphtheria 
develop  afterward.  Fresh  wounds  become  diphtheritic,  and  the  genpral 
disease  arises  from  this  source.  Even  paralysis  will  follow.  I  had  a 
death  from  diphtheria  when  a  long  incision  into  a  phlegmon  of  the  thigh 
had  become  diphtheritic.  A  little  girl,  who  had  a  considerable  amount 
lArch.f.  Kinderheilk.,  vol.  v.,  1883. 


INVASION.  677 

of  discharge  from  a  eatarrhal  vagina,  and  sore  thighs  in  consequence 
exhibited  first,  during  the  epidemic  of  1877,  membranes  on  the  denuded 
cutis,  and  afterward  general  diphtheria.  Brehm  reports  the  case  of  a 
woman  on  whom  he  performed  colotomy.  The  wound  became  thoroughly 
diphtheritic  and  gangrenous,  but  the  pharynx  and  respiratory  organs 
remained  intact.  A  few  days  after,  her  daughter,  who  attended  her  in 
her  sickness,  was  infected.  In  her  the  pharynx  was  the  seat  of  disorder. 
Besides,  the  tonsils  are  very  frequently  coated  with  a  membrane  without 
any  general  symptoms  in  the  beginning,  fever  and  general  illness  occur- 
ring only  later  on.  Now,  all  of  these  facts  tend  to  show  that  there  are 
cases  in  which  the  origin  of  the  disease  is  purely  local. 

It  must,  however,  not  be  forgotten  that  during  the  prevalence  of  an 
epidemic  every  one  is  more  or  less  under  its  influence,  and  but  little  is 
wanting  to  call  forth  the  disease.  Some  years  ago  a  well-known  physi- 
cian, with  whom  I  was  intimately  acquainted,  died  from  facial  erysipelas 
and  meningitis  which  had  originated  in  a  slight  abrasion  of  the  upper  lip. 
During  an  epidemic  of  typhoid  we  daily  see  persons  with  fever,  headache, 
and  lassitude.  Diarrhoeas  are  frequent  during  an  epidemic  of  cholera. 
An  epidemic  of  diphtheria  is  accompanied  by  a  great  number  of  cases  of 
pharyngitis.  When,  in  the  year  I860,1  I  reported  two  hundred  cases  of 
bona  fide  diphtheria,  I  at  the  same  time  observed  one  hundred  and  eighty- 
five  cases  of  non-membranous  inflammations  of  the  throat.  Such  occur- 
rences may  be  considered  as  possible  or  incipient  cases  of  pharyngeal 
diphtheria.  Therefore,  contrary  to  the  view  of  a  local  origin  of  diph- 
theria, it  may  be  claimed  that  the  individual  taking  the  disease  was  already 
saturated  with  the  poison,  and  the  local  membrane  represented  perhaps 
nothing  but  a  symptom,  or  at  the  utmost  the  causa  proxima.  Accord- 
ingly, then,  there  are  undoubtedly  cases  in  which  the  pharyngeal  mem- 
brane is  the  first  cause  and  symptom  of  the  final  affection,  and  others  in 
which  the  poisoning  of  the  blood  through  inhalation  is  the  first  step  in 
the  development  of  the  disease,  amongst  the  symptoms  of  which  the 
pharyngeal  or  nasal  membrane  counts  as  one. 

In  these  cases  the  first  complaints  of  the  patients  relate  to  their  general 
condition.  Sometimes  they  are  ignorant  of  any  local  trouble  when  they 
consult  a  physician.  When  it  is  perceptible,  however,  it  is  usually  found 
on  the  visible  pharyngeal  and  respiratory  mucous  membranes.  This 
would  seem  to  indicate  that  the  infectious  elements  while  being  inhaled 
are .  there  deposited.  Thus  there  is  a  possibility  of  simultaneous  affec- 
tions of  both  the  throat  and  the  blood  in  the  lungs,  in  either  equal  or 
variable  proportions.  We  are  easily  led  to  defend  at  least  a  partial  admis- 
sion of  the  poison  by  the  respiratory  act,  when  we  reflect  that  the  mem- 
branes which  are  swallowed  are  rendered  innocuous  by  the  action  of  the 
gastric  fluids,  and,  therefore,  the  alimentary  canal,  from  the  oesophagus 
downward,  cannot  be  made  responsible  for  the  admission  of  the  poison 
into  the  system.  Thus  it  is  that  the  general  symptoms — as  fever,  lassi- 
tude, etc. — precede  the  local  phenomena  in  very  many  cases,  while  there 
are  exceptional  cases  in  which  the  membrane  appears  first  and  the  fever 
later.  This  is  especially  the  case  when  the  tonsils  are  very  large  and 
occupy  a  prominent  position  in  the  throat. 

Those  cases  which  begin  with  high  fever  and  moderate  or  no  local 
1  Amer.  Med.  Times.,  Aug. 


678  DIPHTHERIA. 

symptoms  must  be  looked  upon  as  constitutional  diseases.  If  a  person, 
in  the  course  of  several  hours  or  a  day,  be  taken  with  high  fever  and  a 
moderate  membrane-formation,  these  symptoms  subsiding  in  one  or  two 
days,  leaving  the  patient  weak  and  exhausted,  but  fully  restored  to 
health  at  the  end  of  a  week,  we  would  be  justified  in  assuming  (caeteris 
paribus)  that  there  was  a  rapid  absorption  of  a  large  amount  of  poison, 
and  an  equally  rapid  elimination  thereof.  They  are,  moreover,  the  same 
cases  in  which  the  second  or  third  day  of  the  disease  furnishes  albumi- 
nuria,  with  rapid  elimination  and  speedy  recovery.  When,  however,  the 
process  is  slow  in  developing,  accompanied  by  moderate  fever,  and  the 
course  is  indolent,  we  have  reason  to  infer  that  moderate  amounts  of  the 
poison  are  being  continually  taken  into  the  system  and  making  their 
influence  felt  to  a  moderate  degree,  but  for  a  longer  period.  Such  are  the 
cases  which,  without  any  violent  symptoms,  are  accompanied  by  frequent 
local  relapses,  or  run,  when  the  absorption  is  constant  as  well  as  copious, 
a  septic  course,  or  terminate  in  paralysis. 

Thus  there  are  cases  in  which  a  local  infection  of  the  skin  or  of  a  wound 
may  be  one  of  the  causes,  or  the  only  cause,  of  the  disease,  and  there  are 
cases  in  which  the  poison,  in  passing  through  and  caught  in  the  pharynx, 
gives  rise  to  local  phenomena  before  the  system  at  large  gives  evidence  of 
infection.  But,  as  a  general  thing,  diphtheria  must  be  looked  upon  as  a 
constitutional  disease,  giving  rise  to  local  phenomena,  in  the  same  way  as 
scarlatina  does  on  the  skin,  on  the  mucous  membrane  of  the  alimentary 
canal,  and  in  the  uriniferous  tubules;  measles  on  the  skin  and  respiratory 
mucous  membrane ;  or  typhoid  in  the  lymph-follicles  and  on  the  mucous 
membrane  of  the  intestine  ;  or,  in  other  words,  the  diphtheritic  poison 
may  enter  the  system  locally  through  a  defective,  or  sore,  or  wounded 
integument  or  through  the  lungs. 

Is  diphtheria  contagious?  Undoubtedly  it  is.  The  contagious  ele- 
ment is  liable  to  be  directly  communicated  by  the  patient ;  it  also  clings 
to  solid  and  semi-solid  bodies,  and  in  this  way  is  transmitted  even  after  a 
long  time.  There  is  hardly  any  disease  which  can  cling  so  tenaciously 
to  dwellings  and  furniture ;  it  can  be  transported  by  the  air,,  though 
probably  not  to  a  great  distance,  and  hence  in  houses  artificially  heated, 
while  the  windows  and  doors  are  mostly  closed,  rises  from  the  lower  to 
the  upper  stories ;  and  it  is  for  this  reason  advisable  to  keep  the  sick  on 
the  top  floor.  It  is  certainly  transmitted  by  spoons,  glasses,  handker- 
chiefs, and  towels  used  by  the  patient.  The  contagious  character 
increases  directly  in  proportion  to  the  neglect  of  proper  ventilation. 
That  it  is  spread  by  the  feccs  is  not  clearly  established  in  my  mind.  I 
can  give  personally  no  examples  of  its  being  carried  by  visitors  or  by 
the  attending  physician ;  this  is  said  to  have  occurred,  however.  The 
character  of  the  disease  communicated,  and  the  local  manifestation,  do 
not  depend  on  that  of  the  original  sufferer;  thus  mild  cases 'may  produce 
severe  ones,  and  vice  versa,  and  convalescents  can  convey  the  disease  in 
its  full  force.  Naturally,  the  softer  character  of  the  tissues  in  children 
renders  them  more  susceptible  to  infection,  and  the  activity  of  their 
lymphatic  system  more  liable  to  severe  forms  of  the  disease. 

Many  tragic  cases  are  recorded  in  literature  of  infection  by  direct  con- 
tact from  pharynx  to  pharynx,  or  from  the  opening  in  the  trachea  to  the 
mouth  of  the  surgeon ;  and  one  of  the  saddest  cases,  perhaps,  is  that  of 


INVASION.  679 

the  much-lamented  Carl  Otto  Weber.    Myself  and  others  have  contracted 
diphtheria  from  sucking  tracheotomy  wounds. 

In  regard  to  the  length  of  the  incubation  periods,  there  can  be  no 
better  authenticated  facts  than  those  contained  in  a  report  of  Elisha 
Harris  to  the  National  Board  of  Health,  an  abstract  of  which  is  found 
in  No.  1,  National  Board  of  Health  Bulletin,  June  28, 1879.  The  report 
says  that  in  the  fourth  school  district  of  the  township  of  Newark 
(Northern  Vermont),  amidst  the  steep  hills  where  reside  a  quiet  people 
in  comfortable  dwellings,  the  summer  term  of  school  opened  on  the  12th 
of  May.  Among  the  twenty-two  little  children  who  assembled  in  the 
school-room  in  the  glen  were  two  who  had  suffered  from  a  mild  attack  of 
diphtheria  in  April,  and  one  of  them  was,  at  the  time  school  opened,  suf- 
fering badly  from  what  appeared  to  have  been  a  relapse  in  the  form  of 
diphtheritic  ophthalmia.  Besides,  it  is  proved  that  these  recently  sick 
pupils  had  not  been  well  cleansed,  one  of  them  having  on  an  unwashed 
garment  that  she  had  worn  in  all  her  sickness  three  weeks  previously. 
At  the  end  of  the  third  day  of  school  several  of  the  children  were 
complaining  of  sore  throat,  headache,  and  dizziness,  and  on  the  fourth 
day  and  evening  so  many  were  sick  in  the  same  way  that  the  teacher  and 
officers  announced  the  school  temporarily  closed.  By  the  end  of  the 
sixth  day  from  school  opening,  sixteen  of  the  twenty-two  previously 
healthy  children  became  seriously  sick  with  symptoms  of  malignant  diph- 
theria, and  some  were  already  dying.  The  teacher  and  six  of  the  pupils 
were  not  attacked,  nor  have  they  since  suffered  from  the  disease. 

A  case1  is  reported  of  a  surgeon  who,  while  attending  a  diphtheritic 
child,  had  some  secretion  thrown  into  his  face.  Twelve  hours  after  his 
right  eye  was  inflamed  and  painful.  The  affection  proved  diphtheritic, 
and  recovery  was  completed  after  several  weeks  only.  In  a  case  seen  by 
me,  with  Dr.  L.  Bopp,  a  child  removed  from  a  house  infected  with  diph- 
theria was  attacked  after  fourteen  days  and  eight  hours. 

It  would  then  appear  that,  in  the  direct  communication  of  the  disease 
to  healthy  or  nearly  healthy  mucous  membranes — as  healthy  as  the  pre- 
vailing epidemic  will  allow — the  period  of  incubation  is  from  one  or  two 
to  fourteen  days.  In  only  a  small  number  of  cases  the  disease  has  an  even 
shorter  period  of  incubation  than  this,  as  when  tonsil  lotorny  or  a  similar 
operation  is  undertaken  during  the  prevalence  of  an  epidemic.  ^  One  may 
rest  assured  that  any  operation  on  the  tonsils  while  an  epidemic  of  diph- 
theria is  at  its  height  will  be  followed  within  twenty-four  hours  by  diph- 
theritic deposits  on  the  wounded  part.  To  what  extent  we  are  justified 
in  considering  this  a  bona-fide  incubation  of  the  disease  in  a  previously 
healthy  body  is,  of  course,  another  question.  It  seems  to  me  that  these 
cases  positively  prove  that  the  operation  is  only  the  caus&  proxima  of  ; 
diphtheritic  affection,  and  that  we  may  take  it  for  granted  that  during  an 
epidemic  evjsry  individual  is  more  or  less  under  its  influence  and  affected 
by  it,  so  that  it  needs  but  a  wound  or  an  accidental  abrasion  of  the  sur- 
face of  the  mucous  membrane  to  call  the  disease  into  action.  In  a  similar 
wav,  fresh  wounds  or  morbid  conditions  of  the  mouth  may  call  forth  tl 

..    •''  ™,  .  -i  '    t  f    _     I*_1i:  —  !„  —    r,4-^mr\4-\t\ci     ava     Itamp    tO 


disease.     The  ruptured  vesicles  of  a  follicular  stomatitis 

serve  as  resting-places  for  diphtheritic  membranes,  and  thus  I  have  i 

the  complication  of  a  follicular  stomatitis  with  oral  diphtheria;  and  any 


iplication 

1  Wilrt.  Med.  Corresp.  Bl.,  1878,  No.  2. 


680  DIPHTHERIA. 

lacerations  of  the  vagina  during  labor  may  become  diphtheritic  within 
twenty-four  hours.  If  now,  on  the  one  hand,  incubation  depends  on  the 
condition  of  the  affected  surface,  it  is  probable,  on  the  other  hand,  that 
the  intensity  of  the  poison  at  the  time  plays  an  important  part  in  deter- 
mining the  period  that  is  to  elapse  between  infection  and  the  invasion  of 
the  disease. 

ETIOLOGY. — Diphtheria  is  pre-eminently  a  disease  of  early  life ;  in 
this  respect  it  is  said  to  differ  from  the  genuine  fibrinous  bronchitis,  which 
by  some  is  held  an  absolutely  different  disease,  and  stated  to  occur  but 
rarely  in  children.  But  even  this  statement  is  probably  incorrect.  In 
the  spring  of  1879  I  met  with  four  cases  of  fibrinous  bronchitis  in 
children  under  three  years  of  age.  The  number  of  cases  of  diph- 
theria in  adult  life  is  not  very  large,  while  in  old  age  it  is  very  small. 
Of  501  deaths  in  Vienna  in  1868,  only  1  had  reached  the  age  of  sixty- 
two  ;  of  more  than  300  cases  in  which  I  performed  tracheotomy  but  2 
were  over  thirteen  years  old. 

I  do  not  know  that  sex  exerts  any  predisposing  influence  over  diph- 
theria, yet  of  the  six  hundred  cases  or  thereabouts  of  laryngeal  diph- 
theria in  which  I  either  personally  performed  tracheotomy  or  observed 
the  progress  of  the  disease  in  the  practice  of  others,  I  found  the  majority 
in  males,  and  the  recoveries  in  inverse  proportion  to  the  number  thereof, 
the  mortality  being  greater  among  boys.  As  far  as  age  is  concerned,  nearly 
all  the  zymotic  diseases  are  seen  most  frequently  in  children.  They  ex- 
hibit a  greater  disposition  to  submit  to  diphtheria  than  adults,  if  we  except 
those  under  ten  months.  Where,  however,  the  disease  has  occurred  pre- 
vious to  the  seventh  or  eighth  month,  the  greater  number  of  cases  has 
been  found  under  three  months.  Tigri  reports  the  disease  in  a  child  of 
fourteen  days.  A  child  of  fifteen  days  was  seen  with  diphtheritic  laryn- 
gitis and  cesophagitis  by  Bretonneau,  one  of  seventeen  days  by  Bednar, 
one  of  eight  by  Bouchut,  one  of  seven  days  by  Weikert ;  Parrot  mentions 
several  cases,  and  Sirecley l  reports  eighteen  cases  of  diphtheria  in  the 
newly-born.  They  occurred  in  the  Hospital  Lariboisiere  in  the  spring  of 
1877,  and  were  probably  infected  by  the  nurses  of  a  neighboring  children's 
asylum.  Membranes  were  found  on  the  soft  palate,  tonsils,  or  larynx, 
and  also  on  both  pharynx  and  larynx.  One  case  occurred  where  the 
posterior  nares  alone  were  affected.  I  have  met  with  four  cases  of  diph- 
theria of  the  pharynx  and  larynx  in  the  newly-born  myself.  One  of 
these  became  sick  on  the  ninth  day  after  birth,  and  died  on  the  thirteenth 
day ;  the  other  died  on  the  sixteenth  day  after  birth  ;  the  third  was  taken 
when  seven  days  old,  and  died  on  the  ninth  day.  The  predisposition  to 
diphtheria  during  childhood 2  seems  to  be  explainable  by  several  circum- 
stances. The  mucous  membrane  of  the  mouth  and  pharynx  in  the  child 
is  more  succulent  and  softer,  and  frequently  the  seat  of  a  congestive  and 
inflammatory  process.  The  nasal  cavities  are  small  and  frequently 
affected  by  catarrhs,  the  buccal  cavity  often  the  seat  of  catarrh  and  of 
stomatitis,  and  insufficient  cleanliness  leads  here  to  irritation  of  the 
mucous  membrane.  Any  abnormal  state  of  the  mucous  membrane,  with 

1  These,  Paris,  1877. 

2  W.  N.  Thursfield  (London  Lancet,  Aug.  3d,  10th,  17th,  1878)  collects  10,000  cases  of 
diphtheria  in  England  between  the  years  1855  and  1877.     Of  these  90  per  1000  were 
under  a  year,  450  per  1000  from  1-5  years,  260  from  6-10,  90  from  11-15,  50  from  16-25, 
35  from  26-45  ;  25  per  1000  were  45  years  and  over. 


ETIOLOGY.  (J3  j 

the  exception  of  an  atrophic  condition  and  cicatricial  changes,  affords  an 
excellent  abode  for  diphtheria.  The  tonsils  are  proportionally  laro-e; 
in  fact,  we  rarely  see  the  tonsils  in  children  completely  sheltered  by  the 
arches  of  the  palate.  On  the  other  hand,  the  pharynx  is  anything  but 
spacious,  and  while  the  protuberant  condition  of  the  tonsils  affords  a  rest- 
ing-place for  the  invading  disease,  the  remaining  space  is  so  small  that  it 
becomes  a  source  of  uneasiness  to  the  well  in  many  instances,  and  very 
much  more  than  that  to  the  child  during  diphtheritic  tumefaction. 
Furthermore,  we  must  take  into  consideration  the  large  number  and  size 
of  the  lymphatics,  which  can  be  more  easily  injected  in  the  child  than  in 
the  adult,  according  to  Sappey,  and  the  fact  of  greater  intercommunica- 
tion amongst  the  lymphatics  and  between  them  and  the  system ;  for  S.  L. 
Schenck  has  found  that  the  network  of  lymphatics  in  the  skin  of  the 
newly-born,  at  least,  are  endowed  with  stomata,  loopholes  through  which 
the  lymph-ducts  can  communicate  with  the  neighborhood,  and  vice  versa.1 
These  circumstances,  although  they  may  have  no  influence  in  calling  the 
disease  into  existence,  yet  assist  in  its  development  and  in  adding  to  the 
severity  of  the  symptoms. 

On  the  other  hand,  while  the  above  reasons  go  to  prove  that  diphtheria 
attacks  children  by  preference,  there  is  again  an  anatomical  and  physio- 
logical condition — to  wit,  the  free  slightly  acid  secretion  of  the  mouth, 
beginning  with  the  third  month — that  acts  as  a  hindrance  to  the  frequent 
occurrence  of  diphtheria  after  the  third  month.  A  poison  or  poisonous 
product  of  whatever  nature  can  less  readily  find  a  hiding-place  so  long  as 
it  can  be  readily — we  might  always  say  must,  surely  be — washed  away. 
During  these  months  of  eruptive  secretion  from  the  mouth  diphtheria, 
therefore,  is  not  very  frequent ;  thus  teething,  in  the  case  of  diphtheria, 
cannot  be  held  responsible  by  mothers  fond  of  diagnosticating  dental 
diseases.  In  this  connection  the  remark  of  Krieger  ought  not  to  be 
overlooked,  who  explains  the  relative  scarcity  of  the  disease  in  the  first 
year  of  life  by  the  fact  that  cumulative  influences  will  produce  a  great 
number  of  cases,  and  cumulation  requires  time.  Undoubtedly,  however, 
an  important  etiological  consideration  is  the  fact  of  having  had  the  dis- 
ease previously.  We  can  cite  a  host  of  zymotic  diseases  the  occurrence 
of  which  once  serves  as  a  protection  against  future  attacks.  Not  only 
can  no  such  security  be  expected  after  one  attack  of  diphtheria,  but, 
cseteris  paribus,  the  disease  shows  a  preference  for  those  who  have  sur-' 
vived  a  previous  attack.  The  statement  that  only  the  mild  cases,  with 
but  slight  elevation  of  temperature  and  freedom  from  severe  constitutional 
symptoms,  are  likely  to  suffer  a  relapse  is  founded  on  error.  True,  I  have 
more  frequently  seen  relapses  after  mild  cases — which,  fortunately,  are  in 
the  majority — but  the  disease  has  also  recurred  where  originally  high 
fever  and  an  extensive  lymphadenitis  proved  it  to  be  a  severe  case. 
Besides,  second  attacks  of  membranous  croup  are  also  recorded  (Guer- 
sant,  N.  F.  Gill,  Quincke). 

As  there  are  individuals,  so  there  are  families,  which  have  a  predispo- 
sition to  diseases,  as  there  are  others  in  whom,  notwithstanding^  ample 
exposure,  infection  does  not  easily  take  place.  Yet  in  the  famih'es  in 
which  diphtheria  is  of  frequent  occurrence  it  cannot  always  be  attributed 
to  enlarged  tonsils  and  a  tendency  to  pharyngeal  or  nasal  catarrh. 
1  Mittheil.  aus  d.  Embryol.  Imtit.,  i.,  1877. 


682  DIPHTHERIA. 

Still,  catarrh  and  the  vulnerability  of  mucous  membranes  must  be  con- 
sidered as  a  frequent  source  of  diphtheria ;  children  will  get  numerous 
relapses  often  after  a  nasal  or  pharyngeal  catarrh.  Sudden  changes  in  the 
temperature  of  the  atmosphere  or  of  the  surface  of  the  body  are  therefore 
dangerous  in  predisposed  persons.  And  thus  it  is  that  while  severe  epi- 
demics have  spared  no  climate  or  land  known  to  us,  the  majority  of  cases 
have  occurred  in  winter  and  spring ;  in  other  words,  at  a  time  when 
catarrhal  disorders  are  of  most  frequent  occurrence.  In  my  experience 
at  New  York,  the  first  quarter  of  the  year  yielded  more  cases  than  any 
other.  Still,  they  are  frequent  enough  in  warm  seasons.  Krieger  insists 
upon  the  injurious  influence  of  hot  summers  and  dry  hot  rooms.  I  do 
not  doubt  the  correctness  of  his  views,  which  cannot  but  be  strengthened 
by  the  damaging  results  of  our  furnace-heating.  But  the  influence  of 
season  on  the  invasion  and  course  of  diphtheria  is  but  indirect  and  condi- 
tional, and  may  be,  perhaps,  after  all,  compared  with  that  exerted  by  filth 
— a  term  which  is  lately  used  to  express  all  sorts  and  forms  of  nastiuess, 
from  filthy  bodies  of  men  to  their  clothes,  their  habits,  their  food,  and  the 
air  they  breathe,  whether  polluted  by  carbonic  acid,  by  excremeutitious 
gases,  or  by  exhalations  of  sewers. 

Cases  of  diphtheria  which  are  traced  to  exhalations  from  sewers  (or 
even  to  filthy  habits  of  life)  are  very  frequent.  Yet  typhoid  is  attributed 
to  the  same  causes.  So  is  dysentery.  Can,  then,  foul  exhalations  pro- 
duce alike  diphtheria,  typhoid,  and  dysentery?  Do  these  diseases  arise 
from  a  common  poison?  Or  is  the  poison  of  a  treble  character,  so  that 
a  part  may  give  origin  to  diphtheria,  another  part  to  typhoid,  a  third 
to  dysentery?1  Have  we  to  deal,  in  such  occurrences,  with  specific 
influences,  or  only  with  a  lowering  of  the  standard  of  health,  thereby 
affording  other  morbid  influences  an  opportunity  to  exercise  their  power  "f 
These  questions  are  still  involved  in  darkness,  and  constitute  problems  the 
solution  of  which  still  engages  the  minds  of  both  individual  writers  and 
authorities.  A  report  of  the  Board  of  Health  of  Massachusetts,  closely 
adhering  to  the  results  of  exact  observations,2  leaves  them  doubtful,  and 
the  affirmative  reports  of  some  modern  writers  do  not  bear  scrutiny.3 

Air  polluted  by  bad  drainage  or  leaky  sewers  has  been  considered 
responsible  for  diphtheria  as  well  as  for  typhoid  fever  and  dysentery. 
Not  only  the  impairment  of  general  health,  but  the  direct  and  unmis- 
takable disease,  has  been  attributed  to  it.  Thus  Bayley  refers,  in  the 
endemic  of  Bromley,4  the  first  cases  to  unventilated  sewers  and  cesspools. 
School-children  multiplied  the  disease.  Thursfield  attributes  the  diph- 
theria at  Ellesmere 5  to  the  accumulation  of  excrements  under  the  school- 
room, and  to  deficient  supply  of  water,  which,  moreover,  was  of  bad  qual- 
ity. Tripe  (like  Railton,  Bailey,  Russell,  Bell)  accuses  sewer  gas ; 6  others 
polluted  waters  or  bad  drainage.7  I  have  not  been  convinced,  however, 
that  diphtheria  can  be  considered  a  sewer-gas  disease,  in  the  same  way  as 
typhoid  fever.  The  deterioration  of  the  general  health  resulting  from  the 
inhalation  of  foul  air  is  sufficient  to  explain  the  outbreak  of  the  individ- 
ual attack  during  a  prevailing  epidemic. 

1  In  regard  to  the  causal  connection  of  the  two  latter  diseases  with  sewer  exhalations 
we  can  be  more  positive  than  in  regard  to  the  former. 
1  Author's  Treatise  on  Diphth,.,  p.  :>>. 

3  M.  A.  Averv,  Med.  Jour,  and  Ohxt.  Rev.,  Feb.,  1882.        *Sanit.  Record,  Aug.  10,  1877. 
5  San.  Rec.,  158,  1877.  *  Ibul.,  June  14,  1878.  T  Ibid.,  April  18,  May  2,  1879. 


ETIOLOGY.  683 

In  regard  to  polluted  water,  I  do  not  think  that  pathologists  who 
attribute  infectious  diseases  to  bacteria  only  are  justified  in  condemning 
it.  It  may  not  be  so  guilty,  after  all,  for  the  admixtures,  inorganic  and 
organic,  minerals,  admixtures  of  wood  and  plants,  also  lower  fungi  and 
their  products — algae,  infusoria — would  render  water  rather  disagreeable, 
but  not  exactly  unhealthy.  The  latter  eifect  can  be  accomplished — always 
assuming  the  bacteria  theory  correct,  for  the  sake  of  argument — by  bac- 
teria only.  But  when  they  arrive  in  the  stomach,  their  doom  is  sealed; 
they  are  decomposed.  The  only  places  where,  possibly,  they  could  take 
root  would  be  diseased  or  ulcerated  places  in  either  the  oral  cavity  or  the 
upper  portion  of  the  oesophagus. 

Not  only  water,  but  the  milk  of  animals  also,  has  been  accused  of 
being  the  direct  cause  of  diphtheria.  Powers  concludes,  though  a 
connection  between  diphtheria  and  the  consumption  of  milk  have  not 
been  proven  as  yet,  that  it  is  very  probable  indeed.  His  careful  investi- 
gations into  the  causes  of  some  local  epidemics  in  North  London  exclude 
any  other  source  from  which  the  people  could  have  been  affected.  Per- 
haps one  of  the  forms  of  garget,  cow  mammitis,  is  of  an  infectious  cha- 
racter. His  reasoning,  however,  is  not  accepted  by  A.  Dowrus,1  who  still 
believes  that  the  milk  which  gave  rise  to  diphtheria  at  a  distance  may  have 
been  soiled  and  infected.  For  though  the  connection  between  milk  and  scar- 
latina and  typhoid  fever  had  been  known  for  years  and  variously  studied, 
no  observation  of  the  kind  had  yet  been  made  in  regard  to  diphtheria. 
Besides,  where  the  young,  in  England,  drink  much  milk — viz.  in  the 
cities — diphtheria  was  very  much  less  frequent  than  where  little  or  no 
milk  was  taken — viz.  in  the  country.  Even  in  the  country  the  well-to- 
do  classes,  who  drink  milk,  had  but  little  diphtheria,  while  the  children 
of  the  poor,  who  obtained  none,  suffered  a  great  deal  from  it. 

In  regard  to  this  transmission  of  diphtheria  by  means  of  milk  O.  Bol- 
linger2  hesitates  to  express  any  opinion,  except  that  the  matter  is  very 
doubtful  indeed.  Probably  the  possibility  of  contracting  diphtheria 
directly  from  animals  is  very  much  greater  than  the  danger  from  water 
or  milk.  On  a  Pomeranian  farm,  during  the  winter  1875-76,  every 
newly-born  calf  died  of  diphtheria.  The  superintendent  of  the  farm  and 
the  woman  who  attended  to  the  calves  were  taken  with  diphtheritic 
angina.3  Similar  occurrences  have  been  recorded.  Bellinger  reports  a 
mycotic  disease  of  the  trachea  and  lungs  in  birds. 

Friedberger's  report,4  presented  to  the  Veterinary  Society  of  Munich, 
on  croup  and  diphtheria  of  domestic  fowls,  leaves  no  doubt  as  to  its  fre- 
quency, particularly  amongst  the  nobler  varieties. 

Nicati5  studied  an  epidemic  diphtheria  amongst  hens  which  nad_  si 
lar  symptoms  and  a  course  very  much  like  that  in  man ;  it  could  be  innoc- 
ulated  into  other  animals,  and  was  contemporaneous  with  the  outbrea     at 
the  epidemic  amongst  the  human  population  of  Marseilles, 
succeeded  in  inoculating  a  healthy  hen  from  a  diphtheritic  one,  but  1 

1  "Diphtheria  and  Milk-Supply,"  Brit.  Med.  Journ.,  Feb.  1,  1879. 

*  D.  Z.f.  Thie>~med,.  ».  vergleich.  Pathol.,  vi.,  1879,  p.  7. 
8  Damman,  in  D.  Zeitxch.  f.  Thiermed.,  1876,  p.  1. 

*  /).  Zeitsch.  f.  Thiermed.,  v.,  1879,  p.  16. 

6  Revue  d'  Hyqten*  ft  de  Police  sanitaire,  1879,  p.  6.  jij^w     i«7Q 

«"De  la  transmission  de  la  Diphth.  des  An.maux  a  I'Homme"  Oaz.  hebtam.,  I 

AvrU  25. 


684  DIPHTHERIA. 

attempts  at  transmission  to  dog,  pig,  and  man  were  unsuccessful.  The 
Med.  and  Surg.  Journal1  contains  the  following:  In  a  house  at  Ogdens- 
burg,  N.  Y.,  five  children  were  ill  with  diphtheria.  Three  kittens  who 
had  been  playing  with  them  from  time  to  time  took  the  disease  and  died. 
Post-mortem  examination  showed  diphtheritic  membranes  in  their 
throats.2 

Gerhardt3  reports  the  following:  2600  hens  were  imported  from 
Verona,  Italy,  into  a  village,  Messelhausen,  in  Baden.  Some  of  these 
hens  were  affected  with  diphtheria  when  they  arrived.  "Within  six  weeks 
600  of  their  number  died  of  diphtheria,  and  800  more  soon  after.  In 
the  following  summer  1000  chickens  were  raised  by  artificial  breeding, 
all  of  which  died  of  diphtheria  within  six  weeks.  Five  cats  kept  in  the 
place  also  died  of  diphtheria ;  a  parrot  fell  sick  with  it,  but  recovered. 
An  Italian  cook,  suffering  from  diphtheria,  in  the  mouth  of  November, 
1881,  while  being  subjected  to  local  treatment  with  carbolic  acid,  bit  the 
head-nurse's  left  foot  and  hand.  Both  these  wounds  became  diphtheritic, 
the  man  falling  sick  with  high  fever,  and  requiring  three  weeks  for  his 
gradual  recovery.  Besides,  four  of  the  six  workiugmen  employed  in 
taking  care  of  the  hens  of  the  establishment  Were  taken  with  diphtheria. 
Not  a  single  case,  however,  occurred  in  the  neighboring  village.  Thus, 
it  is  safe  to  assume  that  the  diphtheritic  disease  of  hens  can  be  trans- 
mitted to  man. 

Diphtheria  may  be  also  produced  by  outside  influences.  In  this 
regard  the  attempts  at  generating  pseudo-membranes  by  artificial  means 
are  very  interesting  indeed.  As  early  as  1826,  Bretonneau,  by  the  intro- 
duction of  tincture  of  cantharides  and  olive  oil  into  the  trachea,  suc- 
ceeded in  producing  a  "dense,  elastic,  reed-like  membranous  concretion." 
Delafond  called  croup  into  existence  by  the  use  of  ammonia,  oxygen, 
chlorine,  corrosive jsublimate,  arsenic,  and  sulphuric  acid.  On  the  other 
hand,  H.  Mayer  asserts  that  it  is  impossible,  by  means  of  ammonia,  to 
produce  a  croup  in  the  windpipes  of  animals  which  in  the  slightest  degree 
resembles  that  occurring  in  human  beings.  Trendelenburg,  however, 
after  producing  membranes  in  the  trachea  by  the  use  of  a  solution  of 
corrosive  sublimate  (1  : 120),  succeeded  in  hardening  the  entire  mass  with 
bichromate  of  potassium,  which  it  was  impossible  to  do  with  the  most 
tenacious  mucus. 

Rey  observed  croup  in  horses  that  inhaled  smoke  in  a  burning  stable.4 
In  the  collection  of  the  veterinary  school  of  Zurich  there  is  a  croup  mem- 
brane from  a  heifer  which  had  been  exposed  to  a  fire  ;  at  Munich,  one 
from  the  trachea  of  a  horse,  produced  by  forcibly  injecting  medicines 
into  the  nose.  Hahu  made  an  observation  on  cows,  W.  Ammon  on 
horses,  of  long  croup  membranes  after  the  animals  had  been  exposed  to 
smoke  and  fire ;  and  Oertel  constantly  insists  on  there  being  "  no  actual 
difference  between  croup  as  it  ordinarily  occurs  and  that  excited  in  the 
windpipe  of  a  rabbit  by  means  of  ammonia.  The  color  and  texture,  the 
physical,  chemical,  and  histological  characteristics,  are  identical." 

1  Med.  Rec.,  Nov.  8, 1879. 

'An  elaborate  description  of  the  croupo-diphtheritic  inflammations  of  mucous  mem- 
branes in  hens,  turkeys,  pheasants,  and  pigeons  may  be  found  in  Z'drn.  Krankh.  d. 
Hausyeflilyds,  1882,  p.  i04. 

3  Verhandlungen  des  (ii.)  Congresses  fur  Tnnere  Medicin,  Wiesbaden,  1883,  p.  129. 

*  Journ.  de  med.  vet.  de  Lyon,  1850,  p.  249. 


MORBID  ANATOMY.  685 

_  MORBID  ANATOMY.— Either  the  membrane  or  the  granular  infiltra- 
tion is  characteristic  of  diphtheria.  The  statement  that  the  former  occurs 
only  when  atmospheric  air  can  gain  access  thereto,  as  A.  d'Espiue  and  C. 
Picot  still  hold,1  is  plainly  contradicted  by  its  appearance  on  the  mucous 
membrane  of  the  lower  intestines.  The  condition  of  the  membrane  is 
not  unalterable,  any  more  than  the  clinical  symptoms  of  the  disease,  for, 
according  to  different  circumstances,  epithelium,  mucus,  blood, '  and 
vegetable  parasites  are  added  thereto.  The  membrane  can  either  be 
lifted  from  the  mucous  membrane  on  which  it  lies  or  is  imbedded  into 
and  underneath  it.  In  the  first  instance,  it  consists  to  a  great  extent  of 
fibrin,  the  result  either  of  epithelial  changes  or  derived  directly  from  the 
exuded  blood-serum.  E.  Wagner,  who  makes  no  anatomical  distinction 
between  croup  and  diphtheria,  considers  epithelial  changes  the  principal 
source.  The  pavement  epithelium  becomes  altered  in  a  peculiar  manner. 
It  becomes  turbid,  larger,  dentated,  and  dissolves  into  a  network ;  it  is  at 
first  uninhabited,  but  serves  later  as  the  vehicle  of  newly-formed  cells 
there  also  occurs  a  considerable  infiltration  of  the  mucous  membrane 
pus-cells  and  granules;  besides,  the  cellular  tissue  is  studded  with 
granules,  the  granular  degeneration  resulting  sometimes  in  necrotic 
destruction,  which  is  looked  upon  by  Virchow  as  the  most  important 
element  in  severe  forms  of  diphtheria.  The  several  conditions  or  degrees 
may  occur  independent  of  each  other,  associated  or  in  succession.  Classen 
shares  Wagner's  views,  but,  according  to  Boldygrew,  the  pseudo-mem- 
brane consists  of  successive  coagulations  of  a  fibrinous  fluid  which 
exudes  from  the  diseased  surface.  Steudener  also  opposes  the  views  of 
Wagner.  He  does  not  believe  in  the  probability  of  an  exclusively  en- 
dogenous origin  of  the  cellular  elements  of  croup  membrane ;  in  fact,  he 
doubts  the  occurrence  of  an  endogenous  formation  of  pus-globules  in  epi- 
thelium. Croupous  membrane,  according  to  him,  is  formed  by  the 
migration  of  numerous  white  blood-globules  through  the  walls  of  the 
vessels  in  the  mucous  membrane,  and  by  a  direct  formation  of  fibrin 
from  the  transuded  plasma.  In  addition  to  this,  the  mucous  membrane 
is  stripped  of  its  epithelium  (except  at  the  mouths  of  the  acinous  glands) 
and  infiltrated  with  migrating  cells.  Fresh  croupous  membrane  consists 
of  a  delicate  network  of  homogeneous  structure  and  shining  appearance, 
in  which  numerous  cells  and  the  epithelium  of  the  various  layers  of  the 
trachea  are  imbedded.  In  old  membranes  the  cells  are  destroyed  by 
granular  degeneration  and  general  maceration.  Tenacious  mucus  with 
pus-cells  and  detritus  are  then  found.  C.  Weigert  looks  upon  the 
deposits  as  analogous  to  those  on  serous  membranes.  Every  inflamma- 
tion yields  an  exudation  which  may  coagulate  when  the  coagulating  fer- 
ment is  added.  This  latter  is  probably  produced  by  the  white  blood-cells 
when  in  disintegration.  But  he  does  not  say  why  it  is  that  there  is  no 
such  coagulation  in  suppurative  processes,  where  the  leucocytes  are  more 
numerous.  He  believes  himself  justified  in  establishing  pathological 
differences  of  croup,  pseudo-diphtheria,  and  diphtheria.  A  croupous 
inflammation  means  destruction  of  epithelium,  which  gives  rise  to  a 
fibrinous  exudation  upon  the  surface,  while  the  cellular  tissue  remains 
intact  The  only  difference  between  it  and  the  pseudo-diphtheritic 
inflammation  is  looked  for  in  the  larger  number  of  emigrated  white 
1  Man.  prat,  rfes  mat.  de  Penfance,  1877,  p.  81. 


686  DIPHTHERIA 

blood-cells.  The  superficial  deposit  consists,  to  a  great  part,  of  them  and 
the  fibrinous  exudation.  When  there  are  but  few  leucocytes  the  deposit 
is  a  network  of  fibrillse  (croup).  When  there  are  many,  the  masses  are 
more  solid  and  voluminous  (pseudo-diphtheritis).  When,  however,  the 
tissue  is  changed  into  a  hard  substance  resembling  coagulated  fibrin, 
when  the  exudation  does  not  exist  on  the  surface,  but  takes  place  into  the 
mucous  membrane,  the  process  is  diphtheria.  Zahii  also  establishes 
three  varieties — viz.  1st,  such  as  result  from  a  peculiar  degeneration  of 
pavement  epithelium;  2d,  such  as  originate  in  the  solidification  of  a 
muco-fi brinous,  and,  3d,  of  a  fibrino-purulent,  exudation.  Each  of  these 
varieties  may  contain  colonies  of  micrococci,  but  these  organisms  are 
neither  essential  nor  are  they  constantly  found. 

The  diphtheritic  process  does  not  merely  consist  of  the  membranous 
changes  in  the  pharynx  and  air-passages.  Its  fatal  cases  have  afforded 
marked  evidence  of  the  implication  of  most  of  the  organs.  Refiner's  17 
3ases  give  the  following  post-mortem  results  :  the  lungs  were  hypera3mic 
in  8  cases,  twice  the  seat  of  pneumonia,  and  three  times  of  embolic  infarc- 
tions ;  in  addition,  emphysema  in  1 2,  cedema  in  6,  atelectasis  in  7,  sub- 
pleural  ecchymoses  in  7,  pericardial  ones  in  4.  The  heart-muscle  had 
undergone  fatty  degeneration  in  6,  and  was  the  seat  of  ecchymoses  of 
the  size  of  a  pin's  head  in  3.  In  addition  to  frequent  hypersemic  condi- 
tions of  the  abdominal  viscera,  emboli  of  the  liver  in  3  (with  capillary 
hemorrhages  of  the  peritoneal  covering  in  1),  emboli  of  the  spleen  in  5, 
desquamative  nephritis  in  7  (in  6  of  which  there  were  colonies  of  micro- 
cocci  in  the  uriniferous  tubules),  cellular  hyperplasia  of  the  cervical  aud 
mediastmal  glands  in  14  (complicated  in  6  with  capillary  hemorrhages  in 
the  glandular  tissue).  The  blood  was  frequently  normal,  very  often 
watery  and  dark,  at  times  leucocythaemic.  Thus  the  disease  exerts  its 
influence  everywhere. 

Rindfleisch  defines  diphtheritic  inflammation  as  that  form  of  inflam- 
mation which  produces  a  coagulating  necrosis  in  the  tissues  by  the  immi- 
gration of  schizomycetse.  The  coagulating  necrosis  differs  from  the  usual 
form  of  necrosis  in  this,  that  the  change  from  life  to  death  is  accompanied 
with  the  coagulation  of  fluid  albuminoids.  This  process  takes  place 
mainly  in  the  interior  of  cells  and  other  parts  of  tissues,  and  therein 
differs  from  the  coagulation  of  fibrin.  In  the  cells  there  is  taking  place 
a  peculiar  homogenization  of  protoplasm ;  at  the  same  time  the  nuclei 
disappear,  and  are  changed  into  irregular  masses  liable  to  cohere  and 
form  membranous  conglomerates,  which  owe  their  peculiar  wax  color  to 
the  invasion  of  a  solid  albuminoid  endowed  with  a  strong  tendency  to 
refract  the  light.  Coagulating  necrosis  is  found  in  circumscribed  localities, 
and  gives  rise,  in  the  neighborhood,  to  a  marked  amount  of  inflamma- 
tion and  suppuration,  which  leads  to  the  expulsion  of  the  necrotic  part, 
with  more  or  less  loss  of  substance — either  mild  or  phagedenic  ulcera- 
tion. 

Leyden  describes  a  gray  degeneration  of  the  muscular  tissue  which  he 
believes  to  be  truly  inflammatory,  and  Unruh  has  lately  published  an 
account  of  some  cases  in  which  myocarditis  occurred.  In  Leyden's  cases, 
the  muscular  nuclei  were  increased,  became  atrophied,  and  underwent 
fatty  degeneration,  giving  rise  thereby  to  extravasations,  softening,  dilata- 
tion and  debility  of  the  heart,  with  general  debility,  collapse,  and — prob- 


MORBID  ANATOMY.  687 

ably  by  reflex  action  on  other  branches  of  the  pneumogastric — vomiting. 
Micrococci  he  found  neither  in  the  heart  nor  in  the  kidneys. 

In  the  heart,  particularly  on  the  right  side,  numerous  thrombi  are  fre- 
quently found  in  various  stages  of  development;  its  muscular  tissue  is  often 
in  a  state  of  fatty  degeneration  or  the  seat  of  parenchymatous  inflammation 
and  hemorrhages.  Bridges  first  called  attention  to  the  occurrence  of  endo- 
carditis in  diphtheria.1  This  complication,  which,  however,  occurs  more 
frequently  with  rheumatism,  puerperal  fever,  diphtheria  of  wounds,  pyaemia, 
and  old  valvular  affections  than  in  the  course  of  an  acute  diphtheria,  does 
not,  tis  found  in  the  latter  affection,  consist  simply  of  a  fatty  degeneration  and 
subsequent  ulceration,  but  is  considered  a  genuine  diphtheritic  process  (Vir- 
chow),  affecting  the  mitral  valve  more  frequently  than  the  tricuspid  or  pul- 
monary valves.  It  begins  with  hypersemia  and  the  exudation  of  plasma  in 
the  cellular  elements,  so  that  they  appear  larger  and  darker.  The  granu- 
lations which  form  are  frail  and  easily  destroyed,  so  that  ulcers  form  on 
which  fibrin  is  deposited,  and  whence  it  is  conveyed  as  emboli  into  the 
terminal  arteries  (Cohnheim)  of  the  spleen,  nerves,  brain,  and  eye. 
Infarctions  may  also  occur  in  the  valveless  veins  of  these  organs,  giving 
rise  rather  to  small  multiple  abscesses  than  to  large  purulent  collections. 
Suppuration  but  rarely  takes  place  in  the  heart ;  the  granular  mass  found 
there  resists  the  action  of  sether  and  alcohol,  and  spreads  throughout  the 
cardiac  parenchyma,  so  that  perforation  of  the  septum  and  of  the  right 
auricle  and  aorta  has  been  observed. 

Bouchut  and  Labadie-Lagrave,  out  of  15  cases  of  diphtheria,  met 
in  14  with  a  plastic  endocarditis,  which  became  the  source  of  emboli. 
Thus,  there  were  infarctions  of  the  lungs,  at  times  in  their  centre  color- 
less, at  other  times  in  a  state  of  purulent  degeneration;  superficial  thrombi 
of  the  small  veins  of  the  heart,  subcutaneous  connective  tissue,  pia  mater, 
brain,  and  liver ;  and  in  addition,  moderate  leucocytosis. 

The  lungs  exhibit  (post-mortem)  all  sorts  of  inflammatory  and  con- 
gestive conditions,  with  their  consequences,  as  oedema,  catarrh,  broncho- 
pneumonia,  atelectasis,  emphysema,  ecchymoses,  and  large  infarctions. 

The  spleen  (and  occasionally  the  liver)  is  frequently  large,  congested, 
and  friable,  and  studded  with  infarctions  to  a  greater  or  less  extent^  ^ 

The  kidneys  are  either  simply  congested  or  the  seat  of  nephritis  or 
infarctions.  The  same  forms  of  *  inflammation  which  accompany  scarla- 
tina— to  wit,  the  desquamative  and  the  diffuse — are  here  observed.  The 
diffuse  form  is  not  of  so  frequent  occurrence  as  in  scarlatina,  but  Is  some- 
times extensive  and  dangerous. 

The  muscles  occasionally  exhibit  ecchymoses,  and  are  at  tunes  the  seat 
of  parenchymatous  inflammation,  gray  degeneration,  and  atrophy. 

The  lymphatic  glands  are  frequently  inflamed  and  swollen,  either  hard 
or  doughy,  oedematous  or  congested.  Large  abscesses  are  rare.  It  is 
more  especially  the  gland  tissue,  and  less  the  connective  tissue  of  the 
glands,  which  takes  part  in  the  pathological  process.  The  periglandular 
tissue  very  soon  becomes  involved,  however.  Necrotic  foci  have  been 
described  by  Bizzozero.  When  the  entire  surface  of  the  mucous  mem- 
brane of  the  mouth  and  of  the  air-passages,  from  the  nose  to  the  trachea, 
is  the  seat  of  the  disease,  there  is  an  impregnation  of  the  mucous  mem- 
brane, from  the  epithelial  surface  to  the  submucous  tissue,  of 
1  Med  Times  and  Qcut.,  ii.  p.  204. 


688  DIPHTHERIA. 

tongue,  borders  of  the  lips,  and  frequently  of  the  lips  and  cheeks,  as  well 
as  of  the  tonsils,  the  lower  portion  of  the  nasal  cavities  and  the  upper, 
and  especially  the  anterior,  portion  of  the  larynx.  The  fossse  Morgagni 
and  the  posterior  aspect  of  the  soft  palate  are  more  frequently  affected  in 
the  same  way  than  the  anterior  aspect.  Small  isolated  spots  are  found 
on  the  tonsils  and  occasionally  on  the  posterior  wall  of  the  pharynx. 
The  so-called  croupous  form — that  is  u)  say,  the  one  in  which  the  mem- 
branes deposited  may  either  be  removed  in  large  patches  or  lie  macerated 
in  the  profuse  secretion  of  subjacent  mucous  glands — is  found  partly  in 
the  nasai  cavities,  on  the  posterior  surface  of  the  soft  palate,  and  also  in 
the  trachea  and  its  subdivisions. 

The  character  of  the  mucous  membrane  varies  with  the  locality,  Its 
different  elements,  as  the  epithelium,  the  basement  membrane,  the  con- 
nective tissue  mingled  with  elastic  fibres,  the  blood-vessels,  the  nerves 
from  the  cerebro-spinal  and  sympathetic  systems,  and  the  papillae  and 
ducts  of  numberless  glands,  all  influence  the  pathological  process  going 
on  upon  the  surface.  Their  distribution  in  the  oral  cavity  and  the  respi- 
ratory organs  is  a  very  interesting  study,  and  in  a  table  already  published,1 
I  have  exhibited  it  in  a  condensed  tabular  form. 

Where  elastic  tissue  predominates,  diphtheritic  impregnation  is  slow  to 
take  place,  and  recovery  is  also  slow  when  the  tissue  has  finally  submitted. 
Pavement  epithelium  yields  the  easiest  foothold  to  diphtheritic  mem- 
brane. Thus  it  is  that  the  tonsils,  not  from  their  prominent  situation 
alone,  favor  the  reception  and  development  of  the  infection.  But  the 
elastic  and  connective  fibres  when  once  affected  are*  apt  to  harbor  the 
disease  a  long  time.  Still,  there  is  another  reason  why  the  diphtheritic 
process  should  favor  the  tonsils.  For  Th.  Hohr  has  demonstrated  that 
their  epithelium  exhibits  interruptions  in  its  continuity.  Through  them 
round  cells  may  emigrate.  Wherever  the  epithelial  covering  of  the  integ- 
uments (skin  or  mucous  membrane)  is  intact  and  unbroken,  diphtheria 
takes  hold  with  difficulty.  But  where  a  defect  is  established,  large  or 
small,  diphtheritic  formations  will  be  apt  to  take  place  according  to  the 
size  of  the  abrasion.  This  is  one  of  the  modes  of  the  formation  of  small 
diphtheritic  deposits  on  the  tonsils,  which  it  has  been  the  tendency  of 
many,  both  practitioners  and  authors,  to  honor  with  special  names. 

Ciliated  epithelium  is  not  so  liable  to  be  affected.  It  occupies  a  higher 
rank  in  the  scale  of  animal  formations,  has  a  more  complex  function  and 
a  greater  power  of  resistance.  The  presence  of  a  large  number  of  mucous 
glands  impedes,  as  a  rule,  by  the  presence  of  the  normal  secretion,  an 
extensive  destructive  action  upon  the  tissues.  The  secreted  mucus  assists 
in  removing  epithelial  masses,  and  even  fibrinous  exudations,  from  the  sur- 
face. Thus  it  is  that  the  deposits  in  the  respiratory  portion  of  the  nasal 
cavities  are  frequently  cast  off  through  the  nostrils,  and  in  a  similar  manner 
the  membranes  that  have  formed  in  the  trachea  are  ejected  in  a  semi-solid 
condition  through  the  opening  made  by  tracheotomy.  The  large  number 
of  mucous  glands  in  the  larynx  and  trachea  is  unquestionably  the  reason 
why  the  lymphatic  vessels  of  the  mucous  membrane  are  not  influenced 
by  the  overlying  loosened  masses,  and  will  not  absorb ;  hence  laryngeal 
and  tracheal  diphtheria,  when  not  complicated,  have  decidedly  a  local 
character,  and  are  usually  devoid  of  constitutional  symptoms.  For  the 

1  Treatise  on  Diphtheria,  p.  126. 


DIAGNOSIS.  689 

same  reason  the  usual  form  of  tonsillar  diphtheria  is  a  mild  disease.  On 
the  other  hand,  the  large  number  and  size  of  the  lymphatic  ducts  of  the 
Schneiderian  mucous  membrane,  as  well  as  their  'direct  communication 
with  the  lymphatic  glands  of  the  neck,  accounts  for  the  dangerous  cha- 
racter of  nasal  diphtheria. 

Diphtheria  of  the  intestinal  canal  is  characterized  by  fibrinous  deposits 
on  the  surface  and  in  the  tissues  of  the  intestine,  with  subsequent  granu- 
lar degeneration.  It  is  mostly  preceded  by  a  catarrhal  process.  The 
same  condition  is  found  in  the  urinary  organs. 

There  are  but  few  autopsies  of  cases  which  have  died  of,  or  during, 
diphtheritic  paralysis.  In  some  instances  there  was  considerable  thicken- 
ing of  the  spinal  nerves  at  the  junction  of  the  posterior  and  anterior  roots, 
with  hemorrhages.  The  superficial  connective  tissue  in  these  places  exhib- 
ited a  diphtheritic  exudation  (Buhl).  There  was  in  the  sheath  of  the 
nerves  of  the  cerebral  and  spinal  meninges  and  in  the  gray  substance 
of  the  cord  voluminous  nuclear  infiltration ;  in  one  case  there  were  exten- 
sive hemorrhages  in  the  spinal  meuinges,  with  nuclear  proliferation  in  the 
gray  substance  of  the  cord  (Oertel).  Disseminated  meningitis  with  peri- 
neuritis  of  the  neighboring  roots,  characterized  by  infiltration  of  nuclei 
between  the  uerve-fibrillse  was  found  by  Pierret ;  and  degeneration  of  the 
palatine  nerves  and  fatty  degeneration  of  the  palatine  muscles  by  Charcot 
and  Vulpian.  Dejerine,  in  five. autopsies,  records  an  atrophy  of  the  ante- 
rior roots  secondary  to  a  myelitic  degeneration  of  the  ganglia  of  the  anterior 
horns.  E.  Gaudier  found  the  same  in  the  case  of  a  boy  who  died  with 
paralysis  of  the  muscles  of  deglutition,  of  the  extremities,  and  of  the 
trunk.  In  a  child  of  two  years  with  paralysis  of  the  palate  and 
extremities  the  autopsy  was  negative.  In  two  cases  Dejerine  reports 
finding  changes  in  the  intramuscular  nerves,  such  as  liquefaction  of 
my  el  in  and  loss  of  axis  cylinders. 

'Thus,  Buhl,  Charcot,  Vulpian,  and  Dejerine  are  unanimous  about  an 
aifection  of  the  peripheric  nerves  and  muscles.  Oertel,  Dejerine,  and 
Gaucher  believe  in  a  disease  of  the  spinal  cord.  It  is  true  that  a 
disease  of  the  gray  substance  would  fully  explain  the  symptoms  of  the 
bad  cases,  but  what  we  know  of  poliomyelitis  anterior,  with  which  this 
aifection  would  be  identical,  precludes  the  idea  of  the  rapid  and  almost 
certain  complete  recovery.  Therefore,  in  most  cases,  diphtheritic  paral- 
ysis consists  of  a  trophic  affection  of  the  motor  system,  almost  always  seated 
peripherally  in  the  nerves  and  muscles,  seldom,  if  ever,  in  the  centres. 
This  aifection  must  be  compared,  in  most  of  its  relations,  with  the  degen- 
erative processes  taking  place  in  the  muscular  tissue  after  typhoid  fever, 
or  in  the  renal  epithelium  after  infectious  diseases,  both  of  which  give 
rise  to  serious  results,  with  usually  a  favorable  termination. 

DIAGNOSIS. — The  characteristic  sign  of  diphtheria  is  either  the  mem- 
brane or  the  gray  infiltration,  with  more  or  less  injection  of  the  surround- 
ing parts.  In  regard  to  this  greater  or  less  injection,  I  will  say  that 
pharyngeal  congestion,  when  it  is  uniform,  may  or  may  not  point  to 
imminent  diphtheria.  When  it  is  local,  confined  to  one  side  mainly,  it  is 
either  traumatic  or  diphtheritic.  White  spots  which  are  easily  washed 
away,  or  which  can  be  removed  with  a  brush,  or  squeezed  out  of  the  follicles 
of  tiie  tonsils,  into  which  a  probe  can  be  introduced  sometimes  to  the 
depth  of  one-half  inch,  soon  announce  their  true  character— viz.  either  a 

VOL.  I.— 44 


690  DIPHTHERIA. 

simple  catarrhal  secretion  or  suppuration.  Even  though  the  superficial 
deposit  contain  oidium  or  leptothrix  in  considerable  numbers,  it  can  easily 
be  removed ;  I  have  only  known  the  totally  inexperienced  to  mistake 
muguet  (thrush)  for  diphtheria.  In  the  larynx  muguet  is,  moreover, 
very  rare  indeed,  and  always  circumscribed.  It  is  sometimes  seen  on  the 
true  vocal  cords.  The  gray  discoloration  of  superficial  follicular  ulcera- 
tions,  as  observed  in  the  ordinary  form  of  stomatitis  follicularis,  can 
hardly  fail  to  be  recognized.  Such  patches  are  very  numerous  in  the 
fauces  and  on  the  lips  and  cheeks — never  on  the  gums,  except  in  ulcerous 
stomatitis  (which  is  not  follicular).  They  are  accompanied,  too,  by 
vesicles  containing  more  or  less  serum  which  have  not  yet  ruptured.  It 
must  be  remembered,  however,  that  the  mucous  membrane,  when  deprived 
of  its  superficial  covering,  is  liable  during  an  epidemic  of  diphtheria  to 
become  infected,  like  every  other  wound.  I  have  seen  cases  in  which 
stomatitis  and  diphtheria  existed  side  by  side,  the  latter  having  invaded 
the  surfaces  exposed  by  the  former.  The  examination  of  the  entire 
throat  is  not  always  easy.  Very  young  children  vomit  frequently  and 
persistently  before  the  whole  surface  is  exposed  to  view,  and  not  infre- 
quently repeated  examination  with  the  spatula  is  absolutely  necessary. 
In  general,  however,  the  slight  attempts  at  vomiting  suffice  to  cause  a 
great  part  of  the  swollen  posterior  portion  of  the  tonsils  to  become  visible. 
I  have  heard  that  the  pale  surface  of  old  hyperplastic  tonsils  has  been 
mistaken  for  diphtheria  ;  I  merely  mention  the  fact.  When  a  discolora- 
tion happens  to  be  the  result  of  a  deposited  flake  of  mucus,  a  drink  of 
water  will  remove  it. 

Fever  is  not  always  a  prominent  symptom;  as  a  rule,  simple  diphthe- 
ria of  the  tonsils  is  accompanied  by  very  little  fever.  Still,  there  are 
plenty  of  exceptions.  But  the  differences  of  temperature  are  not  more 
striking  than  in  most  other  infectious  diseases,  whose  either  mild  or 
severe  invasion  may  offer  an  obstacle  to  immediate  diagnosis.  As  the 
height  of  the  fever  does  not  absolutely  determine,  or  even  indicate,  the 
character  of  the  subsequent  course  of  the  disease,  but  little  importance  is 
to  be  attached  to  the  temperature  unless  there  be  a  very  marked  eleva- 
tion. A  sudden  rise  frequently  occurs  with  lymphadenitis.  High  fever 
in  the  beginning  may  render  the  diagnosis  difficult  or  may  postpone  it. 

The  absence  of  glandular  swelling  does  not  exclude  the  diagnosis  of 
diphtheria,  for  when  the  tonsils  are  affected  by  the  disease  there  is  usually 
little  or  no  swelling  of  the  neighboring  glands.  Swelling  of  the  glands 
enables  us  to  locate  the  affection  in  a  mucous  membrane  richly  endowed 
with  lymphatic  vessels.  It  is  very  marked  when  the  nose  is  affected. 
A  few  hours'  duration  of  nasal  diphtheria  suffices  for  the  development 
of  a  severe  lymphadenitis,  especially  at  the  angles  of  the  jaw.  When 
the  latter  condition  is  found  to  exist,  the  throat  should  be  examined  with 
the  idea  of  finding  a  membrane  extending  upward ;  nasal  diphtheria  is 
very  liable  to  complicate  an  affection  of  the  uvula  and  arches  of  the 
palate.  The  membrane  cannot  well  be  seen  by  looking  through  the  nos- 
trils ;  highly  serviceable  for  this  purpose  is  a  very  short,  broad  rhino- 
scope  reaching  upward  to  the  bony  structure  of  the  nose.  However, 
nasal  diphtheria  may  frequently  be  diagnosticated  some  days  before  the 
membrane  becomes  visible,  by  the  rapid  development  of  lymphadenitis ; 
this  may  be  done  even  where  the  sweetish,  musty  odor  of  certain  forma 


DIAGNOSIS.  .  691 

of  diphtheria  is  absent.  Still,  nasal  diphtheria  may  occur  without  much 
lymphadenitis  ;  as,  for  instance,  when  the  blood-vessels  are  very  numerous 
and  superficial,  and  thereby  give  rise  to  slight  hemorrhages  at  the  very 
beginning  of  the  sickness.  In  such  cases  the  lymphatic  vessels  are  little, 
if  at  all,  required  to  transmit  the  poison,  the  open  blood-vessels  replacing 
them  in  the  function  of  absorbing.  Naturally,  there  are  cases  in  which  an 
ocular  examination  cannot  be  satisfactorily  made.  In  the  journals  we  read  ol 
brilliant  results  of  rhmoscopic  and  laryngoscopic  examination ;  in  practice 
we  see  but  few.  This  holds  good  especially  for  the  cases  of  dyspnoea  accom- 
panying laryngeal  diphtheria,  where  the  diagnosis  may  be  doubtful  when 
no  membrane  can  be  detected  in  the  fauces ;  even  if  membrane  be  observed 
there,  symptoms  of  suffocation  may  still  arise  from  a  laryngeal  stenosis 
independent  of  membranous  deposits  in  the  larynx.  If  aphonia  and  diffi- 
culty of  both  inspiration  and  expiration  be  present  at  the  same  time,  there 
is  certainly  membranous  occlusion.  If  aphonia  appear  late,  or  even  toward 
the  very  last,  and  only  inspiration  be  impeded  while  expiration  is  com- 
paratively free,  there  is  an  cedematous  saturation  of  the  ary-epiglottideau 
folds  and  of  their  copious  submucous  tissue,  and  consequently  of  the 
posterior  attachment  of  the  vocal  cords.  Although  a  general  oedema 
glottidis  in  connection  with  diphtheria  is  of  exceedingly  rare  occurrence, 
the  above  condition  is  not  at  all  uncommon,  and  has  forced  me  to  trache- 
otomize  many  times ;  but,  again,  a  comprehension  of  the  true  condition, 
where  it  occurred  in  not  very  severe  cases,  has  on  several  occasions 
enabled  me  to  avoid  an  operation.  This  local  oedema  may  sometimes  be 
detected  by  palpation  in  the  region  of  the  swollen  posterior  wall  of  the 
pharynx. 

One  of  the  diagnostic  symptoms  of  membranous  laryngitis,  believed 
in  and  referred  to  by  Kronlein,  does  not  exist — viz.  the  swelling  of 
the  lymphatic  glands,  which  in  his  opinion  is  pathognomonic.  Not 
only  'is  that  not  the  case,  but  the  absence  or  scarcity  of  lymphatics 
on  the  vocal  cords  and  in  their  neighborhood  renders  the  absence  of 
glandular  swellings  a  necessity,  provided  the  latter  do  not  depend  on 
complicating  diphtheria  in  other  localities.  In  uncomplicated  diphthe- 
ritic laryngitis  I  expect  no  lymphadenitis.  The  character  of  the  laryn- 
geal pseudo-membrane  does  not  depend  at  all  on  the  condition  of  the 
pharynx.  The  latter  may  have  membranes  of  any  description  or  con- 
sistency without  permitting  the  diagnosis  of  the  condition  of  the  larynx. 
I  lay  stress  on  this  fact  because  no  less  a  writer  than  Kronlein  believes 
that  where  there  is  but  little  or  no  membrane  in  the  pharynx,  that  in  the 
larynx  is  rather  loose  and  movable. 

One  of  the  diagnostic  symptoms  of  diphtheritic  laryngitis,  or  mem- 
branous croup,  is  the  relative  absence  of  fever.  Catarrhal  laryngitis,_  or 
pseudo-croup,  is  a  feverish  disease.  A  sudden  attack  of  croup  with  high 
temperature,  provided  there  is  no  pharyngeal  or  other  diphtheria  present, 
vields  a  good  prognosis ;  without  much  fever,  a  very  doubtful  one. 

The  diagnosis  of  diphtheritic  paralysis  offers  very  little  difficulty  in 
most  cases.  Its  occurrence  after  an  attack  of  diphtheria,  its  beginning  in 
the  fauces  or  in  the  muscles  controlled  by  the  ciliary  nerves,  the  immunity 
of  the  sphincters,  the  gradual  development,  the  irregularity  of  its  prog- 
ress, are  good  diagnostic  points.  Examination  by  the  interrupted 
or  continuous  current  is  not  conclusive.  Very  frequently  m  the  begin- 


692  DIPHTHERIA. 

ning  the  response  to  the  interrupted  current  is  normal,  sometimes  deficient ; 
to  the  continuous  current,  exaggerated.  After  some  time  the  power  of 
both  to  excite  contraction  is  diminished.  When  we  reflect  on  the  numer- 
ous causes  which  may  underlie  diphtheritic  paralysis,  and  that  we  have  not 
to  deal  with  one  and  the  same  anatomical  change  in  all  cases,  it  becomes 
apparent  that  no  reliable  conclusions  can  be  based  upon  electrical  exam- 
ination. 

PROGNOSIS. — In  general,  the  prognosis  in  diphtheria  is  favorable  when 
the  affected  surface  is  of  small  extent  and  where  such  parts  are  the  seat  of 
disease  as  have  little  communication  with  the  lymphatic  system.  To  the  latter 
class  belongs  simple  diphtheria  of  the  tonsils.  Marked  glandular  swelling, 
particularly  if  arising  suddenly,  is  always  an  unfavorable  sign,  and  calls 
for  the  utmost  caution  in  prognosis,  especially  if  the  region  of  the  angles  of 
the  jaw  be  speedily  and  markedly  infiltrated.  .  This,  as  we  have  seen,  is  par- 
ticularly apt  to  occur  with  nasal  diphtheria,  whether  developed  primarily, 
(and  then  accompanied  by  a  thin  fetid  discharge),  or,  as  is  more  commonly 
the  case,  secondarily  from  an  affection  of  the  pharynx  and  palate  which 
ascends  into  the  posterior  nares.  With  the  appropriate  local  disinfection 
this  form  of  the  di§ease  is  neither  so  alarmingly  dangerous  as  Oertel 
depicts  it,  nor  so  assuredly  fatal  as  Roger  but  a  few  years  ago  taught  in 
his  clinique,  or  as  Kohts  appears  to  believe,1  yet  it  is  ever  grave.  With 
energetic  treatment  many  cases  will,  however,  get  well.  Diphtheria  of 
wounds,  complicating  diphtheria  of  the  pharynx,  is  always  an  unfavor- 
able sign ;  that  of  the  mouth  and  angles  of  the  mouth,  associating  itself 
with  a  previously  existing  diphtheria,  having  an  indolent  course,  and 
producing  more  frequently  a  deep  impregnation  of  the  tissues  than  a 
thick  deposit,  causes  a  painful  and  serious  condition.  Diphtheria 
of  the  larynx,  whether  it  be  of  primary  origin  or  the  result  of  exten- 
sion from  the  fauces,  is  nearly  always  fatal.  In  severe  epidemics  the 
mortality  is  95  per  cent.  Tracheotomy,  too,  saves  but  few  of  those 
who  take  the  disease  at  such  a  time.  In  fifty  consecutive  tracheotomies 
from  1872  to  1874  I  did  not  see  one  recovery.  In  the  last  few  years  I 
have  seen  few  good  results.  In  average  epidemics  tracheotomy  will  save 
20  per  cent.  A  pulse  of  140  to  160,  and  high  fever  immediately  after 
the  operation,  render  the  prognosis  bad;  so  does  absence  of  complete 
relief  after  the  operation.  An  almost  normal  temperature  the  day  after 
the  operation  is  an  agreeable  symptom,  but  does  not  exclude  a  downward 
extension  of  the  diphtheritic  process,  and  hence  cannot  be  looked  upon  as 
assuring  a  favorable  prognosis.  A  marked  elevation  of  temperature  is 
apt  to  indicate  a  renewed  attack  of  diphtheria  or  a  rapidly-appearing 
pneumonia,  and  is  an  unfavorable  symptom.  A  dry  character  of  the  res- 
piratory murmur  some  time  after  tracheotomy  indicates  the  approach  of  death 
within  from  twelve  to  twenty-four  hours  from  descent  of  the  membrane; 
so  does  cyanosis,  whatever  be  its  degree  of  intensity.  Diphtheria  of  the 
trachea,  which  ascends  to  the  larynx,  is  positively  fatal.  It  has  a  rapid 
course,  and  tracheotomy  only  postpones  the  end  for  a  little  while,  if  at  all. 
The  general  health  and  strength  of  the  little  sufferer  have  no  influence 
whatever. 

Thick,  solid  deposits  need  not  of  themselves  render  the  prognosis  so 
unfavorable  as  do  septic  and  gangrenous  forms.  Even  in  the  nose  they 

1  Gerhardt,  Handb.  d.  Kinder/cr.,  iii.,  2,  p.  20,  1878. 


PROGNOSIS.  693 

are  not  of  as  serious  import  as  the  thin,  putrid  discharge.  I  have  seen 
recovery  ensue  in  cases  where  I  was  obliged  to  bore  through  the  occluded 
nasal  cavities  with  probes  and  scoops.  Fetid,  putrid  discharges  are 
unfavorable,  but  in  no  wise  fatal;  conscientious  disinfection  accom- 
plishes a  great  deal.  Slight  epistaxis  indicates  the  possibility  of  rapid 
absorption  through  the  blood-vessels;  but  here,  too,  the  final  result 
depends  on  whether  the  disinfection  be  equally  rapid  and  thorough. 
The  same  holds  true  for  the  sweetish,  fetid  odor  of  the  breath,  whether 
of  the  nose  or  mouth,  which,  on  the  one  hand,  demonstrates  the  signif- 
icance of  the  disease,  while,  on  the  other  hand,  it  indicates  the  possibility 
of  infection  by  inhalation. 

The  height  of  the  fever  is  not  in  proportion  to  the  danger  in  any  indi- 
vidual case;  some  have  a  favorable,  some  an  unfavorable  termination, 
without  fever  of  any  account.  Simple  catarrh  of  the  pharynx  and  larynx 
frequently  begins  with  a  sudden  and  marked  rise  of  temperature;  diph- 
theria in  the  same  parts  but  rarely.  There  are  cases,  however,  in  which 
the  height  of  the  fever  and  the  deposited  membranes  are  in  inverse  pro- 
portion to  each  other.  In  these  cases  the  fever  may  subside  rapidly, 
owing  to  a  speedy  elimination  of  the  poison.  Young  children  only  are 
in  danger  of  death  from  convulsions  or  a  rapid  tissue-degeneration  due 
to  hyperpyexia.  If  the  temperature  rise  suddenly  after  some  days  of 
sickness,  cither  a  complication  or  a  fatal  termination  is  to  be  appre- 
hended. Yet,  there  are  as  many  deaths  in  cases  with  comparatively 
low  as  with  very  high  temperatures.  Whether  collapse  has  resulted 
rapidly  or  slowly,  the  patient  dies  often  with  low  temperature.  Thus, 
a  rapid  elevation  is  hardly  a  more  unfavorable  sign  than  a  rapid  fall. 
The  pulse,  too,  may  be  very  variable.  True,  a  small,  rapid,  and  irregu- 
lar pulse  is  always  unfavorable,  because  it  indicates  a  weakening  of  the 
cardiac  function ;  yet  as  long  as  it  retains  an  approximately  normal  rela- 
tion to  the  frequency  of  respiration  a  rapid  pulse  gives  no  cause  for  alarm. 
Moreover,  the  pulse  is  not  always  rapid  when  the  strength  gives  way. 
It  occasionally  becomes  slower,  and  sometimes  very  slow,  and  may  then 
become  a  dangerous  symptom. 

Every  complication  adds  to  the  danger.  Bronchitis  and  pneumonia 
are  not  infrequent,  yet  I  have  seen  cases  of  laryngeal  diphtheria  recover 
in  which  I  had  suspected  pneumonia  before  performing  tracheotomy,  and 
was  enabled  to  diagnosticate  it  after  operating.  Albuminuria  in  the  early 
part  of  a  diphtheritic  attack  with  high  fever  is  of  little  significance ; 
nephritis,  later  in  the  course  of  the  disease,  partakes  of  the  character  of 
scarlatinous  nephritis;  cases  of  acute  diffuse  renal  disease  are  fortunately 
infrequent,  and  the  remainder  are  very  submissive  to  treatment.  I  he 
cases  of  diphtheria  complicated  with  endocarditis  in  my  practice  have 
ended  fatally.  An  early  affection  of  the  sensorium,  not  dependent  on 
pressure  upon  the  jugulars  by  greatly  swollen  glands,  is  an  unfavorable 
symptom.  Purpura,  with  profuse  hemorrhages  and  a  livid  hue  of  the 
skin,  is  ominous;  icteric  discoloration,  together  with  marked  glandular 
and  peridaudular  tumefaction,  is  absolutely  fatal. 

Most  cases  of  diphtheria  of  the  pharynx  and  of  the  tonsils  have  a 
favorable  termination,  yet  a  positive  prognosis  can  in  no  case  be  given 
with  certainty.  Still,  even  in  malignant  epidemics  the  mortality  is  not 
very  great,  for  even  though  there  be  a  large  number  of  severe  cases  in 


694  DIPHTHERIA. 

any  one  epidemic,  yet  it  is  greatly  overbalanced  by  the  number  of 
moderately  severe  and  mild  ones.  True,  not  a  few  cases  end  fatally  in 
several  days,  owing  to  the  high  fever,  or  to  septic  absorption,  or  nephritis, 
or  croup,  but  the  majority  of  cases  end  in  recovery  in  one  or  two  weeks. 
Yet  diphtheria  does  not  always  take  so  regular  a  course ;  not  infrequently, 
after  the  pulse  has  become  stronger,  the  appetite  improved,  and  the  phar- 
ynx cleared,  and  the  patient  is  apparently  on  the  high  road  to  recovery, 
another  attack  occurs  accompanied  by  fever,  as  before,  and  a  rapid  form- 
ation of  membrane.  Occasionally  two  or  three  such  relapses  may  occur 
in  the  course  of  three,  four,  or  five  weeks ;  not  to  speak  of  the  fact  that 
those  who  have  once  suffered  from  diphtheria  are  more  susceptible  to  the 
action  of  the  poison  than  those  who  never  suffered  before. 

TREATMENT. — Every  case  should  be  treated  on  general  principles ; 
thus,  it  is  not  possible  to  lay  down  a  routine  treatment  for  every  indi- 
vidual case.  High  feyer  should  be  reduced  by  sponging  and  bathing, 
quinia,  and  sodium  salicylate ;  collapse  speedily  treated,  and  severe  reflex 
symptoms,  as  vomiting,  etc.,  checked  at  once.  Whether  to  employ  for 
this  purpose  ether,  wine,  cognac,  champagne,  or  coffee  must  be  decided  by 
the  physician  in  individual  cases.  The  administration  of  the  remedy, 
whether  by  mouth,  by  injection  into  the  bowels,  or  subcutaneously,  as  I 
have  employed  cognac,  ether,  alcohol,  and  camphor  dissolved  in  ether  or 
alcohol,  in  some  cases  with  decided  and  rapid  success,  must  depend  on  the 
condition  of  the  organs  and  on  the  urgency  of  the  case.  However,  all 
the  above  remedies  are  frequently  of  no  service,  because  adminis- 
tered too  late  and  in  too  small  doses.  If  I  have  ever  had  cause  to 
feel  contented  with  the  results  of  treatment  in  diphtheria,  it  is  owing 
to  the  fact  that  I  lost  no  time.  No  medicines,  however,  must  be  resorted 
to  which  are  apt  to  derange  the  digestion  of  the  patient ;  alcoholic  stimu- 
lants must  be  given  in  fair  dilution  only,  for  that  reason.  The  nourish- 
ment of  the  patient  is  a  matter  of  very  great  importance.  On  general 
principles  it  is  true  that  care  must  be  taken  in  regard  to  food  administered 
to  febrile  patients,  but  we  must  bear  in  mind  that,  when  the  lymphatic 
vessels  are  kept  empty  and  no  new  and  proper  material  is  introduced  into 
them,  the  absorption  of  locally-existing  poisonous  substances  is  pro- 
portionately increased.  Hungry  lymph-vessels  are  the  organism's  fiercest 
enemies. 

I  dwell  particularly  on  the  foregoing  remarks  for  the  reason  that  in 
diphtheria,  unlike  certain  diseases  having  a  typical  course  and  those  of  a 
simple  inflammatory  character,  expectant  treatment  should  not  be  indulged 
in.  Oertel's  advice,  that  when  neither  high  fever  nor  complications  are 
present  we  should  quietly  wait,  and  "act  only  when  new  and  most 
alarming  symptoms  present  themselves,"  is  decidedly  perilous.  A  mild 
invasion  does  not  assure  a  mild  course.  Never  has  a  "  possibly  super- 
fluous" tonic  or  stimulant  done  harm  in  diphtheria,  but  many  a  case  has 
a  sad  termination  because  of  a  sudden  change  in  the  character  of  the 
disease,  putting  the  bright  hopes  of  the  physician  to  shame.  Only  the 
philosopher  may  be  a  passive  spectator  ;  the  physician  must  be  a  guard- 
ian. When  I  again  read,  in  the  work  of  the  same  meritorious  author, 
"  that  when  in  exceptional  cases,  in  children  and  young  people,  death  is 
imminent,  not  from  suffocating  symptoms  in  the  larynx  and  trachea,  but 
from  septic  disease  and  blood-poisoning,  it  is  necessary  to  resort  to  power- 


TREATMENT.  695 

ful  stimulants,"  it  strikes  me  that  he  is  frequently  too  dilatory  with  his 
remedies,  and,  furthermore,  that  his  experience  concerning  the  terrible 
septic  form  of  diphtheria  which  is  so  frequently  met  with  in  some  epi- 
demics must  have  been  very  limited  at  the  time  he  was  writing.  In  New 
York,  during  the  past  twenty-five  years,  for  every  death  from  diphtheritic 
laryngeal  stenosis  (membranous  croup)  there  have  been  three  from  diph- 
theritic sepsis  or  from  exhaustion.1 

In  regard  to  the  dose  of  stimulants,  it  is  a  fact  that  there  is  more 
danger  in  diphtheria  from  giving  too  little  than  too  much.  When  the 
pulse  barely  begins  to  be  small  and  frequent  they  must  be  administered 
at  once.  A  three-year-old  child  can  comfortably  take  thirty  to  one 
hundred  and  fifty  grammes  (f  §j— v)  of  cognac,  or  one  to  five  grammes  of 
carbonate  of  ammonium,  or  a  gramme  of  musk  or  camphor  (gr.  xv)  and 
more,  in  twenty-four  hours.  In  the  septic  form  especially  the  intoxicat- 
ing action  of  alcohol  is  out  of  the  question ;  the  pulse  becomes  stronger 
and  slower,  and  the  patient  enjoys  rest.  In  those  cases  in  which  the  pulse 
is  slow,  together  with  a  weak  heart's  action,  the  dose  can  hardly  be  too 
large.  The  fear  of  a  bold  administration  of  stimulants  will  vanish,  as 
does  that  of  the  use  of  large  doses  of  opium  in  peritonitis,  of  quinia  in 
pneumonia,  or  of  iodide  of  potassium  in  meningitis  or  syphilis.  I  know 
that  cases  of  young  children  with  general  sepsis  commenced  immediately 
to  improve  when  their  one  hundred  grammes  (f§iij)  of  brandy  were 
increased  to  four  times  that  amount  in  a  day. 

The  remarks  I  have  made  in  reference  to  the  general  treatment  of 
diphtheria  naturally  render  superfluous  a  discussion  of  the  value  of 
abstraction  of  blood.  To  be  sure,  it  could  only  be  a  question  of  local 
bleeding.  For  nobody  would  dare  to  resort  to  jugular  venesection,  as  our 
predecessors  did  in  the  last  century.  It  may  be  safely  asserted  of  the 
latter  that  it  has  no  influence  on  the  process,  but  frequently  increases  the 
local  swelling  and  makes  the  patient  more  anaemic.  There  is  no  case  in 
which  a  resort  to  it  would  not  be  criminal.  I  can  distinctly  recall  the 
time  when  bleeding  and  calomel  formed  the  groundwork  of  the  treat- 
ment. Until  the  year  1862  the  death-rate  in  Rupert,  Vermont,  from 
diphtheria  was  90  per  cent.,  according  to  the  reports  of  the  local  physi- 
cians, and  particularly  of  my  pupil,  Dr.  Guild,  who  at  that  time  finished 
his  studies  in  New  York  and  commenced  practising.  When,  in  the  same 
epidemic,  bleeding  and  calomel  were  replaced  by  stimulants  and  iron, 
with  the  chlorate  of  potassium,  90  per  cent,  recovered. 

That  attention  must  be  paid  to  the  general  condition  mainly  during  a 

1  We  have  to  improve  somewhat  on  the  plan  of  Thomas  Wilson,  though  his  general 
instructions  be  good  (as  laid  down  in  his  Tentamen  medicum  inaugurate  de  cynanche 
rnaliqna,  Edinb,  1790,  p.  24) :  "  Cum  hactenus  nullum  inventum  est  remedium  quod  co: 
tagionem  in  corpus  receptam  suffocare  possit;  cum  medicamentapleraquequfe  putredme 
corrigere  dicuntur,  corpus  ejusque  function*  manifesto  robor t  demue  cum  hun 
morbum  comitantur  virium  prostratio,  et,  etiam  ab  mitio,  su 
qualis  evacuantia  omnigena  prohibet,  indicationem  curandi  u 
bus  obviam  ire,  proponam.  Hinc  corporis  conditioni  obviam  itur 
lantia  adminisirando .»  (As  no  remedy  has  yet  been  found  which  can  Anguish  the  con 
tagion  after  it  has  been  received  into  the  body;  as  most  , medicine*  wh  ^  have  the 
reputation  of  correcting  putrefaction  are  roborants.for  the  body  and  £funrtion^  and 
lastly,  as  this  disease  is  attended  with  great  prostration  and  such  **®*Z*£?ff£Z 
t/i  nreplnde  the  use  of  all  sorts  of  evacuauts,  -I  propose  but  this  one  indication  10  treai 
ment-vT,  to  meet  the  effects  of  debility.  Wis  fulfilled  by  the  administrate  mainly 
of  tonics  and  stimulants.) 


696  DIPHTHERIA. 

retarded  convalescence  from  previous  sickness  is  self-evident.  Any 
complications,  too,  must  be  subjected  to  early  treatment.  Diarrhoea 
must  be  mentioned  among  these ;  it  reduces  the  patient's  strength  very 
quickly ;  likewise,  the  early  appearing  nephritis,  which  may  suddenly 
end  life. 

In  this  connection  I  must  allude  to  the  great  danger  of  self-infec- 
tion, which  may  occur  in  every  variety  of  cases,  severe  or  mild.  The 
poison  is  diffused  by  expiration  and  expectoration.  Though  care 
may  have  been  taken  to  disinfect  the  linen,  towels,  handkerchiefs, 
the  bedstead  and  bedding,  chairs  and  wall-papers,  and  carpets  and 
curtains,  even  the  clothing  of  the  attendants  will  be  infected.  While 
the  patient  is  getting  well  he  will  be  infected  again,  and  have  a  more 
serious  relapse ;  and  a  third  one,  and  succumb!  I  have  met  with  such 
cases  often,  and  with  some  which  went  from  one  attack  into  another,  and 
would  certainly  have  perished  but  for  their  removal  to  a  distant  part 
of  the  town.  Where  there  are  vacant  rooms  the  indication  is  to  change 
rooms  every  few  days  and  to  thoroughly  disinfect  (with  sulphurous  acid) 
that  which  has  been  used  and  infected. 

One  important  axiom  must  be  borne  in  mind — namely,  that  preven- 
tion is  easier  than  cure.  I  do  not  refer  simply  to  the  removal  of  the 
healthy  members  of  the  family  beyond  the  danger  of  infection  or  to  the 
isolation  of  the  patient.  If  the  latter  becomes  necessary,  the  first  indi- 
cation is  his  removal  to  the  top  floor  of  the  house.  There  are,  in  addition, 
however,  certain  prophylactic  measures  which  will  prove  valuable  in  the 
hands  of  every  good  physician.  It  is  necessary  under  all  circumstances 
that  the  mouth  and  pharynx  of  every  child  be  constantly  kept  in  a 
healthy  condition.  Eruptions  of  the  scalp  must  be  treated  at  once,  and 
glandular  swellings  of  the  neck  caused  to  disappear.  Some  cases  of 
laryngeal  diphtheria  have  been  traced  directly  to  the  presence  of  suppu- 
rating bronchial  glands,  with  or  without  perforation.1  The  same  rule 
applies  to  nasal  and  pharyngeal  catarrhs,  the  treatment  of  which  should 
be  commenced  in  warm  seasons,  when  general  or  local  remedies  yield 
better  results.  Enlarged  tonsils  should  be  resected,  or,  where  that  can 
not  be  done,  scraped  out  with  Simon's  spoon,  at  a  time  when  no  diph- 
theritic epidemic  is  raging.  It  is  important  that  this  take  place  at  a 
time  when,  even  though  sporadic  cases  of  diphtheria  occur,  the  danger 
of  infection  is  not  great;  for  during  the  height  of  an  epidemic  every 
wound  will  give  rise  to  general  or  local  infection.  This  holds  good  for 
any  part  of  the  body  as  well  as  of  the  mouth.  I  avoid,  therefore,  an 
operation  at  such  a  time,  provided  it  can  be  postponed. 

Prevention,  after  all,  is  not  the  business  of  the  physician  only,  but  just 
as  much  that  of  the  individual  or  the  complex  of  individuals — viz.  the  town, 
the  state,  and  the  nation.  Those  sick  with  diphtheria  must  be  isolated, 
though  the  case  appear  ever  so  mild,  and,  if  possible,  the  other  children  must 
be  sent  out  of  the  house  altogether.  If  that  be  impossible,  let  them  remain 
outside  the  house,  in  the  open  air,  as  long  as  feasible,  with  open  bedroom 
windows  during  the  night,  in  the  most  distant  part  of  the  house,  and  let 
their  throats,  and  those  of  their  nurses,  be  examined  every  day.  The 
watching  eye  of  a  father  or  mother  will  discover  deviations  from  the 
norm,  so  that  the  physician  can  be  notified.  Let  the  temperature* 
1  Weigert,  in  Virch.  Arch.,  vol.  Ixxvii.,  p.  294,  1879. 


TREATMENT.  697 

of  the  well  children  be  taken  once  a  day,  toward  evening.  Ten 
minutes  of  a  mother's  time  are  well  paid  by  the  discovery  of  a  slight 
anomaly  which  may  require  the  attention  of  the  physician.  Happfly, 
there  are  now  many  mothers  who  keep  and  value  a  self-registering  ther- 
mometer as  an  important  addition  to  their  household  articles.  The  attend- 
ant upon  a  case  of  diphtheria  must  not  get  in  contact  with  the  rest  of 
the  family,  particularly  the  children,  after  his  visiting  and  handling  the 
patient,  for  the  poison  may  be  carried,  though  the  carrier  remain  well 
or  apparently  well.  Unnecessary  petting  of  the  patient  on  the  part  of 
the  well  ought  to  be  avoided,  and  kissing  must  be  forbidden ;  the  bed- 
clothing  and  linen  should  be  changed  often  and  disinfected,  the  air  of  the 
sick-chamber  should  be  cool  and  often  changed,  and  if  possible  the  cham- 
ber itself  should  be  changed  every  few  days. 

The  well  or  apparently  well  children  of  a  family  that  has  diphtheria 
at  home  must  not  go  to  school  nor  to  church.  The  former  necessity  is 
beginning  to  be  recognized  by  the  authorities  and  teachers,  and  also,  in 
consequence  of  partially  enforced  habit,  by  parents ;  the  latter  will  be 
resisted  longer.  Schools  ought  to  be  closed  entirely  when  a  number  of 
cases  have  occurred.  Even  when  the  school-children  have  not  been 
affected  to  a  great  extent,  but  an  epidemic  of  diphtheria  has  commenced  in 
earnest,  it  will  be  better  to  close  the  schools  for  a  time.  If  that  be  not 
advisable,  the  teacher  ought  to  be  taught  to  examine  throats,  and  directed 
to  examine  every  child's  throat  each  morning,  and  to  send  home  every  one 
with  even  suspicious  appearances. 

In  times  of  an  epidemic  every  public  place,  theatre,  ball-room,  dining- 
hall,  or  tavern  ought  to  be  subjected  to  supervision.  Where  there  is  a  large 
conflux  of  people  there  are  certainly  many  who  carry  the  disease  with  them. 
Disinfection  must  be  enforced  by  the  authorities  at  regular  intervals.  Public 
vehicles  must  be  treated  in  the  same  manner.  That  it  should  be  so  when 
a  case  of  small-pox  has  happened  to  be  carried  in  them  appears  quite 
natural.  Hardly  a  livery-stable  keeper  would  be  found  who  would  not 
be  anxious  to  destroy  the  possibility  of  infection  in  any  of  his  coaches. 
He  must  learn  that  diphtheria  is,  or  may  be,  as  dangerous  a  passenger 
as  variola.  And  what  is  valid  in  the  case  of  a  poor  hack  is  more  so  in 
that  of  railroad-cars,  whether  emigrant  or  Pullman.  They  ought  to  be 
thoroughly  disinfected  in  times  of  an  epidemic,  at  regular  intervals,  for 
the  highroads  of  travel  have  always  been  those  of  epidemic  diseases,  and 
railroad  officers  and  their  families  have  often  been  the  first  victims  of  the 
imported  scourge.  Can  that  be  accomplished  ?  Will  not  railroad  com- 
panies resist  a  plan  of  regular  disinfection  because  of  its  expensiyeness  ? 
Will  there  not  be  an  outcry  against  this  as  despotic  and  as  a  violation 
of  the  rights  of  the  citizen?  Certainly  there  will  be.  But  so  there 
was  also  when  municipal  authorities  began  to  compel  parents  to  keep 
their  children  at  home  when  they  had  contagious  diseases  in  the 
family,  and  when  a  small-pox  patient  was  arrested  because  of  endan- 
gering the  passengers  in  a  public  vehicle.  In  such  cases  it  is  not 
society  that  tyrannizes  the  individual;  it  is  the  individual  that  endangers 
society.  And  society  begins  at  last,  even  in  America,  to  believe  m  the 
rights  of  the  commonwealth,  and  not  in  the  rights  of  the  democratic 
person  only.  The  establishment  of  State  and  National  Boards  of  Health 
proves  that  the  narrow-hearted  theories  of  the  strict  construction^ 


698  DIPHTHERIA. 

have  not  only  disappeared  from  our  politics,  but  also  from  the  conscience 
and  intellect  of  society. 

The  sick  room  must  be  kept  cool,  the  windows  kept  open — more  or  less 
— by  night  as  well  as  by  day,  the  floor  frequently  washed,  the  linen  soaked 
at  once,  the  excrements  removed.  Dead  bodies  ought  to  be  kept  moist,  for 
infectious  material,  chemical  or  otherwise,  will  spread  more  easily  when  dry. 
Attendants  must  not  talk  unnecessarily  over  the  mouth  or  diphtheritic 
wounds  of  the  patient,  and  will  do  well  to  carry  a  little  dry  loose  cotton 
— to  be  changed  often — in  each  of  the  nostrils,  for  it  aids  in  protecting 
those  who  are  necessarily  exposed  to  infection.1 

A  very  important  mode  of  prevention  consists  in  disinfection.  The 
experiments  of  Schotte  and  Gaertner,  and  of  Sternberg,  prove  the 
inefficiency  of  small  doses  of  most  of  the  disinfectants  in  common  use. 
The  popular  idea,  sometimes  even  shared  by  physicians,  that  the  faint 
odor  of  chloride  of  lime  or  of  carbolic  acid  in  a  sick  room  or  in  a  foul 
privy  is  evidence  that  the  place  is  disinfected,  is  entirely  erroneous.  Par- 
ticularly in  regard  to  the  latter  agent,  it  may  be  stated  at  once  that  its 
employment  for  disinfecting  purposes  on  a  large  scale  is  impracticable, 
both  on  account  of  the  expensiveness  of  the  pure  acid  and  the  enormous 
quantities,  required  to  produce  the  desired  effect.  For  in  regard  to  its 
efficiency  it  does  not  rank  very  high  in  comparison  with  a  great  many 
other  articles,  as  may  be  seen  from  a  table  of  the  disinfectant  properties 
of  different  chemicals  published  by  Miquel  in  the  Semaine  M6dicale. 

For  practical  purposes  I  know  of  no  better  or  simpler  rules  for  disin- 
fection than  those  published  by  the  National  Board  of  Health.  In  its 
Bulletin  No  10,  of  September  6,  1879,  the  following  instructions  for  dis- 
infection were  published :  Deodorizers,  or  substances  which  destroy  smells, 
are  not  necessarily  disinfectants,  and  disinfectants  do  not  necessarily  have 
an  odor. 

"  Disinfection  cannot  compensate  for  want  of  cleanliness  nor  of  ventila- 
tion. 

"  I.  Disinfectants  to  be  employed : 

"1.  Roll-sulphur  (brimstone)  for  fumigation. 

"2.  Sulphate  of  iron  (copperas)  dissolved  in  water  in  the  proportion  of 
one  and  a  half  pounds  to  the  gallon ;  for  soil,  sewers,  etc. 

"3.  Sulphate  of  zinc  and  common  salt,  dissolved  together  in  water  in 
the  proportion  of  four  ounces  sulphate  and  two  ounces  salt  to  the  gallon ; 
for  clothing,  bed-linen,  etc. 

Carbolic  acid  is  not  included  in  the  above  list,  for  the  following 
reasons :  It  is  very  difficult  to  determine  the  quality  of  the  commer- 
cial article,  and  the  purchaser  can  never  be  certain  of  securing  it  of  proper 
strength ;  it  is  expensive  when  of  good  quality,  and  experience  has  shown 
that  it  must  be  employed  in  comparatively  large  quantities  to  be  of  any 
use ;  it  is  liable  by  its  strong  odor  to  give  a  false  sense  of  security. 

"  II.  How  to  use  disinfectants : 

"1.  In  the  sick-room. — The  most  available  agents  are  fresh  air  and 
cleanliness.  The  clothing,  towels,  bed-linen,  etc.  should,  on  removal  from 
the  patient  and  before  they  are  taken  from  the  room,  be  placed  in  a  pail 
or  tub  of  the  zinc  solution,  boiling  hot  if  possible. 

"All  discharges  should  either  be  received  in  vessels  containing  copperas 
1  Wernich,  in  F.  Cohn's  Beitr.,  iii.,  1859,  p.  115. 


TREATMENT.  (599 

solution,  or,  when  this  is  impracticable,  should  be  immediately  covered 
with  copperas  solution.  All  vessels  used  about  the  patient  should  be 
cleansed  with  the  same  solution. 

"Unnecessary  furniture — especially  that  which  is  stuffed— carpets  and 
hangings,  should,  when  possible,  be  removed  from  the  room  at  the  outset ; 
otherwise  they  should  remain  for  subsequent  fumigation  and  treatment! 

"2.  Fumigation  with  sulphur  is  the  only  practical  method  for  disin- 
fecting the  house.  For  this  purpose  the  rooms  to  be  disinfected  must  be 
vacated.  Heavy  clothing,  blankets,  bedding,  and  other  articles  which 
cannot  be  treated  with  zinc  solution  should  be  opened  and  exposed  during 
fumigation,  as  directed  below.  Close  the  rooms  as  tightly  as  possible, 
place  the  sulphur  in  iron  pans  supported  upon  bricks  placed  in  wash-tubs 
containing  a  little  water,  set  it  on  fire  by  hot  coals  or  with  the  aid  of  a 
spoonful  of  alcohol,  and  allow  the  room  to  remain  closed  for  twenty-four 
hours.  For  a  room  about  ten  feet  square  at  least  two  pounds  of  sulphur 
should  be  used ;  for  larger  rooms  proportionately  increased  quantities. 

"  3.  Premises. — Cellars,  yards,  stables,  gutters,  privies,  cesspools,  water- 
closets,  drains,  sewers,  etc.  should  be  frequently  and  liberally  treated  with 
copperas  solution.  The  copperas  solution  is  easily  prepared  by  hanging  a 
basket  containing  about  sixty  pounds  of  copperas  in  a  barrel  of  water. 

"  4.  Body-  and  bed-clothing,  etc. — It  is  best  to  burn  all  articles  which 
have  been  in  contact  with  persons,  sick  with  contagious  or  infectious 
diseases.  Articles  too  valuable  to  be  destroyed  should  be  treated  as 
follows : 

"A.  Cotton,  linen,  flannel,  blankets,  etc.  should  be  treated  with  the 
boiling-hot  zinc  solution ;  introduce  piece  by  piece ;  secure  thorough 
wetting,  and  boil  for  at  least  half  an  hour. 

"  B.  Heavy  woollen  clothing,  silks,  furs,  stuffed  bed-covers,  beds,  and 
other  articles  which  cannot  be  treated  with  the  zinc  solution,  should  be 
hung  in  the  room  during  fumigation,  their  surfaces  thoroughly  exposed 
and  pockets  turned  inside  out.  Afterward,  they  should  be  hung  in  the 
open  air,  beaten,  and  shaken.  Pillows,  beds,  stuffed  mattresses,  uphol- 
stered furniture,  etc.  should  be  cut  open,  the  contents  spread  out,  and 
thoroughly  fumigated.  Carpets  are  best  fumigated  on  the  floor,  but 
should  afterward  be  removed  to  the  open  air  and  thoroughly  beaten. 

"  5.  Corpses  should  be  thoroughly  washed  with  a  zinc  solution  ^of 
double  strength ;  should  then  be  wrapped  in  a  sheet  wet  with  the  zinc 
solution,  and  buried  at  once.  Metallic,  metal-lined,  or  air-tight  coffins 
should  be  used  when  possible ;  certainly  when  the  body  is  to  be  trans- 
ported for  any  considerable  distance. 

"  It  might  have  been  added  here  that  no  public  funeral  must  be 
permitted." 

In  this  connection  I  have  to  speak  of  a  remedy  which  I  class  among 
the  prophylactic  agents — namely,  the  chlorate  of  potassium  or  the  ^chlo- 
rate  of  sodium.  I  cannot  say  that  I  rely  on  either  of  these  remedies  as 
curative  agents  in  diphtheria,  and  yet  I  employ  them  in  almost  every  case. 
The  reason  lies  in  the  fact  that  the  chlorate  is  useful  in  most  cases  of 
stomatitis,  and  thereby  acts  as  a  preventive. 

There  are  very  few  cases  of  diphtheria  which  do  not  exhibit  larger 
surfaces  of  either  pharyngitis  or  stomatitis  than  of  diphtheritic  mem- 
brane. There  are  also  a  number  of  cases  of  stomatitis  and  pharyngitis. 


700  DIPHTHERIA. 

during  every  epidemic  of  diphtheria,  which  must  be  referred  to  the  epi- 
demic, sometimes  as  kindred  diseases,  and  sometimes  as  introductory 
stages  only,  which,  however,  do  not,  or  do  not  in  the  beginning,  show  the 
characteristic  symptoms  of  the  disease. 

When,  in  I860,1  I  wrote  my  first  paper  on  diphtheria,  I  based  it  upon 
two  hundred  genuine  cases,  and  at  the  same  time  enumerated  one  hundred 
and  eighty-five  cases  of  pharyngitis,  which  1  considered  to  be  brought  on 
by  epidemic  influences,  but  which,  the  membrane  being  absent,  could  not 
be  classified  as  bona  fide  cases  of  diphtheria. 

Such  cases  of  pharyngitis  and  stomatitis,  no  matter  whether  influenced 
by  an  epidemic  or  not,  furnish  the  indication  for  the  use  of  chlorate  of 
potassium.  They  will  usually  get  well  with  this  treatment  alone.  The 
cases  of  genuine  diphtheria,  complicated  with  a  great  deal  of  stomatitis 
and  pharyngitis,  also  indicate  the  use  of  chlorate  of  potassium ;  not,  how- 
ever, as  a  remedy  for  the  diphtheria,  but  as  a  remedy  for  the  accompany- 
ing catarrhal  condition  in  the  neighborhood  of  the  diphtheritic  exudation. 
For  it  is  a  fact  that,  as  long  as  the  parts  in  the  neighborhood  of  the 
diphtheritic  exudation  are  in  a  healthy  condition,  there  is  but  little 
danger  of  the  disease  spreading  over  the  surface.  Whenever  the 
neighboring  surface  is  affected  with  catarrh  or  inflammation,  or  injured 
so  that  the  epithelium  gets  loose  or  thrown  oft',  the  diphtheritic  exudation 
will  spread  within  a  very  short  tinie.  Thus  chlorate  of  potassium  or 
sodium,  the  latter  of  which  is  more  soluble  and  more  easily  digested  than 
the  former,  will  act  as  a  preventive  rather  than  as  a  curative  remedy. 
Therefore  it  is  that  common  cases  of  pharyngeal  diphtheria  will  recover 
under  this  treatment  alone ;  and  these  are  the  cases  which  have  given  its 
reputation  to  chlorate  of  potassium  as  a  remedy  for  diphtheria. 

The  dose  of  chlorate  of  potassium  for  a  child  two  or  three  years  old 
should  not  be  larger  than  half  a  drachm  (2  grammes)  in  twenty-four 
hours.  A  baby  of  one  year  or  less  should  not  take  more  than  one  scruple 
(1.25  grammes)  a  day.  The  dose  for  an  adult  should  not  be  more  than  a 
drachm  and  a  half,  or  at  most  two  drachms  (6  or  8  grammes),  in  the 
course  of  twenty-four  hours. 

The  effect  of  the  chlorate  of  potassium  is  partly  a  general  and  partly  a 
local  one.  The  general  effect  may  be  obtained  by  the  use  of  occasional 
larger  doses,  but  it  is  better  not  to  strain  the  eliminating  powers  of  the 
system.  The  local  effect,  however,  cannot  be  obtained  with  occasional 
doses,  but  only  by  doses  so  frequently  repeated  that  the  remedy  is  in 
almost  constant  contact  with  the  diseased  surface.  Thus,  the  do«es,  to 
produce  the  local  effect,  should  be  very  small,  but  frequently  adminstered. 
It  is  better  that  the  daily  quanity  of  twenty  grains  should  be  given  in 
fifty  or  sixty  doses  than  in  eight  or  ten ;  that  is,  the  solution  should  be 
weak,  and  a  drachm  or  half  a  drachm  of  such  solution  can  be  given 
every  hour  or  every  half  hour  or  every  fifteen  or  twenty  minutes,  care 
being  taken  that  no  water  or  other  drink  is  given  soon  after  the  remedy 
has  been  administered,  for  obvious  reasons. 

I  have  referred  to  these  facts  with  so  much  emphasis  because  of  late 
an  attempt  has  been  made  to  introduce  chlorate  of  potassium  as  the  main 
remedy  in  bad  cases  of  diphtheria,  and.  what  is  worse,  in   large  doses 
(Seeligrnuller,  Sachse,  L.  Weigert,  C.  Kiister,  Edlefsen.) 
1  Amer.  Med.  Times,  Aug.  llth  and  18th. 


TREATMENT.  701 

Large  doses  of  chlorate  of  potassium  (2  drachms  daily  to  an  adult  I 
claim  to  be  a  large  dose,  particularly  when  its  use  is  persisted  in  for  many 
days  in  succession)  are  dangerous.  In  several  of  my  writings  I  have  given 
instances  of  its  fatal  effects.1  I  have  seen  fatal  cases  since,  and  scores  have 
been  published  in  different  journals.  The  first  effects  of  a  moderately 
large  dose  are  gastric  and,  more  especially,  renal  irritation ;  the  latter  it 
was  which  I  experienced  when  I  took  half  an  ounce  twenty-five  years 
ago.  Fountain  of  Davenport,  Iowa,  experienced  the  same  before  more 
serious  symptoms  developed,  of  which  he  died.2  The  symptoms  are 
those  of  acute  diffuse  nephritis,  with  suppression  of  urine,  or  scanty  secre- 
tion of  a  little  black  blood,  and  uraemia  deepening  toward  death  in 
fatal  cases.  My  earlier  cases  I  considered  as  primary  diffuse  neph- 
ritis, and  I  have  even  been  inclined  to  attribute  the  frequent  appear- 
ance of  chronic  nephritis,  amongst  all  classes  and  ages,  in  part  to  the 
influence  of  the  chlorates,  which  have  become  a  popular  domestic  remedy 
and  are  found  in  every  household.  But  the  experimental  researches  of 
Marchand3  and  others  prove  that,  at  least  in  many  instances,  the  exten- 
sive destruction  of  blood-cells  is  the  first  and  immediate  result  of  the 
introduction  into  the  circulation  of  the  chlorate,  and  that  the  visceral 
changes  are  due  to  embolic  processes. 

Special  Treatment. — The  first  axiom  in  the  treatment  of  diphtheria  is 
that  there  is  no  specific ;  the  second,  that  in  no  other  disease  the  individ- 
ualizing powers  of  the  physician  are  tested  more  severely. 

The  treatment  is  both  internal  and  external.  The  local  remedies  are 
either  such  as  dissolve  the  mucous  membrane,  or  such  as  thoroughly 
modify  the  mucous  membrane  from  which  the  pseudo-membrane  has  been 
removed,  or  real  antiseptics,  with  the  power  of  destroying  either  chemical 
or  parasitic  poisons. 

The  number  of  remedies  recommended  in  diphtheria  is  immense.  No 
other  proof  of  its  dangerous  nature  is  needed.  In  the  following  I  shall 
review  those  which  I  consider  it  worth  while  either  to  reject  or  to  recom- 
mend. 

Steam  is  used  partly  to  soften  the  membranes,  but  principally  to  increase 
the  secretion  from  the  mucous  membrane,  and  thereby  throw  off  the 
superjacent  membrane.  This  can  be  done  to  advantage  only  where  there 
is  a  natural  tendency  to  it ;  that  is,  where  there  are  a  great  many  mucip- 
arous  follicles  under  a  cylindrical  or  fimbriated  epithelium.  This  is  the 
condition  on  part  of  the  pharynx,  but  not  on  the  tonsils ;  and  in  a  small  por- 
tion of  the  larynx,  in  the  trachea  and  bronchi,  but  not  on  the  vocal  cords. 
Wherever  there  is  pavement  epithelium  on  the  normal  surface,  and  where 
the  membrane  is  imbedded  into  the  tissue,  steam  can  hardly  be  expected 
to  do  good.  In  the  other  cases  it  will.  Thus,  the  locality  of  the  diph- 
theritic process  determines  to  a  great  extent  whether  steam  is  indicated  or 
not.  If  it  be  used,  the  necessity  of  a  full  supply  of  atmospheric  air 
must  not  be  disregarded.  Steam,  with  an  overheated  room  and  without 
pure  air,  is  liable  to  be  as  injurious  as  steam  in  pure  air  is  beneficial  in  a 
number  of  cases. 

1  C.  Gerhardfs  Handbuch  der  Kinderkrankheiten,  vol.  ii.,  1876 ;  Ned.  Record,  March, 
1879  ;   Treatise  on  Diphtheria,  1880. 

2  Still£,  Therap.  and  Mat.  Med.,  2d  ed.,  1874,  p.  922. 

8  Sitzungsber.  d.  Naturforsch.  Ges.  h.  u.  Halle,  Feb.  8,  1879,  and  Virch.  Arch.,  vol.  IMVU. 


702  DIPHTHERIA. 

There  can  be  no  better  proof  for  the  necessity  of  individualizing,  and 
the  impossibility  of  treating  all  cases  alike,  than  the  fact  that  many  will 
do  well  under  steam  treatment,  and  others  are  certainly  injured  by  it.  I 
have  repeatedly  had  the  joy  of  seeing  children  with  croup  become  less 
cyanotic  after  their  removal  from  an  atmosphere  of  vapor,  and  I  can 
readily  see  that  pure  atmospheric  air  would  be  more  agreeable  and  whole- 
some to  a  child  with  stenosis  of  the  larynx  than  an  atmosphere  laden 
with  steam.  Of  course  this  remark  does  not  apply  to  cases  of  pseudo- 
croup  and  bronchitis,  which  are  generally  benefited  by  a  warm,  moist 
atmosphere.  Those,  however,  who  deem  it  judicious  to  employ  steam  as 
a  vehicle  for  carbolic  acid,  salicylic  acid,  chloride  of  sodium,  chlorate  of 
potassium,  or  lime,  had  best  resort  to  the  atomizer  for  applying  these 
remedies.  It  can  be  used  without  trouble ;  most  children  are  sufficiently 
intelligent  to  allow  the  spray  to  be  directed  upon  the  fauces  and  larynx 
every  ten  or  fifteen  minutes  in  case  of  necessity.  When  it  is  deemed 
advisable  to  administer  steam,  I  warn  against  the  use  of  gas  stoves. 
They  require  a  great  deal  more  oxygen  than  an  alcohol  lamp,  which 
ought  to  be  preferred  when  a  stove  or  slaking  lime  or  hot  iron  or  bricks 
immersed  in  water  are  not  available. 

Water  may  be  made  serviceable  in  different  ways.  Its  effect  on  the 
skin,  when  taken  in  large  quantities,  under  normal  or  abnormal  circum- 
stances, is  a  matter  of  daily  experience.  Copious  perspiration  is  its 
immediate  result.  The  very  same  effect  is  produced  on  the  mucous 
membranes.  In  diphtheria,  besides  professional  hydropathists,  I  know 
of  but  one1  who  favors  the  plentiful  use  of  water,  100-200  grammes 
(3—6  ounces)  every  hour  or  oftener,  either  by  itself  or  mixed  with  an 
alcoholic  beverage. 

Severe  inflammatory  symptoms,  such  as  redness  of  the  throat,  great 
pain,  swelling  of  the  glands,  require  cold  applications,  either  an  ice-bag 
or  ice-cold  cloths  well  pressed  out  and  frequently  changed.  They  must, 
however,  be  placed  where  they  can  do  most  good — in  laryngeal  diphtheria 
around  the  neck,  in  pharyngeal  diphtheria  with  glandular  swelling  over 
the  affected  part.  In  the  latter,  therefore,  the  flannel  cloth  which  covers 
the  whole  of  the  application  must  be  tied  over  the  head,  and  not  behind. 
When  ice-bags  are  used,  care  is  to  be  taken  lest  they  should  be  too  large ; 
if  so,  they  will  not  affect  the  desired  spot  at  all.  Small  pieces  of  ice 
frequently  swallowed  are  greatly  relished  by  the  patient ;  water-ices  in 
small  quantities  will  render  the  same  service  ;  ice-cream,  in  half-teaspoon 
or  teaspoon  doses  every  five  or  ten  minutes,  adds  to  the  necessary  nutri- 
ment. When  the  fever  is  high  and  the  surface  hot,  sponging  with  tepid 
or  cold  water,  or  water  and  alcohol,  will  mitigate  both.  For  the  cold 
bath  or  the  cold  partial  pack  (trunk  and  upper  part  of  the  thighs)  the 
general  indications  hold  good.  As  a  rule,  I  favor  the  latter,  for  many 
cases  have  such  a  tendency  to  debility  and  collapse  that  sometimes  the 
circulation  of  the  surface  of  the  body  is  badly  interfered  with  by  cold 
bathing.  Therefore,  a  contraindication  to  cold  bathing  must  be  found  at 
once  in  cold  feet,  either  before  or  after  a  bath.  When,  unfortunately,  the 
feet  do  not  recover  their  normal  temperature  in  a  very  short  time,  they 
ought  to  be  warmed  artificially,  and  the  cold  bath  not  repeated.  In  such 
cases  the  cold  pack,  however,  is  still  indicated.  A  linen  or  cotton  cloth, 
1  C.  Rauchfuss,  in  C.  Gerhardfs  Handb.  d.  Kinrlerkr.,  iii.  2,  1878. 


TREATMENT.  7Q3 

large  enough  to  cover  the  trunk  and  half  of  the  thighs,  is  dipped  in  cold 
water,  well  pressed  out,  and  the  body  of  the  patient  wrapped  tightly  in 
it.  The  arms  remain  outside ;  the  whole  body  is  then  wrapped  up  in  a 
blanket ;  the  feet  may  be  warmed  meanwhile  when  necessary,  and  the 
cold  pack  repeated  as  often  as  required  to  reduce  the  temperature — viz. 
once  every  five  minutes,  every  half  hour,  every  hour. 

The  contraindications  to  the  use  of  cold  have  in  part  been  alluded  to. 
Very  young  infants  bear  it  but  to  a  limited  extent.  The  beginning  of 
recovery  contraindicates  it,  unless  for  some  local  cause ;  for  instance,  an 
inflamed  gland.  The  extensive  use  of  cold  water  or  ice  is  also  forbidden 
when  there  is  no  fever,  where  there  is  perhaps  an  abnormally  low  temper- 
ature, where  we  have  to  deal  with  the  septic  or  gangrenous  form  of  diph- 
theria, where  the  vitality  is  low  and  the  mucous  membranes  pale  or  even 
cyauotic.  In  such  cases,  on  the  contrary,  while  unlimited  internal  stimu- 
lation is  required,  the  hot  bath,  or  hot  pack  and  hot  injections  into  the 
bowel,  will  be  found  beneficial. 

Lime-water,  glycerine,  lactic  acid,  pepsin,  ueurin,  papayotin,  chino- 
lin,  and  pilocarpine  are  all  solvents  of  pseudo-membrane,  but  whether 
there  is  sufficient  time  and  opportunity  to  produce  a  curative  effect 
by  every  one  of  them  is  a  question  open  for  discussion.  Of  lime-water 
and  glycerine  I  have  employed  a  mixture  of  equal  parts  in  considerally 
more  than  a  hundred  cases  after  the  completion  of  tracheotomy,  directing 
the  remedy  through  an  atomizer  into  and  below  the  canula,  but  cannot  say 
that  the  descent  of  the  membrane  into  the  trachea  or  bronchi  was  pre- 
vented by  it.  Lime-water  may  be  used  in  the  nose  and  throat  as  an 
injection,  spray,  or  gargle,  but  its  solvent  effect  is  greatly  diminished  by 
the  action  of  the  carbonic  acid  of  the  breath  on  the  lime.  I  have  no 
doubt  that  if  water  alone  was  used  with  the  same  persistence  as  lime- 
water,  its  effects  \A  ould  be  nearly  the  same.  Still,  what  little  effect  the 
minute  dose  of  lime  (1  :  800)  in  the  lime-water  may  have  may  just  as 
well  be  utilized.  What  I  object  to  is  the  omission  of  more  powerful 
agents.  If  lime  is  to  be  used,  slaking  lime  frequently  in  the  presence 
of  the  patient  is  attended  with  vastly  more  benefit,  inasmuch  as  by^that 
proceeding  a  large  amount  of  powdered  lime  is  projected  into  the  air  of 
the  room  and  the  mouth  and  respiratory  organs. 

Lactic  acid  also,  in  from  ten  to  twenty-five  parts  of  water,  has  yielded 
no  better  results  in  my  hands.  Those  cases  of  tracheotomy  which  J 
afterward  treated  with  lactic  acid  spray  terminated  no  better  than  such  as 
were  treated  with  lime-water  and  glycerine.  Of  the  solvent  effect  of  pepsin 
I  have  not  been  able  to  convince  myself  so  as  to  recommend  it.  I  he 
accounts  of  neurin  have  not  encouraged  me  to  try  it  at  all.  Chmolm 
(tartrate)  has  been  used  locally  by  O.  Seifert,1  Miiller,  and  others. 
It  is  said  to  remove  the  membranes  and  relieve  the  fever.  ±or  a 
gargle  it  is  dissolved  in  five  hundred  parts  of  water,  or  it  is  mixed  with 
ten  parts  of  water  and  alcohol  each,  and  applied  by  means  of  a  sponge. 
To  relieve  the  burning  sensation  ice  is  swallowed  afterward,  ihe 
applications  of  alcohol  have  the  same  drawback.  There  are 
patients  who  do  not  suffer  intensely  from  its  local  contact. 

Papayotin  has  been  recommended  by  Rossbach  for  the  purpose^  oi 
dissolving  membranes  in  a  one-half  per  cent,  solution.     It  peptomzes 
i  Berl.  Uin.  Woch.,  Nos.  36,  37,  1883. 


704  DIPHTHERIA. 

albuminoids,  and  macerates  meat,  intestinal  worms,  and  croup  mem- 
branes in  both  neutral  and  feebly  alkaline  solution.  In  concentrated 
solutions  it  has  a  caustic  effect.  It  is  recommended,  not  as  an  anti- 
diphtheritic,  but  merely  as  a  solvent  remedy.1  Whatever  reliance  may 
have  been  placed  upon  it  has,  however,  been  jeopardized  by  Rossbach's 
remarks2  on  the  variability  of  the  preparations  in  the  market.  Not  only 
are  the  specimens  very  unequal,  but  each  of  them  is  variable,  easily 
spoiled,  and  particularly  affected  by  moisture. 

Muriate  of  pilocarpine  was  recommened  for  this  purpose  three  years 
ago.  It  was  praised  by  Juttmann  as  a  specific,  and  has  failed.  The 
quackish  recommendations  of  the  drug  have,  indeed,  earned  for  it  a 
certain  amount  of  distrust  which  it  does  not  deserve  in  all  cases.  It  is 
expected  to  increase  the  secretion  of  the  mucous  membranes  to  such  an 
extent  as  to  float  the  pseudo-membranes.  It  sometimes  succeeds  in  so 
doing,  but  only  in  those  cases  in  which  the  membrane  is  deposited  upon 
the  mucous  membranes.  When  the  tissue  is  impregnated  the  drug  fails. 
It  also  fails  in  septic  cases,  and  mostly  for  the  reason  that  it  diminishes 
and  paralyzes  the  heart's  action.  It  ought,  therefore,  never  to  be  given 
unaccompanied  with  large  amounts  of  stimulants.  Where  the  patient  is 
strong,  and  the  heart  healthy,  it  may  be  tried ;  I  know  that  a  few  cases 
of  moderate  laryngeal  diphtheria  improved  with  pilocarpine,  steam,  and 
turpentine  inhalations.  The  dose  is  -£$  grain,  dissolved  in  water,  every 
hour. 

Turpentine  inhalations  were  recommended  by  C.  Edel.3  Fifteen  drops 
of  oil  of  turpentine  are  inhaled  from  a  common  inhalation  apparatus, 
which  is  placed  at  a  distance  of  three  inches  from  the  mouth  of  the 
patient,  for  a  period  of  ten  minutes  every  hour.  He  claims  recoveries  in 
from  twelve  to  forty-eight  hours.  I  allow  the  patient  to  remain  in  his 
bed,  and  keep  water  boiling  constantly  on  an  alcohol  lamp,  on  the  stove, 
or  over  the  gas.  A  tablespoonful  of  turpentine,  more  or  less,  is  poured 
on  the  water,  care  being  taken  that  nothing  is  spilled  in  the  fire.  Thus 
the  room  is  constantly  filled. with  a  penetrating  odor  of  turpentine, 
which  is  not  at  all  disagreeable,  even  when  in  great  concentration.  The 
effects  are  very  satisfactory  indeed.  Where  circumstances  allowed  or 
required  it  I  have  raised  a  tent  over  the  bed,  large  enough  not  to  give 
inconvenience  to  the  patient  and  to  admit  either  the  whole  apparatus  or 
the  tube  containing  the  mixed  vapor  of  water  and  turpentine. 

Ammonium  chloride  may  sometimes  be  used  to  advantage  for  its 
softening  and  liquefying  effects.  Its  internal  administration  in  bronchial 
and  tracheo-laryngeal  catarrh  is  so  old  that  it  has  several  times  been 
obsolete.  Of  late,  more  stimulant  effects  have  been  attributed  to  it  than 
it  actually  possesses.  But  its  liquefying  action,  in  cases  where  the  secre- 
tion of  mucus  is  defective  and  expectoration  scanty  and  viscid,  is 
undoubted.  Thus  it  proves  valuable  in  many  cases  of  simple  catarrh, 
both  when  administered  internally  and  inhaled.  The  latter  mode  I 
have  often  resorted  to,  and  believe  that  its  macerating  influence  has 
been  of  service  to  me  in  cases  of  laryngeal  diphtheria.  Half  a  tea- 
spoonful  of  the  pure  salt  is  spread  on  the  stove  or  burned  over  alcohol 

1  Berl.  klin.  Woch.,  March  10,  1881. 

'  Transactions  of  (he  Congress  for  Int.  Medicine,  1883,  p.  162. 

1  Med.  Rev.,  Jan.  19,  1878. 


TREATMENT.  705 

or  gas.  It  evaporates  immediately,  and  fills  the  room  or  the  tent  with  a 
white  cloud,  which,  when  dense,  excites  coughing.  But  it  does  not 
irritate  to  any  uncomfortable  degree,  and  the  process  may  be  repeated 
in  an  interval  of  an  hour  or  more 

Not  all  cases  of  diphtheria  are  septic  or  gangrenous,  nor  are  all  the 
cases  occurring  during  an  epidemic  of  the  same  type.  Some  have  the 
well-pronounced  character  of  a  local  disease,  either  on  the  tonsils  or  in  the 
larynx.  The  cases  of  sporadic  croup  met  with  in  the  intervals  between 
epidemics  present  few  constitutional  symptoms,  and  assume  more  the 
nature  of  an  active  inflammatory  disease — very  much  like  the  sporadic 
cases  of  fibrinous  tracheo-bronchitis.  These  are  the  cases  in  which  mer- 
cury deserves  to  have  friends,  apologists,  and  even  eulogists.  Calomel, 
0.5-0.75  gramme  (gr.  viij-xij),  divided  into  thirty  or  forty  doses,  of  which 
one  is  taken  every  half  hour,  is  apt  to  produce  a  constitutional  eifect  very 
soon.  Such  doses,  with  minute  doses,  a  milligramme  or  more  (gr.  -g^),  of 
tartar  emetic,  or  ten  or  twenty  times  that  amount  of  oxysulphuret  of 
antimony,  have  served  me  well  in  fibrinous  tracheo-bronchitis.  But  the 
mucous  membrane  of  the  trachea  and  bronchi  is  more  apt  to  submit  to 
such  liquefying  and  macerating  treatment  than  the  vocal  cords.  The 
latter  have  no  muciparous  glands  like  the  former,  in  which  they  are  very 
copious.  And  while  the  tracheal  membrane,  even  though  recent,  is  apt 
to  be  thrown  out  of  a  tracheal  incision  at  once,  the  pseudo-membrane 
of  the  vocal  cords  takes  from  six  days  to  sixteen  or  more  for  complete 
removal.  Still,  a  certain  effect  may  even  here  be  accomplished,  for  mace- 
ration does  not  depend  only  on  the  local  secretion  of  the  muciparous 
glands,  but  on  the  total  secretion  of  the  surface,  which  will  be  in  constant 
contact  with  the  whole  respiratory  tract.  Thus,  either  on  theoretical 
principles  or  on  the  ground  of  actual  experience,  men  of  learning  and 
judgment  have  used  mercury  in  such  cases  as  I  detailed  above,  with  a 
certain  confidence. 

If  ever  mercury  is  expected  to  do  any  good  in  cases  of  suffocation  by 
membrane,  it  must  be  made  to  act  promptly.  That  is  what  the  blue 
ointment  does  not.  In  its  place  I  recommend  the  oleate,  of  which  ten  or 
twelve  drops  may  be  rubbed  into  the  skin  along  the  inside  of  the  forearms 
or  thighs  (or  anywhere  when  their  surface  becomes  irritated)  every  houi 
or  two  hours.  Or  broken  doses  will  be  useful,  such  as  given  above, 
or  hypodermic  injections  of  corrosive  sublimate  in  J  or  1  per  cent,  solu- 
tion in  distilled  water,  four  or  five  drops  from  four  to  six  times  a  day,  or 
more,  either  by  itself  or  in  combination  with  the  extensive  use  of  the 
oleate,  or  with  calomel  internally.  Lately,  the  cyanide  of  mercury  has 
been  recommended  very  strongly.  I  hardly  believe  that  it  will  _  work 
more  wonders  than  any  other  equally  soluble  preparation.  Within  the 
past  few  years  the  internal  administration  of  bichloride  of  mercury  has 
been  resorted  to  more  frequently  and  with  greater  success  than  ever  before. 
My  own  recent  experience  with  it  has  been  encouraging,  and  so  has  that 
of  some  of  my  friends.  Wm.  Pepper1  gave  ^  grain  of  corrosive  sub- 
limate every  two  hours  in  a  bad  form  of  diphtheritic  croup,  with  favor- 
able result.  But  in  this  very  bad  case,  desperate  though  it  was— child 
of  five  years,  resp.  70,  pulse  160— large  membranes,  "evidently  from  the 
larynx,"  had  been  expelled  before  the  treatment  was  commenced  on  the 
1  Tram.  Am.  Med.  Ass.,  1881. 


VOL.  I.— 45 


706  DIPHTHERIA. 

seventh  day  of  the  disease.  The  remedy  ought  to  be  given  in  solution 
of  1  :  5000,  and  in  good  doses.  A  baby  a  year  old  may  take  one-half 
grain  every  day  for  many  days  in  succession,  with  very  little  if  any  intes- 
tinal disorder  and  with  no  stomatitis.1  A  solution  of  the  corrosive  chloride 
of  mercury  in  water  is  frequently  employed  of  late  as  a  disinfectant.  It 
acts  as  such  in  a  dilution  of  1 : 20,000*  As  healthy  mucous  membranes 
bear  quite  well  a  proportion  of  1  :  2000-3000,  any  strength  between  these 
extremes  maybe  utilized.  A  grain  of  the  sublimate  in  a  pint  or  more  of 
water,  with  a  drachm  of  table-salt,  will  be  found  both  mild  and  efficient. 
As  a  gargle  or  nasal  injection  it  will  be  found  equally  good.  But  it 
has  appeared  to  me  that  frequent  applications  give  rise  to  a  copious 
mucous  discharge;  hourly  injections  into  a  diphtheritic  vagina  became 
quite  obnoxious  by  such  over-secretion,  which  ceased  at  once  when  the 
injections  were  discontinued.  Thus,  w"heu  it  is  desirable  not  only  to  dis- 
infect but  also  to  cleanse  the  diseased  surface,  the  injections  with  corro- 
sive sublimate  appear  to  yield  a  result  inferior  to  less  irritating  applica- 
tions. 

Chloride  of  iron  is  undoubtedly  a  valuable  remedy  in  diphtheria,  but 
in  its  administration  it  must  by  no  means  be  forgotten  that  small  doses  at 
long  intervals  are  out  of  the  question.  I  have  not  the  least  doubt  but 
that  the  failure  of  the  remedy  may  be  attributed  in  most  cases  to  the  fact 
that  the  doses  were  too  small  and  administered  too  seldom.  A  dose  of 
from  five  to  fifteen  drops,  properly  diluted,  every  fifteen  minutes,  half 
hour,  or  hour  is  indispensable  for  a  proper  estimation  of  'its  effects. 
Gargles  are  not  of  much  service,  for  the  simple  reason  that  they  do 
not  come  into  sufficient  contact  with  the  affected  parts,  and  reach  at 
the  utmost  to  the  anterior  pillars  of  the  soft  palate.  A  direct  appli- 
cation of  the  remedy  to  the  mucous  membrane  of  the  pharynx  may  also 
be  desisted  from,  thereby  avoiding  any  irritation,  the  internal  administra- 
tion at  short  intervals  causing  the  pharynx  to  be  sufficiently  influenced 
by  local  contact  with  the  remedy.  It  must,  of  course,  not  be  expected 
that  the  chloride  will  remove  the  membrane,  but  it  can  frequently  be 
seen  to  reduce  the  hypersemia  and  swelling  and  prevent  the  reproduction 
of  exuded  material.  The  chloride  of  iron  exerts  a  decided  influence  on 
the  vital  contractility  of  the  blood-vessels.  This  increased  contractility 
certainly  assists  in  diminishing  the  rapidity  of  absorption  of  putrid  fluids 
through  the  blood-vessels,  which  constitutes  the  principal  source  of  dan- 
ger from  the  disease. 

It  cannot  yet  be  positively  asserted  that  the  chloride  of  iron  exerts  a  direct 
effect  on  the  lymphatic  vessels.  Naturally,  this  was  claimed  when  the  rem- 
edy was  recommended,  in  the  treatment  of  diphtheria,  on  account  of  its 
therapeutic  effects  in  erysipelas,  with  the  accompanying  inflammation  of 
the  lymphatic  vessels  of  the  skin.  Although  we  know  of  no  direct  com- 
pression of  the  lymphatic  vessels  due  to  the  action  of  the  chloride,  yet  it 
may  be  assumed  that  perhaps  the  compression  of  the  blood-vessels  exerts 
a  similar  influence  upon  the  neighboring  lymphatics.  In  consequence  of 
this  there  would  be  an  impediment  to  the  absorption  and  further  devel- 
opment of  poisonous  substances  in  the  lymph.  The  chloride,  like  the 
sulphate  of  iron,  is  a  tolerably  powerful  disinfecting  agent.  If  this 
observation  be  correct,  it  may  go  very  far  toward  explaining  the  action 

1  Med.  Record,  May  24,  1884. 


TREATMENT.  70? 

of  the  chloride  of  iron  in  septic  diseases,  which  are  accompanied  by  an 
exalted  activity  of  the  lymphatic  vessels  and  an  increase  of  the  white 
blood -corpuscles.  Furthermore,  Saase  has  endeavored  to  show  that  the 
ferrous  salts  possess  the  power  of  converting  oxygen  into  ozone. 
They  share  this  power  with  the  blood-globules  exclusively,  and 
could  hence,  to  a  certain  degree,  supply  a  deficiency  of  the  latter. 
Pokrowsky,  too,  has  shown  that  iron  increases  the  process  of  oxida- 
tion in  the  body  by  demonstrating  that  in  health  there  is  an  eleva- 
tion of  temperature  and  an  increase  of  the  percentage  of  urea  in  the 
urine  during  its  administration.  In  anaemic  persons,  to  whom  iron  has 
been  given  for  the  purpose  of  increasing  the  amount  of  blood,  the  above 
phenomena*  may  be  observed  before  this  object  is  accomplished.  Thus 
iron  appears  to  replace  the  blood-corpuscles  to  a  certain  extent.  Now,  in 
infectious  disorders  of  the  blood,  where  the  red  globules  are  perpetually 
menaced  with  destruction,  it  seems  plausible  that  the  preparations  of  iron 
should  exert  an  antiseptic  action. 

Finally,  it  has  been  found  that  of  all  the  preparations  of  iron  the  chlo- 
ride possesses  the  greatest  power  of  stimulating  the  nervous  system.  Pos- 
sibly this  effect  may  be  traced  to  an  increase  of  the  arterial  pressure  in 
the  nerve-centres.  It  has  been  said  that  this  effect  has  been  vividly 
illustrated  in  certain  forms  of  chlorosis.  If  this  be  true,  iron  would  be 
all  the  more  indicated  in  diphtheria,  since  it  would  act  as  a  prophylactic 
against  a  series  of  nervous  phenomena  that  so  frequently  present  them- 
selves, both  during  and  subsequently  to  the  diphtheritic  process.  Thus 
it  is  that  for  many  years  the  muriate  of  iron  has  constituted  the  main  ele- 
ment, with  me,  of  internal  medication  in  most  cases  of  diphtheria,  both 
of  the  mild  and  the  most  dangerous  septic  type.  A  common  formula  is, 
for  a  child  of  two  years, 

fy  Tinct.  Ferri  Chloridi  f  gij  ; 
Potass.  Chlorat.  gr.  xx; 

Aquae  f  3v ; 

Glycerin.  Pur.  f3j.     M. 

S.  A  teaspoonful  every  fifteen,  twenty,  or  thirty  minutes. 

Carbolic  acid  exerts  a  powerful  influence  on  the  vitality  of  all  living 
elements,  and  hence  also  on  rapidly  proliferating  epithelium,  which 
constitutes  a  part  of  the  diphtheritic  membrane.  It  is  of  great  advan- 
tage for  local  use.  Its  local  effect,  undiluted  or  diluted  with  equal  or 
larger  parts  of  glycerine  or  alcohol,  in  shrinking  and  removing  mem- 
branes, is  sometimes  very  useful;  in  mild  solutions  in  water  (J,  1,  or  2  per 
cent.)  it  is  very  efficient  in  nasal  injections  or  for  external  applications 
or  mouth-washes.  Rothe's  prescription  for  external  use  is  carbolic  acid 
and  alcohol  each  2  parts,  water  10,  tincture  of  iodine  1.  Its  internal 
administration  to  the  extent  of  five  to  twenty  grains  daily,  given  largely 
diluted,  in  small  and  frequent  doses,  is  of  less  positive  value. 

Salicylic  acid,  in  a  solution  of  1  :  30-50,  is  caustic.  A  milder  solu- 
tion, 1  :  200-300  relieves  or  removes  foul  odor  from  the  nose  or  throat, 
but  it  does  not  detach  membranes  or  shorten  the  duration  of  the  disease, 
apparently.  Internally,  it  acts  no  longer  as  a  disinfectant,  but  is  changed 
into  a  salicylate  and  is  an  antipyretic.  It  is  then  better  to  replace  it  by 
the  sodium  salicylate.  With  its  administration  (for  a  child  of  2  years  t 
grains  every  hour  until  20  or  25  grains  are  taken)  it  ought  not  to  be  f 


708  DIPHTHERIA. 

gotten  that  serious  brain  troubles,  collapse,  and  irregular  and  paralytic 
breathing,  as  well  as  gastric  and  intestinal  disturbances,  may  follow  its 
use.  It  ought  not  to  be  given  without  careful  watching  and  the  simul- 
taneous free  use  of  alcoholic  stimulants. 

Binz  found,  as  the  result  of  experiments  with  solutions  of  pure 
quiuia  varying  from  one  part  in  a  hundred  to  one  in  a  thousand,  that 
the  latter  sufficed  to  prevent  the  development  of  bacteria  in  fluids 
capable  of  undergoing  putrefaction ;  but  even  estimated  thus,  a  patient 
with  eighteen  pounds  of  blood  would  require  one  hundred  and  thirty- 
eight  grains  of  quinia  circulating  therein  in  order  to  satisfy  the  condi- 
tions of  Binz's  experiment.  If  Binz  considers  two  grammes  (half  a 
drachm)  of  quinia  per  day  sufficient  for  an  individual  weighing  one  hun- 
dred and  twenty  pounds,  his  calculation  is  founded  on  experiments  with 
dogs,  in  which  septicaemia  was  avoided  by  the  injection  of  quiuia.  It  is 
also  necessary  to  bear  in  mind  that  Binz  makes  a  distinction  with  regard 
to  the  preparations  of  quinia  employed.  He  warns  against  the  use  of 
the  bisulphate  as  being  the  most  inactive.  No  matter  which  preparations 
are  used — I  prefer  the  muriate — I  have  come  to  look  upon  quinia  as  of 
no  great  service  in  reducing  the  temperature  in  infectious  fevers.  The 
main  indication  for  its  use  can  only  be  found  in  inflammatory  fevers. 
When  it  is  given,  however,  salicylate  of  sodium  may  be  added  for  a  short 
time  to  obtain  a  speedier  effect. 

On  the  part  of  bromine  Wra.  H.  Thompson  claims  the  following 
advantages:  1.  When  applied  locally,  it  promptly  arrests  fetor  by 
arresting  directly  the  gangrenous  process,  and  thus  lessens  risk  from 
absorption.  2.  It  acts  as  an  anti-putrefactive  likewise  in  the  fluids  of  the 
body  generally — i.  e.  blood,  interstitial  circulation,  and  secretions — owing 
to  its  high  rate  of  diffusibility,  equal  to  that  of  sodium  chloride  itself. 
3.  It  locally  destroys  the  communicable  property  of  the  discharges, 
shown  by  the  immunity  of  attendants  from  any  sore  throat  when  it 
Is  used,  and  from  its  checking  the  spread  of  the  disease  in  the  locality. 
He  orders  two  solutions  to  be  used:  the  first  of  equal  parts  of  Lawrence 
Smith's  solutio  bromiui  and  of  glycerine,  applied  with  a  hair  pencil  to  the 
membrane,  as  gently  as  possible.  Sometimes  he  uses  the  solution  full 
strength.  The  brush  should  be  washed  at  once  in  water,  and  does  not 
last  more  than  one  day,  owing  to  the  action  of  the  bromine  on  the  hair.  If, 
however,  the  membrane  be  very  extensive  and  the  parts  much  swollen  or 
difficult  to  reach,  he  resorts  instead  to  douching  with  a  Davidson  syringe, 
using  half  a  drachm  to  one  drachm  of  the  solution  to  a  pint  of  warm 
water.  By  beginning  gently  with  the  stream  directed  against  the  buccal 
mucous  membrane,  the  child  soon  becomes  accustomed  to  the  current  and 
allows  it  then  to  play  against  the  deeper  parts. 

Internally  he  orders  from  six  to  twelve  drops  of  the  solution  in  a  half 
ounce  of  sweetened  water,  every  hour,  two,  or  three  hours,  according  to 
the  urgency  of  the  case,  and  continuously. 

The  most  convenient  way  of  making  Smith's  solution  is:  Take  two 
ounces  of  a  saturated  solution  of  potassium  bromide  in  water;  add  to  this, 
very  slowly,  in  a  bottle  and  with  constant  shaking,  one  ounce  of  bromine. 
It  is  better  to  add  a  part,  and  then  let  it  stand  a  while  before  adding  the 
rest;  then  fill  up  gradually,  and  with  constant  shaking  with  water,  until 
it  measures  four  ounces. 


TREATMENT.  709 

Ozone  has  been  used  as  an  anti-fermentative  in  inhalation  during  three 
or  five  minutes  every  hour  or  two,  by  Jochheim. 

Boric  (boracic)  acid,  in  saturated  (1  :  25)  or  milder  solutions,  has  some 
antiseptic  effect.  It  is  mild,  and  not  very  injurious  when  swallowed  by 
necessity  or  mistake.  In  diphtheritic  conjunctivitis  it  is  valued  highly, 
and  in  nasal  injections  I  have  found  it  very  useful.  It  is  less  repugnant 
than  most  other  substances  administered  in  that  way. 

Sodium  benzoate  cannot  be  relied  on  either  as  an  an ti -diphtheritic  nor 
as  an  anti-febrile.  The  doses  which  were  recommended  were  two  scruples 
or  a  drachm  daily  for  a  child  a  year  old. 

Sulphur  has  been  used  locally.  It  gives  rise  to  coughing  and  vomit- 
ing. 

Cubebs  have  been  given  in  incredible  doses,  two  drachms  of  the  powder 
to  a  child  a  year  old.  The  drug  disorders  the  stomach  and  kidneys. 

Local  Treatment. — The  mechanical  removal  of  the  membranes  is  not 
permissible  unless  they  are  almost  detached.  It  is  best  to  avoid  their 
being  cast  off,  unless  partly  loosened  membranes  in  the  larynx  or  trachea 
afford  an  indication  for  an  emetic.  Scratching  and  eroding  the  mucous 
membrane  of  the  neighborhood  give  rise  to  new  deposits.  Even  after 
spontaneous  elimination  of  a  membrane  a  new  one  may  be  formed  within 
a  few  hours. 

To  cauterize  a  diphtheritic  membrane  or  infiltration  I  consider  wrong, 
unless  I  shall  be  able  to  do  so  thoroughly  and  to  limit  the  action  of  the 
caustic  to  the  diseased  surface.  Therefore  potassa  or  chromic  acid  cannot 
be  utilized,  because  of  the  impossibility  of  limiting  their  effect.  Nitrate 
of  silver  and  mineral  acids  can  be  restricted  in  their  effects,  but  these  are 
not  sufficiently  thorough,  particularly  as  but  few  patients  will  consent  to 
have  the  remedy  applied  properly.  When  I  do  cauterize,  I  prefer  a  mix- 
ture of  equal  parts  of  carbolic  acid  and  glycerine  or  the  undiluted  acid. 
The  membrane  crumbles  and  falls  off  in  pieces.  Force  must  never  be 
used.  Where  it  would  be  required  in  the  case  of  obstinate  children  mild 
washes  must  be  employed  instead  of  the  caustic.  Besides,  the  internal 
medication  detailed  above  meets  every  indication.  When  there  is  a  slight 
swelling  of  the  lymphatic  glands,  cold  water  or  ice  applications  are  usually 
all  that  is  needed.  The  latter  should  be  made  according  to  general  indi- 
cations. The  glandular  and  peri-glandular  swellings  are  less  the  result 
of  an  actual  filling  up  with  foreign  matter  than  of  secondary  irritation. 
Ice  has  a  happy  effect  in  such  cases,  both  on  internal  administration,  in 
the  form  of  frequent  small  quantities  of  ice-water,  ice-pills,  ice  cream, 
and  iced  medicaments,  and  also  externally  by  ice-cold  cloths  or  india- 
rubber  bags  filled  with  ice. 

In  general,  the  treatment  of  the  swelled  glands  must  be  both  based  en, 
its  causes  and  adapted  to  the  present  condition.     The  adenitis  and  pen- 
adenitis  is  of  secondary  nature,  the  irritation  being  in  the  mouth,  pharynx, 
and  nares.     In  these  localities  is  where  the  main  treatment  is  required 
The    sooner  the  primary  affection  is  removed   or  relieved  or  renderc 
innocuous,  the  better  it  is  for  the  secondary  complaint      Frequent  doses 
of  chlorate  of  potassium  or   sodium,   or   biborate  of  sodium    in   mil 
doses  frequently  repeated,  according  to  the  principles  laid  down  in  an- 
other part  of  this  article,  mouth-washes,  gargles    nasal  injections  with 
water    salt  water,  or  solutions  of  disinfecting  substances,  are  not  only 


710  DIPHTHERIA. 

indicated,  but  highly  successful.  When  the  case  is  recent,  cold  applica- 
tions are  required,  but  uo  washes.  When  it  is  of  older  date,  stimulant 
embrocations  are  in  order.  Iodine  ointments  are  absorbed  but  slowly ; 
mercurial  plasters  do  good  in  some  cases ;  iodide  of  potassium  dissolved 
in  glycerine  (1  :  3—4),  frequently  applied,  iodine  in  oleic  acid  (1  :  8—12), 
iodoform  in  collodion  or  flexible  collodion  (1  :  12—15)  applied  twice  daily, 
the  latter  frequently  with  very  good  result,  are  beneficial.  Copious  sup- 
puration is  very  rare.  Cases  in  which  a  free  incision  meets  with  an 
abscess  ready  to  heal  are  very  uncommon.  But  numerous  small  abscesses 
with  gangrenous  walls  and  pus  mixed  with  a  sero-sanguinolent  or 
sero-purulent  liquid,  are  more  frequently  found.  In  such  cases  a  probe 
introduced  into  the  lancet  wound  enters  easily  into  the  broken-down 
tissue  in  every  direction,  to  a  distance  even  of  three  to  six  centimetres, 
(several  inches),  according  to  the  size  of  the  tumefaction.  I  have 
seen  fatal  hemorrhages  from  such  gangrenous  destructions ;  therefore 
the  treatment  must  be  both  timely  and  energetic.  The  incision  must  not 
be  delayed  too  long.  When  the  skin  assumes  a  purplish  hue  or  is  simply 
discolored,  it  is  time  to  incise  and  to  apply  concentrated  or  nearly  concen- 
trated carbolic  acid  to  the  interior,  unless  the  neighborhood  of  very 
important  blood-vessels  or  nerves  yields  a  contraindication  to  concentrated 
applications.  In  that  case  a  milder  preparation  is  advisable,  but  the 
application  should  be  repeated  often,  until  the  suppuration  becomes  more 
normal.  Then  mild  disinfectant  injections  into  what  has  now  become  a 
cavity  will  be  found  satisfactory,  particularly  when  meanwhile  the  general 
condition  of  the  patient  has  been  improved. 

Treatment  of  Nasal  Diphtheria. — Especially  during  the  prevalence  of 
an  epidemic  of  diphtheria  must  we  be  careful  not  to  allow  a  nasal  catarrh 
to  have  its  own  way ;  we  must  likewise  guard  against  considering  the  thin' 
and  flocculent  discharge  in  infected  cases  as  a  mucous  secretion.  What- 
ever be  the  origin  of  nasal  diphtheria,  whether  primary  or  the  result  of 
a  similar  affection  in  the  throat,  local  treatment  should  at  once  be  insti- 
tuted, and  if  this  be  done  the  great  majority  of  cases  will  terminate  favor- 
ably. The  danger  in  this  form  of  disease  consists  in  an  excessive  absorp- 
tion of  putrid  substances  and  in  the  breathing  of  contaminated  air. 
The  interior  of  the  nasal  cavities  must  be  thoroughly  cleaned  and  disin- 
fected. If  this  be  commenced  early,  the  original  seat  of  the  aifection  may 
be  reached,  and  the  disinfectant  process  will,  as  a  rule,  have  good  results. 
It  is  not  necessary  to  select  very  energetic  disinfectants ;  a  solution  of 
twelve  to  twenty-five  centigrammes  (two  to  four  grains)  of  carbolic  acid 
in  thirty  grammes  (an  ounce)  of  water  is  at  once  mild  and  effective,  and 
hardly  gives  rise  to  more  discomfort  than  lukewarm  water.  Nasal  injec- 
tions must  be  made  very  frequently,  until  each  time  the  stream  of  fluid 
has  a  free  exit  through  the  other  nostril  or  through  the  mouth.  They 
must  be  made  at  least  every  hour,  and  even  oftener  if  necessary ;  at  the 
same  time  it  is  advisable  to  be  careful  that  the  fluid  does  not  enter  the 
Eustachian  tube.  This  can  be  prevented,  to  a  certain  extent,  by  compel- 
ling the  patient  to  keep  the  mouth  open  during  the  procedure.  I  have  sel- 
dom seen  evil  or  even  disagreeable  results  from  the  administration  of  nasal 
injections  in  diphtheria.  It  is  likely  that  the  mucous  membrane  of  the 
pharynx  is  swollen  as  far  as  the  openings  of  the  Eustachian  tubes  to  such 
a  degree  as  to  render  the  entrance  of  fluids  into  the  latter  improbable 


TREATMENT  711 

The  hardness  of  hearing,  which  is  of  so  frequent  occurrence  in  the  course 
of  a  severe  catarrh  or  of  a  diphtheritic  attack,  seems  to  indicate  that  the 
mucous  membrane  of  that  part  is  in  a  state  of  swelling.  An  ordinary 
syringe  will  suffice.  However,  when  administered  by  parents  or  nurses 
the  blunt  nozzle  of  au  ear  syringe  is  preferable.  Occasionally  here,  as  in 
local  applications  to  the  mouth  and  pharynx,  the  atomizer  may  be  used 
to  advantage,  but  the  tube  must  be  properly  introduced  into  the  nostrils. 
There  are  cases  of  nasal  diphtheria,  however,  which  are  far  more  trouble- 
some to  manage  than  the  foregoing  would  seem  to  indicate.  I  have  seen 
cases  in  which  the  nasal  cavities,  from  the  anterior  to  the  posterior  nares, 
were  filled  and  completely  occluded  by  a  dense,  solid  membranous  mass. 
I  was  then  compelled  to  bore  a  passage  with  a  silver  probe,  to  gradually 
introduce  a  larger-sized  one,  and  then  to  apply  the  pure  carbolic  acid,  in 
order  to  remove  the  densest  and  thickest  masses,  and  finally  was  able  to 
make  injections ;  even  in  such  cases  I  have  had  the  gratification  of 
being  able  to  give  a  favorable  prognosis.  The  dangerous  secondary  swell- 
ing of  the  glands  will  often  subside  after  a  steady  employment  of  disin- 
fectant injections  for  from  twelve  to  twenty-four  hours.  It  will  be  found 
that  children  frequently  do  not  object  to  this  method  of  treatment ;  I 
have  even  met  with  some  who,  after  convincing  themselves  of  the  relief 
afforded  thereby,  asked  for  an  injection.  When  we  are  about  to  bring 
each  injection  to  a  close  it  is  well  to  press  together  the  nasal  cavities  for 
an  instant  with  the  fingers.  By  this  procedure  the  fluid  is  forced  back- 
ward to  the  pharynx,  and  is  swallowed  or  ejected  through  the  mouth,  and 
thus  washes  the  pharynx  and  mouth  at  the  same  time.  Frequently, 
however,  this  latter  object  is  obtained  with  every  injection  ;  for,  the  palate 
being  swelled,  cedematous,  and  paretic,  the  fluid  is  not  prevented  from 
reaching  the  pharynx,  even  in  the  average  case.  In  regard  to  the  choice 
of  a  disinfecting  agent,  I  have  but  a  few  words  to  say.  I  believe  that 
no  one  of  them  has  important  qualifications  above  the  others.  I  avoid 
those  which  stain  or  which  produce  firm  coagula.  For  the  latter  reason  I 
do  not  use  the  subsulphate  and  perchloride  of  iron;  for  the  former,  ^the 
permanganate  of  potassium.  I  employ,  as  a  rule,  carbolic  acid  in  solution, 
of  the  strength  above  mentioned.  Where  there  is  but  a  slightly  fetid  odor 
I  have  frequently  employed  lime-water  or  water  with  glycerine,  or  a 
solution  (1  :  100,  1  :  50)  of  chloride  of  sodium,  or  of  bicarbonate  of  soda 
or  of  borax,  or  a  saturated  solution  of  boric  acid.  Disinfecting  agents 
and  antiseptics,  whether  carbolic  acid,  salicylic  acid,  or  iron,  are  of  no 
service  when  administered  internally  only,  unless  the  seat  and  cause  of 
the  septic  infection  be  attended  to  previously.  Under  the  local  employ- 
ment of  antiseptics,  as  described,  or  by  simply  washing  out  with  water 
or  salt  water,  most  cases  recover ;  without  them,  death  will  result.  Of 
late,  in  many  cases,  the  local  applications,  injections,  etc.  of  the  corrosive 
chloride  of  mercury  in  water  (I  :  5000-10,000)  has  proved  very  effective. 
It  has  this  advantage  over  carbolic  acid,  that  the  swallowing  of  the  former 
is  not  so  dangerous.  This  much,  after  all,  my  experience  has  assured  me 
of,  that  there  is  a  certain  number  of  cases  which  terminate  fatally ;  but 
is  likewise  true  that  the  mortality  need  not  be  excessively  great.  1  cannot 
grant  that  it  is  hard  to  carry  out  the  exact  and  apparently  barbarous  treat- 
ment necessary  for  a  favorable  result,  for  it  is  certainly  more  barbarc 
sacrifice  than  to  save  life. 


712  DIPHTHERIA. 

It  is  a  positive  fact  that  when  children  suffering  from  nasal  diphtheria, 
with  its  peculiarly  septic  character,  are  permitted  to  sleep  much — and 
they  are  apt  to  be  drowsy  under  the  influence  of  the  poison — they  will 
certainly  die.  To  allow  them  to  sleep  is  to  allow  them  to  die. 

The  first  symptom  of  improvement  is  often  a  rapid  diminution  of  the 
glandular  swelling  wherever  it  exists.  It  is  not  present  in  all  cases, 
but  chiefly  in  those  in  which  a  bloody  serum  was  discharged  in  an  early 
period  of  the  disease.  In  these  the  blood-vessels  appear  to  be  very  vul- 
nerable, superficial,  and  apt  to  absorb ;  these  are  also  the  most  dangerous 
cases,  and  require  the  greatest  attention  and  care,  and  also  prompt  disin- 
fection. 

Treatment  of  Laryngeal  Diphtheria. — The  severest  form  of  diphtheria 
is  that  located  in  the  larynx,  constituting  membranous  croup.  Its  gene- 
ral treatment,  whether  the  disease  has  originated  primarily  in  the  larynx 
or  trachea  or  has  been  communicated  from  the  pharynx,  does  not  differ 
from  that  laid  down  for  diphtheria  in  general.  Naturally  the  larynx  calls 
for  special  treatment  on  account  of  the  symptoms  of  suffocation  which 
result  from  its  stenosis.  The  main  indication  of  removing  viscid  mucus 
or  partly-detached  membranes  is  best  met  by  the  administration  of  an 
emetic.  Such  is  their  only  indication  in  my  experience.  The  selection 
of  the  emetic,  when  indicated,  is  of  great  importance.  Antimonials  ought 
to  be  avoided  because  of  their  depressing  and  purgative  effect.  Ipecac- 
uanha is  but  rarely  effective.  The  sulphates  of  zinc  and  copper,  and 
particularly  the  latter,  deserve  preference.  Turpeth  mineral  acts  promptly 
and  satisfactorily.  When  no  emesis  can  be  obtained  the  prognosis  is 
decidedly  bad.  Recourse  must  then  be  had  to  tracheotomy,  the  good 
results  of  which  are  however  only  too  often  delusive  and  transient. 

"When,  after  the  operation,  there  is  scarcely  any  relief,  and  particularly 
when  the  case  takes  a  very  rapid  course,  it  is  probably  one  of  ascending  croup 
which  commenced  in  the  trachea.  Mechanical  relief  by  pushing  down  a 
hen's  feather  or  a  bundle  of  them,  and  turning  it  about  and  twisting, 
must  be  tried.  It  is  a  much  better  instrument  than  pincers  of  all  sorts 
and  shapes.  But  what  relief  will  be  accomplished  is  but  of  very  short 
duration.  When  fever  sets  in  within  a  few  hours  it  means  very  much 
more  frequently  pneumonia  than  diphtheritic  fever.  It  is  apt  to  be  soon 
complicated  by  that  disproportion  between  pulse  and  respiration  so  cha- 
racteristic of  inflammatory  diseases.  Then  quinia  in  larger  doses,  0.25 
or  0.5  (grs.  iv— viij)  every  two,  four,  eight  hours,  at  the  same  time  doses 
of  sodium  salicylate  0.25-0.40  (grs.  iv— vj)  every  hour  or  two  hours  until 
the  temperature  goes  down,  and  small  doses  of  digitalis  where  the  heart 
requires  it,  must  be  given  at  once.  Procrastination  is  dangerous;  the 
patients  want  careful  watching  ;  many  of  them  die  within  two  days  after 
the  operation. 

Diphtheritic  conjunctivitis  requires  great  attention  and  permits  of  no 
loss  of  time.  Cold  applications  to  the  affected  eye  must  be  made  con- 
stantly. Pieces  of  linen  or  lint  kept  on  ice  (better  than  in  ice-water)  of 
little  more  than  the  size  of  the  eye,  must  be  changed  every  minute  or  two 
day  and  night.  The  danger  to  the  cornea  is  so  imminent  that  constant 
watchfulness  is  required.  Boric  acid  in  concentrated  solution  should  be 
dropped  into  the  eye  once  every  hour.  Care  must  be  taken  that  the 
well  eye  shall  not  get  infected ;  for  that  purpose  it  is  best  to  cover  it 


TREATMENT.  713 

with  lint  and  collodion,  or  with  lint  or  cotton  held  in  place  by  adhesive 
plaster. 

Cutaneous  diphtheria  requires  the  destruction  of  the  membrane  or  of  the 
infected  surface  by  carbolic  acid,  either  concentrated  or  somewhat  diluted 
with  glycerine,  or  the  application  of  the  actual  cautery.  After  that  the 
use  of  ice  or  iced  cloths,  or  diluted  carbolic  acid,  is  indicated.  As  soon 
as  the  surface  is  no  longer  diphtheritic  the  local  and  general  treatment 
is  to  be  continued  on  general  principles. 

Diphtheritic  paralysis  is  invariably  complicated  by  ansemia  and  debility, 
and  the  diet  and  medical  treatment  must  be  regulated  accordingly.  How- 
ever, neither  overfeeding  nor  a  sameness  of  diet  are  to  be  permitted,  for  not 
rarely  the  muscular  coat  of  the  stomach  suffers  with  the  rest  of  the  mus- 
cular ^tissue,  and  the  secretion  of  gastric  juice  is  very  deficient  in  anaemic 
individuals.  While,  therefore,  iron  is  indicated,  we  must  not  neglect  to 
pay  particular  attention  to  nutrition  and  digestion,  and  to  aid  the  latter 
with  pepsin  and  moderate  amounts  of  muriatic  acid,  well  diluted.  Qui- 
nia  in  small  doses  and  stimulants  are  appropriate  whenever  there  is  no 
contraindication  to  their  employment.  The  treatment  of  the  paralysis 
itself  will  naturally  depend  on  the  diagnosis  of  the  condition  present 
in  each  individual  case,  which  we  have  seen  to  differ  considerably.  This 
alone  can  explain  why  various  modes  of  treatment,  the  electric  current 
among  others,  after  being  recommended  by  some  authors,  are  branded  by 
others.  Where  we  have  to  deal  with  those  rare  changes  in  the  brain  and 
spinal  cord,  the  utmost  care  is  necessary  in  order  not  to  make  the  con- 
dition still  worse ;  and  in  such  cases  there  would  be  a  contraindication  to 
the  use  of  the  faradie  current,  though  this  would  not  hold  true  with 
regard  to  the  use  of  the  galvanic  current  in  short  sittings.  Besides, 
central  paralyses  are  by  no  means  so  frequent  as  peripheral  ones.  In 
most  cases  there  is  not  the  slightest  elevation  of  temperature  during  the 
course  of  the  paralytic  phenomena.  I  lay  great  stress  upon  this  point, 
for  I  am  aware  that  many  cases  of  central  congestion  and  even  of  inflam- 
mation exhibit  but  very  insignificant  elevations  of  temperature.  But, 
as  the  diagnosis  will  depend  on  a  positive  knowledge  of  whether  there 
have  been  changes  of  temperature,  I  rely  on  the  rectal  temperature  only, 
for  many  a  myelitis  runs  its  course  with  no  greater  elevation  above  the 
normal  than  one-half  or  one  degree.  In  all  cases  in  which  the  tem- 
perature is  normal  or  subnormal,  I  do  not  hesitate  for  a  moment  to 
employ  the  faradie  or  the  galvanic  current.  In  addition  to  the  internal 
administration  of  iron  I  advise  by  all  means  the  employment  of 
strychnia.  When  there  is  no  necessity  for  haste,  we  may  give^  mode- 
rate doses,  gradually  increasing  them,  and  using  iron  in  combination. 
When  there  is  danger  in  delay,  recourse  ought  to  be  had  to  subcuta- 
neous injections  of  the  sulphate  of  strychnia,  once  or  twice  daily. 
They  are  mainly  indicated  in  paralysis  of  the  muscles  of  deglutition  and 
of  respiration.  Of  course,  where  the  former  are  affected  it  is  necessary 
to  nourish  the  patient  artificially,  partly  perhaps  by  nutrient  enemata, 
but  principally  by  means  of  the  stomach-tube.  In  using  the  latter  it  is 
unnecessary  to  introduce  it  into  the  stomach,  as  it  only  requires  to  be 
passed  a  few  inches  below  the  affected  parts,  when  the  oesophagus  will 
usually  be  found  able  to  undertake  the  further  disposal  of  the  food. 
In  these  cases  strychnia  should  be  injected  subcutaneously  in  the  neck, 


714  DIPHTHERIA. 

once  or  twice  daily.  In  a  similar  manner  it  should  be  injected  in  the 
region  of  the  chest,  diaphragm,  or  neck  in  paralysis  of  the  respiratory 
muscles  or  of  the  glottis.  In  paralysis  of  the  muscles  of  accommodation 
(in  which  Scheby-Buch  claims  to  have  seen  the  process  cut  short  by  the 
use  of  the  Calabar  bean,  considered  as  inert  by  Hassner)  they  may  be 
given  in  the  forehead  or  temples. 

Frictions   dry  and   alcoholic,  hot   bathing,  friction  with   hot  water, 
kneading  of  the  affected  parts,  will  be  found  beneficial  and  pleasant. 


CHOLERA. 

BY  ALFKED   STILLE,    M.  D.,    LL.D. 


DEFINITION. — Cholera  is  an  epidemic  disease,  characterized  by  the 
transudation  of  serum  into  the  stomach  and  bowels,  and  usually  by  the 
profuse  discharge  by  vomiting  and  purging  of  a  liquid  resembling  rice- 
water,  followed  by  a  tendency  to  collapse.  It  is  endemic  in  India,  but 
has  been  conveyed  thence  to  almost  every  part  of  the  world. 

SYNONYMS. — Cholera  algida,  C.  asiatica,  C.  asphyxia,  C.  maligna,  C. 
spasmodica.  In  English  it  is  generally  spoken  of  as  Asiatic  cholera. 

HISTORY. — It  is  sometimes  stated  that  Hippocrates,  Galen,  Celsus, 
and  the  Greek,  Roman,  and  Arabian  medical  writers  generally  record 
"  the  fact  of  the  presence  of  cholera  in  the  various  countries  in  which 
they  lived"  (Macnamara).  Nothing  could  be  more  contrary  to  the 
truth.  All  of  these  writers  describe  "  cholera  morbus  "  in  nearly  iden- 
.  tical  terms  ;  they  all  include  bilious  discharges  among  its  symptoms,  and 
no  one  of  them  speaks  of  it  as  a  mortal  or  even  as  an  epidemic  disease. 
(Compare,  especially,  Celsus,  Aretaeus,  Cselius  Aurelianus,  and  Paulus 
TEgineta.)  Their  description  of  sporadic  cholera  morbus  is  very  precise. 
For  example,  Cselius  Aurelianus  says :  "  Cholericam  passionem  aiunt 
aliqui  nominatam  a  fluore  fellis,  per  os  et  ventrem  effecto."1 

Asiatic  epidemic  cholera  is  a  very  different  disease.  It  seems  to  have 
been  known  in  India  from  a  very  remote  period,  but  no  detailed  account 
of  it  was  published  until  the  beginning  of  the  sixteenth  century.  ^  Dur- 
ing that  century  many  successive  descriptions  of  the  disease  exhibited  its 
extreme  violence  and  mortality.  It  is  believed  to  have  occurred  repeat- 
edly, if  not  annually,  in  the  same  localities  down  to  the  present  time. 
The  invasion  of  India  by  the  Portuguese,  and  afterward  by  the  English, 
contributed  to  spread  the  disease  throughout  the  Peninsula,  partly  by 
military  occupation  and  partly  through  commercial  channels,  by  which  it 
was  also  carried  to  the  islands  in  the  Indian  Ocean.  It  prevailed  iu 
Batavia  in  1629.  Between  1768  and  1790  numerous  epidemics  of  cholera 
occurred.  About  the  former  date  no  less  than  60,000  persons  are  said  to 
have  perished  near  Pondicherry,  and  in  1783  it  is  reckoned  that  20,000 
victims  to  the  disease  fell  in  a  single  week  during  the  religious  gathering 
at  the  sacred  city  of  Hurdwar,  where,  as  will  be  seen  hereafter,  it  became 
in  later  years  more  fatal  still.  The  English  armies  extended  their  con- 
quests in  Hindostan,  and  established  commerce  between  that  country  and 
Western  Ask  and  Europe,  and  by  the  year  1817  opened  new  channels  of 
1  Acul.  Morb.,  lib.  iii.  cap.  xix- 

715 


716  CHOLERA. 

communication  in  every  direction,  both  within  and  beyond  the  Peninsula. 
Along  them  the  disease  was  carried;  it  invaded  Ceylon  and  the  Burmese 
empire,  and  extended  to  Batavia,  Java,  and  China  on  the  east,  and 
advanced  westward  to  Persia  in  1821.  In  that  year  also  it  was  carried 
from  Arabia  into  Africa,  and  at  various  later  periods  penetrated  more  and 
more  deeply  into  the  Dark  Continent,  always  following  the  track  of  pil- 
grims returning  from  Mecca,  the  routes  of  armies  engaged  in  war,  or 
those  of  trading  caravans.1 

In  these  cases,  as  in  others  elsewhere,  the  spontaneous  origin  of  the  dis- 
ease has  been  assumed  by  certain  writers,  but  at  every  stage  of  its  progress 
careful  investigation  led  uniformly  to  the  conclusion  that  it  was  propagated 
directly  or  indirectly  from  pre-existent  cases  of  cholera.  From  Persia  it 
moved  northward  as  far  as  the  shores  of  the  Caspian  Sea,  and  westward 
to  the  Levant  in  1823,  and  there  for  a  time  its  ravages  were  stayed. 
Meanwhile,  it  prevailed  at  various  places  throughout  Hindostan,  and, 
assuming  a  greater  degree  of  violence  in  1826,  it  advanced  steadily  in  a 
north-western  direction  across  Afghanistan  and  Persia  in  the  following 
year.  In  1829  it  reached  Orenburg,  to  the  north  of  the  Caspian  Sea,  and 
was  speedily  conveyed  into  the  interior  of  the  Russian  empire,  where  it 
raged  with  great  violence  in  1830.  In  1831  it  prevailed  at  Mecca  among 
the  pilgrims,  who  had  brought  it  from  India,  and  so  virulently  that  one- 
half  of  them  are  computed  to  have  perished.  Hence  it  speedily  passed 
with  returning  pilgrims  to  Alexandria  and  Constantinople,  and  was  car- 
ried to  St.  Petersburg,  to  Sweden,  to  Hamburg,  and  other  places  in 
Northern  continental  Europe.  From  Hamburg  and  other  seaports  it 
was  conveyed  to  commercial  towns  on  the  eastern  coast  of  England, 
whence  it  extended  to  Edinburgh  in  the  north  and  London  in  the  south: 

In  1832  cholera  prevailed  in  France,  and  within  the  year  caused  120,000 
deaths,  7000  of  which  occurred  in  Paris  in  the  space  of  eighteen  days. 
In  the  spring  and  summer  of  that  year  it  was  reproduced  in  England, 
and  extended  to  Ireland.  From  Liverpool,  Cork,  Limerick,  and  Dublin 
five  vessels  filled  with  emigrants  sailed  for  Quebec,  Canada,  and  they, 
together,  lost  179  passengers  by  cholera  during  the  voyage. 

The  immediate  results  of  this  importation  and  first  appearance  of 
cholera  on  the  American  continent  are  described  by  Dr.  Peters  as  follows : 
"All  these  ships  and  their  passengers  were  quarantined  at  Grosse  Isle,  a 
few  miles  below  Quebec.  On  June  7th  the  St.  Lawrence  steamer  Voya- 
geur  conveyed  a  load  of  these  emigrants  and  their  baggage,  some  to  Que- 
bec, but  the  majority  to  Montreal  on  the  10th.  The  first  cases  of  cholera 
occurred  in  emigrant  boarding-houses  in  Quebec  on  the  8th,  and  the  same 
pest-steamboat,  the  Voyageur,  landed  persons  dead  and  dying  of  cholera 
at  Montreal,  a  distance  of  two  hundred  miles,  in  less  than  thirty  hours. 
Over  this  long  distance,  thickly  inhabited  on  both  shores  of  the  St.  Law- 
rence, cholera  made  a  single  leap,  without  infecting  a  single  village  or  a 
single  house  between  the  two  cities,  with  the  following  exceptions.  A 
man  picked  up  a  mattress  thrown  from  the  Voyageur,  and  he  and  his 
wife  died  of  cholera;  another  man,  fishing  on  the  St.  Lawrence,  was 
requested  to  bury  a  dead  man  from  the  Voyageur,  and  he  and  his  wife 
and  nephew  died.  The  captain  of  a  passing  boat  requested  an  Indian  to 
bury  a  man  from  on  board ;  this  man  and  five  other  Indians  were  attacked 
1  Christie,  Cholera  Epidemics  in  Africa,  1876. 


HISTORY.  717 

and  died  The  town  of  Three  Rivers,  halfway  between  Quebec  and 
Montreal,  forbade  steamers  to  land,  and  escaped  for  a  long  time.  From 
Montreal  the  great  influx  of  emigrants  were  forwarded  away,  by  the  Emi- 
grant Society,  as  fast  as  they  arrived,  and  by  them  the  pestilence  was 
sown  at  each  stopping-place.  Kingston,  Toronto,  and  Niagara  soon 
became  affected.  In  the  end,  over  4000  persons  died  of  cholera  in  Mont- 
real, and  more  than  an  equal  number  in  Quebec.  The  epidemic  reached 
Detroit  in  the  same  way,  ....  and  continued  west  along  the  Great  Lakes, 
until  in  September  it  reached  our  military  posts  on  the  Upper  Mississippi. 
.  .  .  .^Fort  Dearborn,  near  Chicago,  was  temporarily  reoccupied  in  1832, 
and  it  was  here  that  epidemic  cholera  displayed  its  most  fatal  effects 
among  our  troops.  Out  of  1000  men,  over  200  cases  were  admitted  into 

hospitals  in  the  course  of  seven  or  eight  days When  these  troops 

again  marched  for  the  Mississippi,  they  appeared  in  perfect  health,  yet 
the  cholera  broke  out  again  on  the  way,  and  when  the  command  reached 
the  Mississippi  it  had  been  as  fatal  as  it  had  been  at  Fort  Dearborn." 

Meanwhile,  an  emigrant  ship  with  cholera  on  board  reached  New 
York,  whence  the  disease  spread  up  the  Hudson  River,  and  was  also  car- 
ried southwardly  to  Philadelphia  and  the  West.  The  mortality  in  New 
York  City  from  this  epidemic  is  stated  at  3500.  In  1833  the  disease 
broke  out  in  the  cities  of  Havana  and  Matanzas  in  Cuba,  and  is  said  to 
have  destroyed  one-tenth  of  the  entire  population.  Hence  it  was  carried 
to  Mexican  and  American  towns  on  the  Gulf  of  Mexico,  and  up  the 
Mississippi  and  Ohio  as  far  as  the  western  border  of  Pennsylvania.  In 
the  following  year  it  was  again  introduced  at  the  port  of  Quebec  by  a 
vessel  filled  with  emigrants,  of  whom  many  had  died  during  the  passage. 
It  prevailed  in  Canada  and  the  State  of  New  York  and  spread  over  the 
whole  country  in  1835  and  1836.  In  the  former  of  these  two  years  it 
was  confined  to  several  Southern  cities,  whither  it  was  brought,  as  on  a 
former  occasion,  directly  from  Cuba.  It  then  gradually  subsided,  and  at 
last  disappeared  for  the  space  of  nearly  ten  years. 

But  in  1845  it  was  known  to  be  advancing  on  its  former  path,  which  it 
steadily  pursued,  and  entered  England  in  October,  1848,  at  Sunderland, 
the  very  town  at  which  it  first  appeared  in  1831.  "During  the  second 
epidemic  in  Europe,  in  1848,  two  vessels  sailed  from  Havre,  where  cholera 
prevailed — one,  the  New  York,  for  New  York,  and  the  other,  the  Swan- 
ton,  for  New  Orleans.  Both  contained  large  numbers  of  German  emi- 
grants. On  one  vessel  the  cholera  appeared  when  it  was  sixteen  days  out, 
with  fourteen  deaths;  on  the  other,  in  twenty-six  days,  with  thirteen 
deaths.  The  New  York  arrived  at  Staten  Island  Dec.  2,^1848,  and  a 
severe  epidemic  broke  out,  but  was  confined  to  the  quarantine  grounds. 
The  Swanton  arrived  at  New  Orleans  Dec.  llth;  no  quarantine  was  insti- 
tuted, and  in  two  days  its  sick  were  taken  into_  the  Charity  Hospital. 
This  was  the  beginning  of  a  severe  epidemic,  which  increased  in  power 
all  winter,  till,  in  June,  1849,  2500  died  of  it  in  New  Orleans.  Decem- 
ber 20,  1848,  it  reached  Memphis  by  steamboat  from  New  Orleans, 
and  for  twenty-five  days  was  confined  to  the  landing-place  of  the  former 
city,  whence  it  afterward  spread.  In  the  spring  it  was  carried  to  St. 
Louis  and  Cincinnati  and  the  whole  Mississippi  Valley.  In  October  ii 
reached  Sacramento,  Cal.,  by  means  of  overland  emigrants,  and,  almost 
at  the  same  time,  San  Francisco,  by  the  U.  S.  steamer  Northerner  from 


718  CHOLERA. 

Panama.  The  Chinese  of  California  suffered  most  severely"  (Peters). 
In  April,  1849,  cholera  reappeared  in  the  public  stores  at  the  quarantine 
station,  Staten  Island,  N.  Y.,  and  in  the  city  of  New  York,  where  it  was 
fatal  to  5000  persons. 

A  pause  now  took  place  in  the  ravages  of  the  disease  which  lasted  until 
1853.  In  that  year  it  destroyed  no  less  than  11,000  persons  in  the  Per- 
sian citv  of  Teheran.  At  Messina  its  victims  numbered  12,000,  in 
France  114,000,  and  in  England  about  16,000.  In  1854  it  was  intro- 
duced by  emigrant  ships  into  New  York,  causing  a  mortality  of  2000 
persons,  and  was  carried  to  Philadelphia,  where  its  victims  numbered 
500.  It  extended  to  many  towns  in  New  England  and  westward  along 
the  great  channels  of  emigration.  In  Montreal  the  deaths  were  1300, 
and  in  the  then  small  town  of  Detroit,  1000. 

After  an  interval  of  quiescence  longer  than  any  previous  one  the  cholera 
again  broke  out  among  the  pilgrims  to  Mecca  in  December,  1864.  It 
appeared  in  Alexandria  during  May,  1865,  and  thence  was  carried  to 
many  parts  of  Europe,  and  from  them  to  North  America  and  the  West 
Indies.  This  period  of  exemption  included  that  of  the  Civil  War  in  the 
United  States,  when,  if  ever,  the  local  causes  which  have  been  erroneously 
assigned  to  the  disease  existed  in  all  their  forms  and  in  the  most  intense 
degree.  It  was  only  when  its  specific  germs  were  once  more  imported 
that  cholera  began  to  prevail  again.  Official  records  show  that  in  1866 
it  was  introduced  from  Europe  into  Halifax,  N.  S.,  the  city  of  New  York, 
and  the  military  posts  of  New  York  harbor.  Thence  it  was  carried  in 
troop-ships  to  various  Southern  ports,  from  which  its  progress  could  be 
traced  to  Texas  and  other  Gulf  States,  and  to  the  towns  on  the  Mississippi 
and  Missouri  Rivers.  From  New  York,  also,  the  disease  travelled  west- 
ward to  Cincinnati  and  the  U.  S.  barracks  at  Newport,  on  the  opposite 
side  of  the  Ohio  River,  whence  it  advanced  in  a  south-westerly  direction 
to  meet  the  trail  that,  coming  from  the  South,  followed  the  great  rivers 
of  the  Mississippi  Valley.  During  the  summer  of  1867  cholera  again 
prevailed,  although  less  fatally,  at  most  of  the  points,  especially  of  the 
Mississippi  Valley,  which  had  been  invaded  the  previous  year,  and  some 
cases  occurred  at  the  military  posts -around  New  York  in  recruits  who  had 
shortly  before  arrived  from  places  in  the  West  where  cholera  prevailed. 
Thus  did  the  disease  complete  the  circuit  of  the  United  States. 

Meanwhile,  cholera  prevailed  to  a  greater  or  less  extent  in  the  east  of 
Europe  between  1865  and  1874.  After  the  latter  date  it  seems  to  have 
been  confined  to  Syria,  Arabia,  and  the  African  shore  of  the  Mediterra- 
nean. In  1877—78  it  existed  to  a  limited  extent  among  the  pilgrims  at 
Mecca,  and  since  then  it  has  not  been  known  in  Europe.  The  latest 
appearance  of  cholera  in  the  United  States  was  in  1873,  when  it  occurred 
at  three  points  far  distant  from  one  another.  It  was  introduced  in  the 
effects  of  immigrants.  The  vessels  that  brought  them  were  in  a  perfect 
sanitary  condition.  The  passengers  themselves  were  healtKy,  and  remained 
so  after  landing  and  until  they  reached  the  distant  points  of  Carthage, 
Ohio,  Crow  River,  Minn.,  and  Yankton,  Dak.,  where  their  goods  were 
unpacked.  At  each  place,  "within  twenty-four  hours  after  the  poison 
particles  were  liberated,  the  first  cases  of  the  disease  appeared,  and  the 
unfortunates  were  almost  literally  swept  from  the  face  of  the  earth" 
(E.  McClellan). 


HISTORY.  719 


In  1881  cholera  was  brought  from  Hindostan  to  Arabia  by  pilgrims  on 
their  way  to  Mecca,  where  it  soon  afterward  broke  out  and  caused  the 
death  of  about  8000  persons.     In  the  following  year  several  vessels  from 
Bombay  evaded  the  quarantine  and  reached  Djeddah,  the  port  of  Mecca, 
and  the  pilgrims  on  reaching  the  latter  city  disseminated  the  disease. 
The  unusually  small  number  of  persons  who  were  there  at  the  time,  and 
their  prompt  dispersion   before  the  danger,  limited  the  mortality,  and 
gradually  cases  of  cholera  ceased  to  appear.     In  1882,  the  English  at  that 
time  carrying  on  war  'in  Egypt,  very  rigid  sanitary  precautions  against 
the  importation  of  cholera  were  enacted  and  successfully  enforced,  but  in 
the  following  year,  the  same  urgent  necessity  no  longer  commanding,  they 
were  considerably  relaxed.     At  the  end  of  June,  1883,  the  cholera  made 
its  appearance  at  Damietta  (at  one  of  the  mouths  of  the  Nile),  and  soon 
afterward  at  Rosetta,  Port  Said,  and  Mansourah.     During  July  it  spread 
to  various  places  in  direct  communication  with  those  named.     At  Cairo  it 
was  peculiarly  fatal,  and  on  July  20th  it  was  reported  to  have  caused  600 
deaths.     For  several  days  the  daily  mortality  varied  between  500  and  600. 
The  disease  prevailed  somewhat  in  Alexandria  during  the  height  of  the 
epidemic,  and  near  the  end  of  October  it  was  fatal  to  numerous  European 
residents  of  that  city,  and  some  deaths  occurred  in  the  British  army  of 
occupation.     In  all  Egypt,  during  the  week  ending  Aug.  13th,  the  total 
mortality  is  said  to  have  been  5000,  but  in  the  following  week  it  fell  to 
2000.     It  is  estimated  that  the  epidemic  destroyed  at  least  20,000  lives. 
The  germ  of  this  epidemic  has  not  been  accurately  determined.     Some 
regard  it  as  a  survival  of  the  cholera  of  the  previous  year — a  supposi- 
tion which  is  at  least  plausible  and  sufficient;  but  certain  "sanitarians" 
have  attributed  the  outbreak  to  the  ordinary  causes  of  disease  intensified 
by  the  civil  war  which  had  recently  devastated  Egypt.     It  is  sufficient 
here  to  say  that  while  such  causes  liave  in  all  ages  generated  typhus  and 
typhoid  fevers  and  dysentery,  they  never  produced  cholera.     Some,  more 
unwise  than  judicious,  declared  that  the  Egyptian  disease  of  1883  was 
not  cholera.     It  is  alleged,  on  the  one  hand,  that  several  East  Indian 
merchants  from  Bombay  arrived  at  Damietta  on  June  18th,  or  three  days 
before  the  disease  was  recognized  in  that  city.     It  is  also  said  that  a  stoker 
from  on  board  an  English  steamer  from  Bombay  introduced  the  cholera 
into  Damietta.     But  the  judgment  of  Surgeon-General  Murray  carries 
with  it  greater  weight.1     He  is  of  the  opinion  that  the  Egyptian  epidemic 
of  1883  was  simply  a  revival  of  the  Arabian  epidemic  of  1882.     He 
shows  that  cholera  existed  in  several  villages  on  the  Damietta  branch  of 
the  Nile  in  the  latter  part  of  May  and  during  June,  and  that  it  broke  out 
in  the  capital  itself,  during  a  fair  which  had  lasted  for  eight  days,  on  the 
22d  of  June,  and  was  spread  by  the  people  on  their  return  from  Damiett 
to  their  villages.     This,  adds  Mr.  Murray,  "is  a  literal  transcript  of  the 
accounts  of  many  of  the  severe  epidemics  that  have  raged  over  . 
It  also  appears  from  M.  Proust's  narrative 2  that  the  Ottoman  government 
had  alridy,  as  early  as  April,  notified  the  government  of  Egypt  that 
certain  Indo-Javanese  pilgrims  were  on  their  way  to  Mecca^  and  that 
ought  not  to  be  allowed  to  land  without  quarantine.     The  French  delegate 
to  the  sanitary  council  also  begged  ^^.^^^S^S^ 
Suez  without  previous  quarantine  should  be  isolated  and  kept  undei 
i  Times  and  Gazette,  Feb.,  1884,  p.  209.  '  Le  Cholera,  1* 


720  CHOLERA. 

veillance  for  three  days.  But  owing  to  the  opposition  of  the  English  dele- 
gates these  measures  were  not  duly  enforced,  the  council  did  not  meet 
again,  and  no  protective  system  was  adopted. 

ETIOLOGY. — The  essential  cause  of  cholera  is  unknown,  unless  the 
investigations  of  Koch,  described  below,  may  have  revealed  it.  Its 
secondary  causes,  or  the  conditions  of  its  dissemination,  are  better 
understood.  Some  general  propositions  concerning  them  will  here  be 
laid  down,  and  illustrated  so  far  as  the  argument  requires  and  the  avail- 
able space  will  allow. 

Cholera  is  endemic  in  no  other  country  than  India,  and  more  particu- 
larly in  Bengal.  When  it  has  occurred  elsewhere  it  has  invariably  been 
carried  from  India.  The  cholera  poison  has  been  imagined  to  be  of  an 
aerial  nature,  but  its  diffusion  has  no  relation  whatever  to  the  velocity  or 
the  direction  of  the  wind.  In  no  instance  whatever  has  its  rate  of  prog- 
ress exceeded  that  of  man  on  land  or  water,  nor  has  it  ever  taken  a 
direction  different  from  that  of  commercial  or  military  movements.  On 
land  it  has  usually  crept  from  place  to  place,  and  if  sometimes  it  has 
seemed  to  leap  across  wide  spaces,  and  even  seas  and  oceans,  it  has  never 
invaded  any  inland  town  or  seaport  without  having  been  brought  thithei  • 
from  a  point  already  affected  with  the  disease.  Nor,  having  once  entered 
an  inland  or  seaboard  town,  does  it  spread  equally  therein  in  all  direc- 
tions, but  prevails  chiefly  in  the  quarter  immediately  surrounding  the 
place  of  its  entrance.  If  appropriate  sanitary  measures  are  enforced,  it 
is  sometimes  confined  to  that  quarter,  and,  in  the  case  of  quarantine  sta- 
tions, it  has  repeatedly  been  prevented  from  extending  beyond  them. 
This  statement  may  be  illustrated  by  the  fact  that  of  fourteen  epidemics 
of  cholera  at  Staten  Island,  the  quarantine  station  of  New  York,  all  but 
four  were  prevented  from  reaching  that  city.1  When  the  disease  does 
overleap  the  barrier  opposed  to  it,  its  origin  and  subsequent  course  can 
usually  be  traced. 

A  high  atmospheric  temperature  is  everywhere  associated  with  the  prev- 
alence of  cholera.  Its  origin  in  the  hot  climate  of  Hindostan  and  its 
general  progress  prove  this  conclusively.  In  nearly  all  of  the  places 
where  a  great  difference  exists  between  the  summer  and  the  winter  tem- 
perature the  disease  has  disappeared  during  the  cold  season,  and  attained 
its  greatest  intensity  during  the  hot  months  of  the  year.  The  only 
apparent  exception  to  this  rule  is,  that  cholera  has  prevailed  in  several 
Russian,  Swedish,  and  Norwegian  cities  during  the  winter.  But  these 
very  exceptions  confirm  the  rule ;  for  in  the  countries  mentioned  the 
intense  cold  of  the  winter  compels  the  inhabitants  to  seal  their  houses 
by  every  possible  means,  while  the  atmosphere  within  them  is  kept  at  a 
high  temperature  by  huge  stoves,  which  hinder  ventilation,  and  indeed 
render  it  almost  impossible.  Difference  of  temperature  likewise  explains 
the  fact  that  of  two  cholera-ships  .arriving  from  Havre,  the  one  at  New 
York  and  the  other  at  New  Orleans,  in  December,  1848,  the  former  did 
not  disseminate  the  disease,  but  the  latter  formed  the  starting-point  of  an 
epidemic  which  lasted  all  the  winter. 

A  good  deal  has  been  written  of  the  predisposing  causes  of  cholera, 
and  poverty,  crowding,  filth,  intemperance,  and  depression  of  spirits  have 
been  given  prominent  places  in  the  catalogue.     But  to  any  one  familiar 
1  Peters's  Notes,  etc.,  2d  ed.,  p.  94. 


ETIOLOGY.  721 

with  the  history  of  epidemic  diseases  it  will  at  once  be  apparent  that  every 
one  of  these  conditions  favors  the  spread  of  all  communicable  infectious 
diseases.  There  is  not  the  slightest  evidence  that  these  agencies,  singly 
or  combined,  can  generate  cholera  or  favor  its  spread  apart  from  the  pres- 
ence of  the  specific  poison  of  the  disease  and  the  facility  with  which  it 
is  transmitted  from  the  sick  to  the  well  whenever  the  population  is 
crowded,  poor,  of  filthy  habits,  and  weakened  by  dissipation.  Because 
among  such  people  intemperance  prevails,  this  vice  has  been  regarded  as 
predisposing  to  cholera.  Apart  from  the  brutish  mode  of  living  of 
drunkards,  there  is  nothing  to  show  that  they  are  more  liable  to  cholera 
than  the  most  abstemious  of  water-drinkers.  On  the  contrary,  it  is 
notorious  that  during  cholera  epidemics  drunkards  in  the  better  classes  of 
society  enjoy  a  certain  degree  of  immunity  from  the  disease  ;  which  it  is  easy 
to  explain  on  the  ground  that  they  imbibe  but  little  water,  which  is  the 
main  channel  through  which  the  infectious  principle  of  the  disease  is  spread. 
The  specific  cause  of  cholera  is  taken  into  the  alimentary  canal,  and 
acts  through  it  to  produce  the  characteristic  symptoms  of  the  disease.  It 
is  conveyed  from  the  sick  to  the  well  by  means  of  the  gastro-intestinal 
discharges,  either  moist  or  dry ;  in  the  former  state,  by  means  of  drink- 
ing-water, and  in  the  latter  through  the  air,  whose  suspended  noxious 
particles  are  received  into  the  fauces  and  swallowed.  There  is  reason 
to  believe  that  the  poison  does  not  enter  the  system  through  the  lungs, 
or  through  any  other  channel  than  the  gastro-intestinal  canal.  "W.  B. 
Carpenter1  appears  to  hold,  however,  that  the  poison  may  be  ab- 
sorbed through  the  lungs.  To  this  view  there  are  two  objections :  1, 
That  whatever  is  taken  into  the  mouth  or  throat  by  inspiration  may 
very  well  be  swallowed;  and,  2,  that  all  the  primary  lesions  of 
cholera  affect  the  digestive  and  not  the  respiratory  apparatus.  It  is  not 
at  all  necessary  to  the  propagation  of  cholera  that  its  excreta  should ^be 
furnished  by  persons  laboring  under  the  fully-formed  disease.  A^specific 
choleraic  diarrhoea  is  as  infectious  as  the  evacuations  which  occur  in  com- 
pletely developed  cholera.  But  neither  will  propagate  the  disease  through 
the  air  to  a  distance.  The  tendency  to  its  propagation  in  this  manner 
depends  chiefly  upon  the  concentration  of  the  poison ;  thus,  it  much  more 
frequently  occurs  in  close  than  in  well-ventilated  rooms  or  than  in  the 
open  air.  It  has  been  argued  that  cholera  is  not  contagious,  because  so 
few,  comparatively,  of  the  attendants  upon  cholera  patients  contract  the 
disease.  On  the  other  hand,  as  some  of  them  are  attacked,  this  positive 
fact  outweighs  an  indefinite  number  of  negative  instances.  It  should  also 
be  noted  that  different  diseases  enter  the  system  and  infect  it  through 
different  channels— some  through  the  lungs,  others  through  the  aliment- 
ary canal,  etc.  Small-pox,  the  most  contagious  of  all  diseases,  is  intro- 
duced through  the  air-passages,  and  is  probably  harmless  when  its  virus 
is  taken  into  the  stomach.  That  the  converse  of  this  proposition  applies 
to  cholera  is  sustained  by  the  whole  history  of  the  disease, 
poison  may  be  taken  to  considerable  distances  in  either  a  moist  or  a 
condition.  In  the  former  state  it  is  mainly  conveyed  by  water,  as  m 
rivers,  water-pipes,  etc. ;  in  the  latter,  by  foraites  and  especially  by  cloth- 
ing saturated  or  merely  soiled  with  cholera  discharges,  and  which  may 
retain  their  infectious  quality  for  an  indefinite  time. 
1  The  Nineteenth  Century,  Feb.,  1884. 


VOL.  I.— 46 


722  CHOLERA. 

Great  stress  has  been  laid  upon  the  humidity  and  foulness  of  the  soil, 
a  damp  atmosphere,  filth,  crowding,  etc.,  as  elements  in  the  production 
of  cholera,  but  in  reality  they  have  no  more  essential  relation  to  it  than 
to  any  other  disease  that  occurs  epidemically.  Cholera  may  prevail 
whether  they  are  present  or  absent.  It  is  evident  that  from  the  earliest 
historical  periods  all  of  these  causes  of  disease  have  existed,  and  in  Europe 
much  more  generally  and  excessively  than  during  the  present  century, 
and  fhat  they  have  never  been  removed  in  Asia  Minor,  Egypt,  Arabia, 
and  Africa.  Yet  cholera  never  was  known  in  any  of  these  countries 
until  it  was  brought  into  them  about  the  end  of  the  first  third  of  the 
present  century. 

According  to  Pettenkoffer,  cholera  is  most  prevalent  when  the  subsoil 
water  is  lowest,  and  least  so  when  the  subsoil  water  is  highest.  It  would 
be  more  descriptive  of  the  fact  to  say  that,  so  far  as  cholera  has  any- 
thing to  do  with  the  condition  of  the  soil,  it  is  most  apt  to  be  severe  and 
prevalent  when  very  dry  weather  follows  a  very  wet  period.  Such  cir- 
cumstances are  the  most  favorable  to  putrefactive  fermentation  and  the 
dissemination  of  its  products,  which  thus  reach  wells  of  drinking-water, 
and  even  rivers,  especially  when  sewers  empty  into  the  latter.  The 
identity  of  this  explanation  with  that  which  is  generally  accepted  for  the 
dissemination  of  typhoid  fever  is  too  evident  to  be  insisted  upon.  AVe 
might  go  farther,  and  say  that,  in  typhoid  fever  as  in  cholera,  the  disease 
is  communicated,  although  exceptionally,  by  the  air  of  the  sick  room  and 
by  the  exhalations  of  the  soiled  fomites  of  the  patient.  Now,  if  typhoid 
fever  resembled  cholera  not  only  in  being  transmitted  by  means  of  the 
dejections,  but  also  in  its  poison  being  derived  from  one  primary  source 
only,  the  analogy  betwreeu  the  causes  of  the  two  diseases  would  be  very 
striking  indeed.  But,  in  point  of  fact,  the  typhoid-fever  poison  may  proba- 
bly be  generated  de  novo  by  fecal  fermentation  and  other  forms  of  putre- 
faction, and  the  disease  is  only  exceptionally  communicable ;  whereas,  the 
poison  of  cholera,  once  received,  is  conveyed  from  man  to  man  and  far 
and  wide  through  various  channels ;  but,  so  far  as  is  known,  it  has  but 
one  primary  source,  and  that  is  in  India.  Lebert  states  that  he  did  not 
find  the  localities  that  are  the  ordinary  seats  of  typhoid  fever  peculiarly 
liable  to  invasions  of  cholera.  But  it  must  be  noted  that  typhoid  fever  is 
very  far  from  being  exclusively  a  disease  of  the  poor,  squalid,  and  vicious. 
Like  death  itself,  "regum  turres  pauperumque  tabernas  sequo  pede 
pulsat ;"  while  cholera  much  more  commonly  plants  itself  and  dissemi- 
nates its  seeds  in  the  rank  soil  of  moral  and  physical  degradation. 

All  morbid  causes  whatever,  derived  from  race,  climate,  religion,  dwell- 
ings, food,  clothing,  habits  of  living,  etc.,  have  no  more  to  do  with  the 
development  of  cholera  than  with  that  of  the  eruptive  fevers,  and  even 
less  than  with  the  causation  of  typhus  and  typhoid  fevers  and  dysentery. 
The  eruptive  fevers  are  caused,  as  cholera  probably  is,  by  specific  germs 
which  no  known  combination  of  natural  causes  has  ever  developed,  while 
the  poisons  of  the  other  diseases  named  appear  to  be  generated  anew 
whenever  certain  more  or  less  definite  physicial  conditions  coexist.  It 
would  seem  that  cholera  differs  radically  from  all  of  these  affections  by 
the  fact  that  its  cause  does  not  enter  the  circulation,  but  confines  its  direct 
operation  to  the  gastro-intestinal  mucous  membrane.  In  this  way  it 
becomes  intelligible  that  while,  on  the  one  hand,  physicians  and  nurses  of 


ETIOLOGY.  723 

cholera  patients,  although  often,  in  fact,  yet  in  relation  to  their  numbers 
are  comparatively  seldom  infected,  provided  they  duly  observe  proper 
sanitary  rules,  the  disease,  on  the  other  hand,  spreads  like  wildfire  among 
those  who  drink  water  polluted  by  cholera  excretions,  and  only  a  little 
less  rapidly  among  people  crowded  into  ill- ventilated  apartments  alon<r 
with  cholera  patients. 

The  special  fomites  of  the  cholera  poison  are  articles  of  clothing  and 
furniture  soiled  with  the  discharges  of  the  sick,  and  the  emanations  from 
privies,  sewers,  etc.  into  which  these  discharges  have  been  cast.  Many 
considerations  render  it  probable  that  a  very  small  quantity  of  cholera 
matter  may  suffice  to  render  infectious  a  very  large  quantity  of  liquid, 
and  especially  of  matters  in  process  of  putrefactive  fermentation,  and 
that  the  gaseous  or  vaporous  emanations  from  them  become  diffused  in  the 
atmosphere  and  infect  all  who  imbibe  them.  But  water  contaminated  by 
cholera  discharges  is  the  most  rapid  and  efficient  agent  in  disseminating 
the  disease.  Innumerable  instances  of  this  mode  of  action  are  fur- 
nished by  its  history  in  Asia  and  Africa,  where  water  is  often  scarce, 
and  naturally  so  impure  that  its  additional  defilement  by  cholera  dejec- 
tions is  apt  to  pass  unnoticed.  From  the  illustrations  of  this  proposition 
which  might  be  adduced  only  a  few  of  the  more  striking  will  here  be 
selected. 

Hurdwar  is  a  town  in  Northern  India  at  the  base  of  the  Himalayas, 
where  the  Ganges  begins  its  course  in  the  plains.  It  is  the  seat  of  a 
great  Hindoo  pilgrimage,  which  takes  place  annually  in  April,  when 
sometimes  from  2,000,000  to  3,000,000  of  people  occupy  an  encampment 
of  about  twenty-two  square  miles,  comprising  a  low  flat  island  in  the 
Ganges  and  the  opposite  banks  of  the  river.  Bathing  in  the  sacred 
stream  on  a  certain  day  is  the  main  object  of  the  devotees ;  which  day,  in 
the  year  1867,  fell  on  the  12th  of  April.  The  bath  was  taken  early  in 
the  morning.  From  noon  on  that  day  the  pilgrims  began  to  disperse  so 
rapidly  that  on  the  morning  of  the  15th  the  encampment  was  quite 
deserted.  It  appears  that  up  to  the  former  date  the  health  of  the 
encampment  was  excellent,  and  it  was  the  opinion  of  the  reporter  (Dr. 
Cunningham)  that  cholera  was  introduced  into  the  camp  by  pilgrims 
from  the  neighboring  districts  going  late  to  the  fair.  He  believed  that 
the  cholera  excreta  may  have  been  buried  in  the  trenches  and  carried  by 
a  heavy  rain  into  the  river,  and  there  swallowed  by  the  pilgrims ;  for  to 
drink  of  the  water  of  the  Ganges  as  well  as  to  bathe  in  it  is  a  religious 
obligation. 

Immediately  after  the  breaking  up  of  the  camp  cases  occurred  in  the 
surrounding  districts,  the  epidemic  widening  in  all  directions.  The  pil- 
grims were  almost  always  the  first  persons  attacked  in  any  locality,  and 
the  cholera  attended  them  on  their  route  wherever  they  went.  In  all  the 
districts  where  the  disease  prevailed  no  cases  occurred  until  ample  time 
had  been  given  for  the  pilgrims  to  reach  them.  In  a  word,  "  the  cholera 
first  showed  itself  among  them  ;  it  followed  their  lines  of  route  only,  and 
did  not  outrun  them ;  their  progress  was  its  progress,  and  their  limits  its 
limits."  The  mortality  caused  by  this  epidemic  among  the  whole  civil 
population  of  the  North-western  Provinces  of  the  Punjab  has  been  esti- 
mated at  about  117,1s!.1  The  history  of  the  religious  festival  of 
1  Brit,  and  For.  Med.  Chir.  Rev.,  Jan.,  1870,  p.  137. 


724  CHOLERA. 

was  identical  with  that  just  sketched,  except  that  the  number  of  the  pil- 
grims was  smaller  and  the  deaths  proportionally  less.1 

Out  of  the  numberless  illustrations  of  the  manner  in  which  cholera  is  dis- 
seminated by  water  the  following  may  be  cited :  In  1865  about  100,000 
pilgrims  were  assembled  at  Mecca,  of  whom  from  10,000  to  15,000 
fell  victims  to  the  disease,  two-thirds  of  them  within  a  period  of  six 
days.  Some  cause  acting  simultaneously  upon  the  whole  number  of 
persons  must  be  admitted  to  account  for  so  extraordinary  a  fact,  and  such 
a  cause  is  not  far  to  seek.  At  a  certain  sacred  well  "  one  hundred 
thousand  people  had  skinfuls  of  water  poured  over  them  at  the  side  of 
the  well,  and  every  one  of  them  then  drank  largely  of  water  drawn  from 
the  well.  Much  of  the  water  poured  over  the  pilgrims  must  have  found 
its  way  by  soakage  back  into  the  well,  and  if  any  of  the  pilgrims  were 
at  the  time  suffering  from  cholera,  or  had  cholera-tainted  garments  about 
them,  the  well  would  be  exposed  to  pollution."  2 

In  the  cholera  epidemics  of  Zanzibar  the  disease  produced  the  greatest 
havoc  among  the  negroes,  the  Persians,  and  the  East  Indians  ;  very  few 
Europeans  were  attacked,  and  quite  as  few  of  the  sect  of  the  Banyans, 
who  drank  only  water  drawn  from  their  own  wells.  The  persons  among 
whom  the  disease  prevailed  so  fatally  used  chiefly  the  water  of  a  certain 
well  which  was  highly  prized,  but  which  on  this  occasion  had  become 
polluted  by  soakage  from  an  adjacent  cesspool  into  which  the  dejections 
of  cholera  patients  had  been  thrown.  It  appears,  also,  that  in  Zanzibar 
the  streams  are  very  rarely  bridged,  and  hundreds  of  negroes,  in  passing 
backward  and  forward,  wade  through  them  and  pollute  them.  In  these 
streams,  also,  the  negroes  wash  their  clothes  and  all  the  foul  clothing  of 
the  contiguous  town.  While  this  business  is  going  on  "  a  gang  of  negroes 
may  be  at  work  at  not  many  hundred  yards'  distance  filling  water-casks 
for  the  shipping."  Subsequently  to  the  watering  of  the  ships  in  this 
manner  sailors  were  attacked  with  cholera,  and  others  who  used  water 
drawn  from  the  stream  below  the  place  where  it  became  polluted  were 
attacked,  and  many  of  them  died ;  while  Europeans  living  on  shore,  and 
who  drank  the  water  of  the  same  stream,  but  drawn  from  a  much  higher 
point  in  its  course  and  after  having  been  filtered,  escaped  the  disease.3 

The  history  of  the  disease  in  Europe  furnishes  a  multiplicity  of 
similar  cases,  and  even  more  distinctly  exhibits  the  dissemination  of 
cholera  by  contaminated  water.4  In  Holland  not  less  than  five  epidemics 
of  the  disease  occurred  between  1832  and  1869,  all  of  them  causing  a 
great  mortality,  to  which  the  epidemic  of  1866  alone  contributed  not  less 
than  20,000  deaths.  This  was  about  55  deaths  for  every  10,000  inhabit- 
ants. Such  exceptional  mortality  over  so  wide  a  territory  has  been 
ascribed  to  the  extreme  porosity  and  humidity  of  the  soil,  which  is  nearly 
all  below  the  level  of  the  sea.  Such  a  soil  must  necessarily  retain  longer 
than  other  soils  whatever  it  absorbs,  and  thus  tend  to  render  the  well- 
water  habitually  impure.  If,  then,  to  the  ordinary  impurities  a  specific 

1  Murray,  Practitioner,  xxvi.  309. 

2  Christie,  Cholera  Epidemics  in  East  Africa,  p.  488.  *  Ibid.,  pp.  320,  492. 

4  It  is  of  interest  to  note  that  on  the  first  appearance  of  cholera  in  England,  at  Sunder- 
land.  in  1831,  a  surgeon  of  that  place,  Mr.  Ainsworth,  collected  and  published  conclusive 
proofs  of  the  importation  of  the  disease,  of  its  communication  from  the  sick  to  the  well, 
"  and  of  its  propagation  by  clothes,  and  even  by  emanations,  from  the  dead  "  ( Observations 
on  the  Pestilential  Cholera,  Lo'ndon,  1832). 


ETIOLOGY.  725 

poison  is  added,  its'  characteristic  effects  may  assuredly  be  looked  for. 
The  conditions  now  stated  explain  the  conclusions  of  Ballot  of  Rotter- 
dam, drawn  from  a  study  of  the  several  epidemics  referred  to.  They  are 
as  follows :  "  1.  Holland  is  highly  affected  by  the  cholera  at  every  epi- 
demic, chiefly  in  those  parts  where  they  drink  water  directly  from  the 
rivers  and  canals  or  from  ground  saturated  with  sewage.  2.  In  places 
where  rain-water  is  generally  drunk  the  disease  is  far  less  violent. 

3.  Places  where  there  is  no  other  drinkable  water  but  rain-water  are  not 
affected  by  the  epidemic ;  the  single  cases  occurring  there  are  imported. 

4.  When  places  affected  by  the  cholera  were  supplied  with  pure  water 
instead  of  the  vitiated  water  the  disease  disappeared." l     In  like  manner, 
we  find  that  the  cholera  epidemic  of  1873  in  Germany  seemed  specially  to 
select  those  situations  where  the  subsoil  was  impregnated  with  decompos- 
ing organic  matter ;  and  it  is  evident  that,  in  cities  especially,  such  situa- 
tions would  include  the  most  poverty-stricken  districts,  while  the  higher, 
drier,  and  at  all  times  more  salubrious  localities  are  inhabited  by  the 
classes  enjoying  the  greatest  material  prosperity.2 

This  mode  of  infection  has  been  traced  in  numberless  individual  cases 
of  cholera.  In  London  there  was  a  certain  well  into  which  the  liquid 
contents  of  a  sewer  had  been  percolating  for  months.  Of  the  water  of 
this  well  hundreds  of  persons  had  been  drinking  without  obvious  injury. 
At  last  a  case  of  cholera  occurred  hard  by ;  the  discharges  were  thrown 
into  a  privy  which  communicated  with  the  sewer  and  indirectly  with  the 
well,  whereupon  more  than  500  persons  who  drank  water  drawn  from 
that  particular  well  were  attacked  with  cholera  within  three  days.  So 
in  1856  cholera  prevailed  in  the  county  jail  of  Oxford,  Eug.,  the  drain 
from  which  emptied  into  a  pool  from  which  the  water  was  drawn  to 
supply  the  city  prison.  In  the  latter  institution  cholera  began  to  prevail, 
but  declined  as  soon  as  the  pipes  conveying  the  water  were  cut  off,  and 
soon  afterward  ceased  entirely.3  Again,  in  Constantinople  in  1865  the 
clothes,  mattrasses,  etc.  of  cholera  patients  were  washed  at  a  fountain 
the  basin  of  which  was  divided  into  two  parts  by  a  wall ;  one  part  was 
used  for  washing  clothes  and  the  other  for  drinking  purposes.  Unfortu- 
nately, the  waste-pipe  of  the  former  being  obstructed,  the  foul  water  of  one 
side  communicated  with  the  clean  water  of  the  other,  and  in  one  day  60 
people  died  of  cholera  in  the  small  portion  of  the  city  which  was  sup- 
plied from  the  infected  source.  The  striking  case  has  often  been  cited 
which  occurred  at  Epping,  Eng.,  where  a  woman  brought  the  disease 
from  a  distance  into  a  perfectly  healthy  house  'and  neighborhood,  and  of 
ten  persons  affected  with  it  seven  died,  including  a  physician  in  attend- 
ance upon  one  of  them.  An  examination  of  the  premises  "discovered, 
below  the  pipes  leading  from  the  water-closet  and  from  the  eye-hole  of 
the  sink  through  which  the  choleraic  dejections  had  been  passed,  a  leak- 
age which  extended  under  the  foundations  of  the  building  and  entered 
the  well.  The  sewage  was  distinctly  traceable  on  the  side  of  the  well 
corresponding  with  the  leakage  in  the  drain."  After  this  discovery  and 
the  disuse  of  the  foul  water  not  another  case  occurred.4  In  1868,  Dr. 


»  Med.  Times  and  Oaz.,  May,  1869,  p.  459 ;  June  1869,  p.  626. 
2  "  Report  of  the  German  Imperial  Commission,"  Practitioner, 
1  Edinb.  Med.  Jour.,  i.  1122. 
4  Trans,  of  the  Epidemiological  Soc.,  u.  428. 


xxvt.  153. 


726  CHOLERA. 

Farr,  in  his  History  of  the  London  Cholera  Epidemic  of  1866,  showed 
that  water  into  which  cholera  dejections  find  their  way  produces  cases  of 
cholera  all  over  the  district  in  which  it  is  distributed  for  a  certain  period 
of  time,  and  that  if  the  distribution  is  in  any  way  cut  short  the  deaths 
from  cholera  begin  to  decline  within  about  three  days  of  the  date  at 
which  the  distribution  is  stopped.1 

Analogous  instances  are  furnished  by  every  cholera  epidemic  of  which 
the  history  has  been  accurately  observed,  including  that  which  extended 
so  widely  over  the  United  States  in  1873.  Most  of  the  following  are 
cited  from  the  official  reports  prepared,  under  the  direction  of  the  Sur- 
geon-General of  the  army,  by  Surgeon  Ely  McClellan  and  Dr.  John  C. 
Peters.  Several  of  the  first  cases,  however,  are  foreign. 

In  1861,  at  a  station  in  India,  some  fresh  cholera  dejecta  found  their  way 
into  a  vessel  of  drinking-water.  Early  on  the  following  morning  a  small 
quantity  of  this  water  was  swallowed  by  nineteen  persons,  five  of  whom 
were  attacked  with  cholera  between  the  first  and  the  third  day  afterward.2 
In  1876  an  outbreak  of  cholera  took  place  in  a  village  in  Hiudostan,  which 
followed  the  arrival  of  wedding-guests,  one  of  whom  was  attacked,  and  from 
whom  it  rapidly  spread.  The  soiled  clothes  of  one  or  more  of  the  patients 
were  washed  in  a  pool  from  which  all  the  villagers  obtained  their  drink- 
ing-water, and  on  the  discontinuance  of  this  source  of  water-supply 
cholera  speedily  diminished  in  frequency  and  fatality.3  In  the  German 
epidemic  of  1873  many  cases  occurred  where  persons  deriving  their  drink- 
ing-water from  special  sources  were  attacked  with  cholera,  while  their 
neighbors,  supplied  from  a  different  source,  remained  free.  Again,  it  has 
frequently  happened  that  outbreaks  of  cholera  have  been  checked  by  the 
prohibition  of  the  suspected  water  and  the  substitution  of  a  pure  supply.4 
It  seems  probable  that  a  very  small  portion  of  cholera  discharges  suffices 
to  infect  a  very  large  body  of  water  and  maintain  its  infectiousness  for  a 
considerable  time. 

In  December,  1871,  an  outburst  of  cholera  occurred  which  was  con- 
fined to  the  inmates  of  three  excellent  houses  in  a  fine  block  of  buildings 
in  Calcutta.  'There  had  been  no  cholera  in  that  neighborhood  for  four 
years.  Within  forty-eight  hours  a  majority  of  the  lodgers  were  sick, 
and  on  investigation  it  was  found  that  the  disease  was  carried  in  the 
drinking-water  and  in  the  milk  diluted  with  it.5  The  particular  locality 
in  which  Dr.  Koch  made  the  discovery  of  the  microscopic  representative 
of  cholera  furnishes  an  example  of  the  same  nature :  "  At  Saheb  Ragau, 
a  locality  which  has  repeatedly  been  visited  by  cholera  during  the  last 
hundred  years,  numerous  cases  of  the  disease  were  reported,  and  these, 
on  inquiry,  were  found  exclusively  in  the  huts  situated  round  a  certain 
tank.  Of  the  few  hundred  people  who  dwelt  in  these  huts,  as  many  as 
seventeen  died  of  cholera,  though  the  disease  was  not  at  that  time  preva- 
lent in  the  neighborhood,  or  indeed  in  the  whole  police  district  of  Cal- 
cutta. It  was  proved  that,  as  usual  in  such  cases,  the  dwellers  around 
the  tank  used  it  for  bathing,  and  drew  thence  their  drinking-water ;  it 
was  also  elicited  that  the  linen  of  the  first  fatal  case,  befouled  with 
cholera  dejections,  had  been  washed  in  the  tank."6  In  June,  1873,  a  new 

1  Lancet,  April,  186S,  p.  217.  2Macnamara,  op.  dt.,  p.  196. 

*  Surg.-Major  Cornish,  Practitioner,  xxiv.  215.          *  Practitioner,  xxvi.  ]  59. 

*  U.  6'.  Report,  p.  85.  «  Times  and  Gaz.,  April,  1884,  p.  527 . 


ETIOLOGY.  727 

hotel  was  opened  at  Vienna,  and  many  of  the  guests  became  affected  with 
diarrhoea  that  was  attributed  to  the  drinking-water,  which  was  offensive 
to  the  taste  and  smell.  After  a  fortnight  a  gentleman  died  of  cholera  in 
the  hotel,  and  two  days  later  several  of  the  guests  were  attacked  with  the 
disease,  of  whom  fourteen  died.  The  gentleman  who  first  died  was 
believed  to  have  brought  the  poison  with  him  into  the  hotel,  so  that  the 
drinking-water,  which  previously  had  been  polluted  with  ordinary  fecal 
discharges,  became  specifically  affected  through  him.1  The  discharges  of 
one  ill  of  cholera  were  thrown  into,  and  the  vessels  used  by  him  were 
washed  near,  a  well  from  which  all  the  residents  of  a  farm-house  drank. 
The  wooden  curbing  of  the  well  had  rotted,  and  the  ground  immediately 
around  had  sunken ;  a  heavy  rain  burst  the  curb,  overflowed  the  well,  and 
washed  into  it  the  entire  surface-drainage  of  the  surrounding  ground. 
No  attention  was  paid  to  this,  and  the  water  was  used  as  before.  It 
became  so  offensive  that  its  use  was  forbidden,  but  too  late  to  save  the 
family,  nine  of  whom  died  of  cholera.2 

At  Farmington,  Tenn.,  a  man  arrived  who  had  contracted  the  cholera 
at  Nashville;  his  illness  ran  its  course  at  a  point  just  forty  paces  from  a 
well.  Families  that  obtained  their  water  from  this  well  suffered  in 
nearly  all  their  members;  where  only  certain  members  drank  of  it,  they 
alone  were  affected.3  At  Huntsville,  Ala.,  during  an  epidemic  of  cholera, 
the  city  authorities  forbade  the  use  of  well-water,  and  supplied  pure  water 
from  another  source,  but  only  for  one  week.  During  this  time  no  new 
cases  of  the  disease  occurred,  and  the  negroes,  thinking  themselves  secure, 
resumed  the  use  of  the  well-water,  and  within  four  days  six  fatal  cases  of 
cholera  occurred  in  the  vicinity.  The  use  of  the  well-water  was  again 
prohibited,  and  again  the  progress  of  the  disease  was  arrested.4 

It  has  already  been  intimated  that  the  cholera  poison  may  be  diffused 
through  the  air  from  either  moist  or  dry  sources,  and  especially  from  con- 
taminated clothing,  and  then  be  taken  into  the  throat  and  swallowed. 
Dr.  Richardson  refers  to  a  local  epidemic  in  England  in  which  "  the  per- 
sons most  constantly  and  fatally  attacked  were  the  women  who  washed 
the  clothes  of  the  sick ;"  and  this  circumstance  has  been  largely  confirmed 
by  other  observers.5  In  a  village  not  far  from  Marseilles,  and  in  an  iso- 
lated place,  a  peasant  and  his  wife  who  had  not  left  the  country  sickened 
and  died  of  the  disease.  The  woman,  who  was  a  laundress,  had  received 
a  bundle  of  linen  belonging  to  a  person  recently  arrived  from  Egypt,  and 
the  husband  opened  the  bundle  and  unfolded  the  pieces.  During  the 
Crimean  War  many  of  the  washermen  attending  to  the  washing  of  the 
French  hospitals  were  attacked  by  cholera.  In  the  post-office  at  Marseilles 
none  of  the  clerks  who  handled  the  outgoing  mails  were  attacked,  but  of 
those  who  sorted  the  mails  coming  from  the  East,  where  the  disease  pre- 
vailed, one  after  another  suffered  from  cholera.6 

The  cholera  was  introduced  into  Guadaloupe  by  clothing  contained 
in  a  trunk  belonging  to  a  person  who  died  on  the  voyage  thither  from 
Marseilles,  where  the  cholera  then  prevailed.  The  woman  who  washed 
the  clothing  died,  with  all  her  family.  Attracted  by  the  circumstances  of 

*  Times  and  Oca.,  p,  86.  *  Ibid.,  p.  140.  »  Ibid.,  P-.  172. 
4  Ibid.,  p.  408.     For  other  examples  of  the  spread  of  cholera  by  means  < 

water  see  Macnamara,  p.  149  and  seq. 

•  Trans.  Epidem.  fiifiL  429-  Eead'  B°StOD' 


728  CHOLERA. 

the  case,  many  came  to  her  house,  and  of  these  several  died.  From  this 
point  the  disease  spread  over  the  island.1  A  sailor  died  at  some  port  in 
Europe  of  Asiatic  cholera  in  1832.  A  chest  containing  his  personal 
effects,  clothing,  etc.  was  sent  home  to  his  family,  who  lived  in  a  small 
straggling  village  on  the  Atlantic  coast  of  the  State  of  Maine.  It  reached 
them  about  Christmas,  and  was  opened  on  its  arrival.  The  inmates  of 
the  house  were  all  immediately  and  suddenly  seized  with  a  disease  resem- 
bling Asiatic  cholera  in  all  its  malignity,  and  died.  There  had  been  no 
cholera  in  the  State.  The  last  case  of  cholera  that  occurred  in  the 
garrison  at  Malta  in  the  epidemic  of  1865  was  that  of  a  woman  who  had 
stolen  a  chemise  the  property  of  one  who  had  died  of  the  disease.  She 
put  on  this  fatal  garment,  probably  soiled  with  cholera  discharges,  and 
certainly  unwashed,  many  days  after  the  death  of  its  former  possessor; 
she  took  the  disease  and  died.2 

It  is  sometimes  said,  and  oftentimes  repeated,  that  cholera  is  not  directly 
contagious — is  not  communicated  by  the  sick  to  the  well.  No  statement 
could  be  more  unfounded.  The  whole  history  of  cholera  proves  that  the 
physicians  and  nurses  of  cholera  patients  are  often  affected  by  the  disease. 
"In  Constantinople  no  less  than  twenty-seven  physicians  and  medical 
assistants  were  attacked  and  died  during  their  attendance  on  cholera 
patients;  and  in  Paris  and  Toulon  similar  results  followed.  At  Halifax, 
N.  S.,  two  of  the  physicians  who  volunteered  in  aid  of  the  steamer  Eng- 
land, which  put  in  there  disabled  by  the  ravages  of  cholera  among  the 
officers  and  crew,  as  well  as  among  the  steerage  passengers,  took  the  dis- 
ease, and  one  died"  (Read).  In  1832  the  cases  of  cholera  in  Edinburgh 
were  in  the  proportion  of  1  to  every  1200  of  the  population  of  the  city, 
while  among  those  in  attendance  upon  the  sick  the  proportion  was  1  to  5. 
In  1848—49  one-fourth  of  the  nurses  employed  in  the  cholera  hospital  took 
the  disease,  while  in  the  general  hospital,  only  a  few  paces  distant,  where 
no  cholera  patients  were  received,  not  a  single  attendant  was  attacked. 
In  the  London  Hospital,  in  1866,  none  of  the  medical  officers,  volunteer 
nurses,  or  sisters  were  attacked.  Of  the  (regular)  nurses  five  contracted 
the  disease,  and  of  these  four  died.3  In  1849  a  severe  and  fatal  epidemic 
broke  out  in  the  Philadelphia  Almshouse.  The  resident  physicians  of 
the  hospital  were  abundantly  occupied  with  the  care  of  the  sick  of  other 
diseases,  and  it  was  thought  prudent  not  to  allow  any,  even  an  indirect, 
communication  between  them  and  the  cholera  patients.  The  latter  were 
therefore  removed  to  an  isolated  building  in  the  middle  of  the  quadrangle, 
and  attended  by  physicians  from  the  city  who  had  volunteered  their  aid. 
Th  ee  or  four  of  these  physicians  had  attacks  of  cholera,  and  two  of  them 
died.4  At  this  time  there  was  no  cholera  at  all  in  the  city,  and  the  young 
physicians  could  not  have  become  infected  outside  of  the  almshouse. 
They  were  attacked  while  attending  the  sick  of  cholera,  but  the  regular 
house-physicians,  who  seldom  visited  the  cholera  patients,  escaped  alto- 
gether. 

The  importance  of  recognizing  the  communicability  of  cholera  is  so 
great  that  no  apology  need  be  made  for  introducing  the  following  addi- 
tional illustrations  of  it  furnished  by  Griesinger  in  his  article  on  the 
dangers  of  cholera  to  medical  men.  They  are  the  more  important  because 

1  Med.  Times  and  Gaz.,  April,  1874,  p.  387.          2  Lancet,  Feb.  17,  1866. 

3  London  Hasp.  Rep.,  iii.  439.  *  Pkilada.  Med.  Examiner,  Nov.,  1849. 


ETIOLOGY.  729 

in  many  other  instances  cholera  physicians  have  suffered  little  for  their 
devotion  to  duty  :  "  At  Moscow,  in  1 840,  hospital  attendants  contracted  the 
disease  to  the  extent  of  30  or  40  per  cent.,  while  in  the  general  population 
only  3  per  cent,  were  attacked  ;  at  Berlin,  in  1831,  in  Romberg's  hospital, 
54  out  of  115  persons  were  attacked  :  in  1837  one-fifth  of  the  attendants 
took  the  disease,  and  on  one  occasion  no  less  than  seven  of  them  fell  ill 
on  a  single  day.  In  La  Charite"  Hospital  in  Paris,  in  1849,  one-sixth 
of  *Jie  attendants  had  the  disease,  while  only  one-twenty-fifth  of  the 
general  population  of  the  city  suffered  from  it ;  at  Mittau,  in  1848,  one- 
half  of  the  physicians  took  the  disease ;  in  1842,  at  Toulon,  ten  health 
officers  out  of  thirty-five  were  ill  with  cholera,  and  five  of  them  died, 
while  of  thirty  workmen  who  were  employed  to  carry  the  dead  bodies 
one-third  succumbed ;  at  Stockholm,  in  1853,  of  536  attendants  one- 
eighth  took  the  disease,  and  half  of  that  number  died;  at  Vienna,  in 
1854,  out  of  thirty-six  nurses,  seven  caught  the  disease,  and  seven  men 
employed  in  removing  the  dead  became  affected  with  a  prolonged  and 
exhausting  diarrhoea;  in  1849,  at  Strasburg,  five  nurses  out  of  ten  were 
attacked,  etc."  ....  "Physicians,  nurses,  students,  etc.  are  less  fre- 
quently affected,  however,  than  patients  ill  with  other  diseases  who  are 
lying  in  the  wards  where  cholera  patients  are  treated,  and  are  therefore 
more  constantly  exposed  to  the  emanations  from  the  discharges ;  and  phy- 
sicians usually  suffer  less  than  the  attendants  who  are  constantly  waiting 
on  the  cholera  patients."  ' 

It  may  be  added  that  Surgeon-General  John  Murray,  who  served 
continuously  for  thirty-eight  years  in  British  India,  caused  upward  of 
five  hundred  circulars  to  be  addressed  to  the  local  governments  and  filled 
up  by  the  local  medical  officers.  From  these  returns  it  appeared  that  the 
belief  in  the  communicability  of  cholera,  in  one  way  or  another,  was 
practically  unanimous;  for  of  the  whole  number,  those  who  believed 
that  it  is  conveyed  from  person  to  person  were  75  per  cent. ;  from  place  to 
place,  85  per  cent.;  through  the  atmosphere,  80  per  cent.;  with  the  drink- 
ing-water, 85  per  cent.;  by  the  evacuations,  92  per  cent.;  and  by  cloth- 
ing, 98  per  cent.2  This  g'entleman  has  more  recently  furnished  addi- 
tional facts  supporting  the  same  conclusion.  For  example  :  Out  of  four- 
teen cases  that  occurred  at  Ramleh  during  the  Egyptian  epidemic,  eleven 
occurred  in  patients  already  in  the  hospital  for  other  diseases.  In  185b, 
after  visiting  the  dead-house  where  the  bodies  of  fourteen  cholera  patients 
lay  as  he  entered  the  cholera  ward  he  felt  a  sudden  shock  in  the  epigas- 
trium, followed  by  a  deadening  sensation  that  rapidly  spread  over  the 
whole  body.  On  another  occasion  he  saw  a  clergyman  who  was  talk 
to  a  cholera  patient  suddenly  seized  with  vomiting  of  a  watery  liquid. 
Several  analogous  instances  are  related  by  him.3 

It  has  been  objected  to  the  communicability  of  cholera  that  its  dissemi- 
nation does  not  always  follow  the  deposit  of  cholera  discharges  in  privies, 
wells,  etc.,  and  also  that  when  infection  does  take  place,  it  may  occur 
between  remote  extremes  as  to  time,  and  therefore  cannot  be  attributed  to 
infectious  germs.  Such  objections  are  frivolous,  because  we  know  i 
ing  of  the  nature  or  vitality  of  cholera-germs,  and  they  are,  moreojr 
drawn  from  exceptional  cases.  The  power  of  infected  fomites  to  develop 

'  Trait*  des  Maladies  ivfeclieuses,  1868,  p.  409.  '  Practitioner,  six.  470. 

s  Med.  Times  and  Gaz.,  March,  1884,  p.  281. 


730  CHOLERA. 

the  disease  has  been  preserved,  iu  a  journey  from  Arabia  into  Africa, 
for  at  least  twelve  days,  and  for  even  a  longer  period  in  passing  from 
Germany  to  Chicago,  as  already  related.  It  is  true  of  every  infectious 
and  contagious  disease  that  it  may  possess  one  or  both  of  these  qualities 
in  various  degrees — that  at  one  time  it  is  only  exceptionally  communi- 
cated, and  that  at  another  time  it  appears  to  propagate  itself  virulently. 
So  the  phenomena  of  cholera  may  consist  of  little  more  than  a  watery 
diarrhoea,  which  may  be  so  mild  as  hardly  to  disable  the  patient  from 
working,  while  at  other  times  the  attack  may  include  all  those  terrible 
and  fatal  symptoms  which  have  won  for  the  disease  the  name  of  malig- 
nant. That  a  certain  quantity,  or  "  dose,"  of  the  cholera  poison  is 
required  to  develop  the  disease,  but  one  that  varies  considerably  in 
different  cases,  may  be  inferred  from  these  facts :  1.  Out  of  a  certain 
number  of  persons  equally  exposed  to  receive  the  disease,  only  a  portion 
may  be  attacked  at  all,  and  these  in  very  unequal  degrees.  2.  Persons 
so  slighly  affected  as  to  be  ignorant  of  the  nature  of  their  sickness,  and 
believing  it  to  be  an  ordinary  diarrhoea,  may  nevertheless  become  the 
innocent,  because  ignorant,  disseminators  of  cholera.  The  explanation 
of  such  facts  may  be  manifold  :  they  may  depend  upon  the  dose  or  upon 
the  energy  of  the  morbid  poison,  on  various  possible  conditions  of  its 
recipient,  and  so  on  ;  but,  however  explained,  their  reality  is  none  the  less 
certain.  The  receptivity  of  persons  exposed  to  the  contagion  of  cholera 
is  very  different.  It  is  well  known  that  some  persons  appear  to  be  proof 
against  other  contagious  diseases,  while  others  seem  never  to  acquire  an 
immunity  from  them.  On  this  very  important  point  the  conclusions  of 
Fauvel  directly  bear.1  They  include  the  following  propositions:  The 
East  Indian  ports  where  cholera  exists  as  an  endemic  disease  are  never 
the  seat  of  an  extensive  epidemic  among  the  native  population.  But 
strangers  to  these  localities  are  liable  to  the  disease,  and  such  are  the 
Mussulman  pilgrims  who  come  to  Bombay  to  take  ship  for  Mecca.  A 
severe  epidemic  of  cholera  confers  upon  the  locality  in  which  it  has  taken 
place  an  immunity  which  in  India  appears  to  be  of  several  years'  dura- 
tion. Such  an  epidemic  in  any  country  is  a  proof  that  the  cholera  is  not 
endemic  there. 

If  a  contagious  disease  preserved  its  virulence  undiminished,  it  might- 
continue  to  prevail  indefinitely.  But  we  know  that  all  other  contagious 
epidemics  do  come  to  an  end  sooner  or  later,  and  hence  we  must  conclude 
that  their  specific  cause  progressively  loses  its  virulent  qualities.  There 
is  every  reason,  therefore,  to  believe  that  the  same  is  true  of  cholera.  Its 
commuuicability,  and  therefore  its  diffusion,  may  vary  with  climatic,  sea- 
sonal, local,  personal,  and  other  conditions ;  but  of  what  nature  those 
conditions  are,  and  especially  of  the  last  and  most  important,  the  personal, 
hardly  anything  is  known.  Nor  need  we  too  curiously  investigate  them, 
so  long  as  the  fact  remains  that  outside  of,  and  independent  of  them  all, 
there  is  but  one  essential  cause  of  cholera — a  morbid  poison  as  specific  in 
its  nature  as  that  of  any  of  the  eruptive  fevers — a  poison  which  no  deter- 
minable  conjunction  of  circumstances  has  ever  engendered,  and  which  was 
unknown  in  Europe  and  America  before  it  was  carried  to  them  from 
India.  In  just  such  a  way  did  small-pox  first  arise  in  the  Western 
World.  It  had  never  appeared  in  Europe  until  the  latter  part  of  the 
1  Memoire  lu  &  I' Academic  des  Sciences,  1883. 


SYMPTOMATOLOGY.  731 

sixth  century,  when  for  a  short  time  it  prevailed  in  Marseilles  ami  the 
neighboring  country.  Afterward  it  was  not  heard  of  until  it  was  rein- 
troduced  by  the  Crusaders  on  their  return  from  Palestine  in  the  twelfth 
century,  since  which  period  it  has  hardly  ever  ceased.  The  history  of  the 
diffusion  of  cholera  is  closely  analagous  to  this  in  several  particulars,  and 
we  may  reasonably  expect  that  what  was  in  the  last  generation  a  new 
disease  will  henceforth  be  liable  to  prevail  again  and  again  as  the  inter- 
course increases  between  the  nations  of  the  West  and  the  immemorial 
source  of  cholera  in  Hindostan.1 

In  the  preceding  discussion  of  the  origin  and  dissemination  of  cholera 
the  broad  facts  of  its  specific  nature  and  its  contagion  by  means  of  excreta 
have  been  chiefly  insisted  upon.  Little  has  been  said  either  of  the  nature 
of  the  contagium  or  of  the  conditions  that  modify  its  activity.  These 
points  will  be  considered  hereafter.  But  it  is  proper  in  this  place  to 
state  that,  in  the  opinion  of  most  investigators,  the  contagious  element 
has  the  power  of  multiplying  itself,  not  only  within  the  body,  but  wher- 
ever it  is  in  contact  with  decomposing  organic  matter,  provided  that  the 
degree  of  heat  and  amount  of  moisture  present  are  adapted  to  promote 
such  a  change,  which  is  certainly  analogous  to  fermentation,  if  not  iden- 
tical with  it.  And  the  facts  already  mentioned  may  be  recalled,  which  show 
that  the  contagium  cannot  be  a  light  and  subtle  substance,  since,  as  hah 
been  stated,  the  immediate  attendants  upon  cholera  patients  are  not  as 
apt  as  might  be  expected,  on  that  hypothesis,  to  contract  the  disease, 
while  washerwomen  inhaling,  and  probably  swallowing,  the  moist  fumes 
from  cholera  fomites  much  more  frequently  do  so ;  that  fomites  saturated 
with  the  dried  discharges  are  very  infectious ;  and  that  water  is  the  prin- 
cipal vehicle  by  which  cholera-germs  are  carried  into  the  stomach. 

SYMPTOMATOLOGY. — Like  other  diseases,  cholera  occurs  under  very 
dissimilar  aspects  and  with  various  degrees  of  gravity.  Like  those 
especially  which  are  caused  by  specific  morbid  poisons,  it  _  may  be_so 
insignificant  as  to  escape  recognition,  or,  on  the  other  hand, _  it  may  give 
rise  to  violent  and  distressing  symptoms  which  come  on  without  warn- 
ing and  hurry  the  patient  to  inevitable  death.  Whenever  epidemic  dis- 
eases present  such  opposite  extremes  of  severity  in  their  symptoms,  it 
may  reasonably  be  inferred  that  the  differences  depend  mainly  upon  the 
quantity  of  the  poison  that  has  been  received  into  the  system,  precisely 
as  the  dose  which  has  been  taken  of  a  narcotic  or  acrid  poison  may  be 
estimated  by  the  gravity  of  its  effects.  Individual  peculiarities,  consti- 
tutional or  acquired,  may  modify  the  characteristic  phenomena,  and 
sometimes  a  careful  inquiry  may  be  necessary  even  to  detect  their  exist- 
ence •  but  a  study  of  cholera  in  all  its  grades  shows  that  its  symptoms 
are  all  the  effects  of  one  and  the  same  cause,  and  that  the  cholera  poison 
acts  primarily  upon  the  gastro-intestinal  mucous  membrane.  It  follows, 
as  a  matter  of  course,  that,  being  thus  applied,  it  will  occasion  symptoms 
differing  in  degree  and  in  kind  according  to  the  energy  of  its  action  and 
that  this,  again,  will  depend  partly  upon  the  inherent  virulence  of  the 
agent  and  partly  upon  its  quantity.  In  fact,  this  feature  in  the  cimica 
history  of  the  disease  can  be  explained  only  by  the  operation  of  a  specia 
irritant  acting  with  different  degrees  of  power  upon  the  gastro-mte; 

*  Additional  illustrations  of  the  communicability  of  cholera  are  contained  in  the  Brit, 
and  For.  Med.  Cliir.  Rev.,  July,  1872,  p.  56. 


732  CHOLERA. 

mucous  membrane.  In  other  words,  the  different  forms  under  which  it 
is  convenient  clinically  to  recognize  and  describe  cholera  are  nothing 
more  than  different  degrees  of  the  operation  of  one  and  the  same  poison, 
modified  more  or  less  by  the  peculiarities  of  individual  patients.  In  the 
most  typical  of  the  fully-formed  cases  of  cholera  there  is  a  stage  of  diar- 
rhoea, a  stage  of  cholera  morbus — i.  e.  of  vomiting  and  purging — with 
more  or  less  evidence  of  stagnation  of  the  blood,  which  is  followed  either 
by  reaction  and  recovery  or  collapse  and  death.  The  phenomena  of  those 
several  stages  will  now  be  described,  after  which  certain  symptoms  will 
be  more  particularly  considered. 

It  has  more  than  once  been  pointed  out  that,  however  mild  an  attack 
of  cholera  may  be,  the  dejections  accompanying  it  are  infectious,  and  may 
produce  in  other  persons  the  gravest  types  of  the  disease.  Hence  the 
importance,  not  only  to  the  patients,  but  also  to  others,  of  recognizing  it 
in  the  earliest  stage ;  for  while  this  knowledge  may  suggest  measures  for 
preventing  an  extension  of  the  disease,  it  leads  to  the  prompt  use  of 
remedies  at  the  only  period  in  which  their  success  can  at  all  be  counted 
upon.  The  characteristic  of  this  stage,  which  has  generally  been  called 
either  choleraic  diarrhoea  or  cholerine,  is  a  diarrhoea  remarkable  for  its 
profuseness  and  the  frequency  and  serous  quality  of  the  stools,  which  are, 
however,  of  a  more  or  less  yellow  color.  They  are  preceded  by  rum- 
bling and  gurgling  noises  in  the  abdomen,  are  voided  without  colic  or 
tenesmus,  and  are  followed  by  a  remarkable  sense  of  exhaustion  or  faint- 
ness,  which  is  sometimes  also  accompanied  with  nausea,  and,  if  they  are 
very  frequent  and  copious,  cramps  are  apt  to  be  felt  in  the  calves  of  the 
legs.  In  this  variety  or  stage  of  the  attack,  as  a  rule,  there  is  not  any 
vomiting;  there  is  complete  anorexia,  but  urgent  thirst,  a  white  and 
clammy  tongue,  and  a  peculiar  alteration  of  tone,  a  huskiness,  faiutness, 
or  hoarseness  of  the  voice.  The  stools  vary  from  six  to  twelve  a  day, 
and,  as  above  stated,  are  slightly  yellow ;  they  are  also  alkaline,  and  on 
standing  deposit  a  granular  sediment  which  consists  largely  of  the  debris 
of  intestinal  epithelium.  Unless  the  attack  is  very  severe  the  tempera- 
ture is  not  lowered  by  much  more  than  1°  F.  The  symptoms  now 
described,  especially  in  their  milder  grades,  may  last  for  a  week  or  even 
longer,  and  then,  according  to  circumstances,  end  either  in  cure  or  in 
fully-developed  cholera ;  but  under  appropriate  treatment  they  usually 
subside  in  a  day  or  two,  and  more  or  less  rapidly  according  to  the  degree 
of  damage  done  to  the  digestive  mucous  membrane. 

Between  the  above,  which  is  the  mildest  type  of  epidemic  cholera,  and 
the  fully-developed  disease  must  be  placed  that  grade  of  the  disease 
which  is  more  appropriately  called  cholerine,  comprising  cases  in  which 
vomiting  occurs  as  well  as  purging,  with  increased  debility  and  a  tend- 
ency, more  or  less  decided,  to  collapse.  The  matters  vomited,  after  the 
rejection  of  undigested  food,  are  at  first  bilious,  but  they  gradually 
become  less  and  less  so  the  longer  the  attack  lasts,  and,  together  with  the 
stools,  assume  the  appearance  of  rice-water — i.  e.  they  consist  of  a  pale 
grayish,  semi-transparent  liquid  in  which  white  flocculi  are  suspended. 
Its  reaction  is  alkaline,  and  it  has  a  faint  albuminous  or  spermatic  smell. 
Along  with  these  symptoms  the  other  effects  of  serous  depletion  arise — 
debility  with  pallor,  duskiness,  coldness,  profuse  perspiration,  and  a 
sodden  condition  of  the  skin,  while  the  secretion  of  urine  is  diminished, 


SYMPTOMATOLOGY.  733 

and  all  the  symptoms  that  belong  to  the  first  stage  of  cholera  are  present 
in  an  aggravated  degree. 

A  curious  feature  of  this  disease  is  that  sometimes  the  onset  even  of 
its  graver  forms  is  not  attended  by  any  evacuations,  although  the  stom- 
ach and  intestine  may  be  filled  with  liquid.  It  is  perhaps  chiefly  in  such 
cases  that  the  patient  experiences  a  rapid  depression  of  all  the  mental 
and  physical  faculties.  The  senses  are  irritable,  the  head  aches  and  is 
confused,  there  is  a  disinclination  to  sleep,  the  limbs  totter  under  the 
weight  of  the  body,  the  pulse  is  frequent  and  feeble,  occasionally  fainting 
takes  place ;  the  skin  is  cool  and  bedewed  with  perspiration.  In  other 
cases,  again,  the  attack  is  sudden ;  the  patient  is  smitten  with  an  unac- 
countable feebleness,  speedily  followed  by  profuse  vomiting  and  purging 
and  general  spasms,  and  dies  without  any  suspension  of  the  symptoms  or 
any  tendency  to  reaction. 

But  more  usually  the  attack  begins  with  the  diarrhoea  and  vomiting 
described  above,  which  then  assume,  more  or  less  rapidly,  a  high  degree 
of  violence,  expressed  by  their  frequency  and  excess.  The  stools  with 
proportionate  rapidity  lose  all  their  fecal  qualities  and  acquire  the  rice- 
water  appearance  before  mentioned,  and  the  liquid  rejected  by  vomiting 
in  all  respects  resembles  them.  It  is  poured  forth  less  by  an  ordinary 
act  of  vomiting  than  by  gushes,  as  if  it  overflowed  from  the  throat  and 
mouth ;  and  it  often  escapes  from  the  stomach  and  the  bowels  at  the 
same  instant.  Such  profuse  evacuations  necessarily  occasion  an  urgent 
thirst  which  cannot  be  satisfied,  for  liquids  are  thrown  up  immediately 
on  being  swallowed.  Sometimes  a  distressing  hiccough  accompanies  these 
symptoms.  It  is  indeed  only  one  of  the  many  spasms  which  may  affect 
the  muscular  system.  They  generally  begin  in  the  fingers  and  toes, 
which  become  bent  and  stiff;  they  seize  upon  the  muscles  of  the  calves 
of  the  legs,  and  render  the  muscular  wall  of  the  abdomen  as  hard  as  a 
board.  The  pain  they  produce  is  extremely  severe,  and  unless  the  patient 
is  exceedingly  prostrated  he  endeavors  to  assuage  it  by  a  constant  change 
of  position. 

At  this  period  the  debility  is  very  great,  and  progressively  increases, 
and  the  patient  is  unable  to  rise,  or  even  to  move  at  all  except  under  the 
stimulus  of  the  painful  spasms.  The  features  are  shrunken ;  the  nose 
is  sharp  and  pallid,  and  bent  to  one  side ;  the  dusky,  lack-lustre,  and 
sunken  eyes,  the  thin  lips,  the  hollow  cheeks,  and  the  contracted  muscles 
that  stand  out  like  cords  under  the  tense  and  clammy  skin,  present  a 
physiognomy  that  belongs  to  no  other  disease  in  the  same  degree.  The 
hands  and  feet  grow  cold,  and  steadily  the  coldness  creeps  upward  toward 
the  trunk;  the  temperature  falls  to  94°  or  95°  F. ;  the  feeble  and  even 
flickering  pulse  ranges  from  100  to  120.  The  integuments  of  the  limbs 
are  shrivelled  and  damp,  and  look  as  if  they  had  been  macerated  in 
water ;  and  if  a  fold  of  the  skin  is  pinched  up  it  subsides  very  slowly 
indeed.  The  eyes  grow  dull  and  dry,  the  tongue  has  a  pasty  or  sticky 
feel,  and  the  urine  is  almost  suppressed.  If  any  of  this  excretion  can  be 
obtained  for  examination,  it  is  found  to  contain  both  albumen  and  sugar. 
As  the  attack  advances  the  patient  falls  into  a  dull,  listless,  and  motion- 
less state,  which  may  be  mistaken  for  insensibility  or  even  unconscious- 
ness but  is  really  due  to  exhaustion  of  all  the  faculties  of  mind  and 
body  He  may  express  no  interest  in  anything,  and  hardly  notice  the 


734  CHOLERA. 

attention  or  the  distress  of  his  friends,  yet  he  will  generally  give  clear, 
although  languid,  answers  to  questions,  and  fall  again  into  an  inert  and 
unobservant  state. 

As  these  symptoms  continue  and  the  fluids  of  the  body  decrease,  the  blood 
accumulates  and  stagnates  in  the  veins,  giving  to  the  hands  and  feet,  the 
nose  and  lips  and  other  features,  to  the  neck,  and  even  to  the  entire  sur- 
face of  the  body,  a  bluish,  leaden,  or  violet  tint,  precisely  like  that  of 
cyanotic  children.  The  pulse,  that  was  already  weak  and  thready,  is  no 
longer  perceptible ;  the  carotids  even  and  the  impulse  of  the  heart  cease 
to  be  felt,  and  the  second  sound  of  the  latter  becomes  inaudible.  The  skin 
is  everywhere  cold ;  the  hands,  feet,  and  face  are  sometimes  of  an  icy 
coldness,  and  yet  the  patients  seldom  perceive  that  they  are  so ;  indeed, 
complaint  is  more  apt  to  be  made  of  suffering  from  internal  heat.  Even 
the  breath  as  it  issues  from  the  nostrils'  feels  cold.  The  blood  no  longer 
circulates,  and  the  heart  seems  still.  If  a  vein  is  opened  a  few  drops  of 
black  and  viscid  blood  will  trickle  from  the  wound,  which  if  it  coagulates, 
yields  but  little  serum,  and  in  place  of  a  firm  clot  only  a  diffluent  jelly. 
The  voice  has  sunk  _  to  a  mere  whisper  or  is  quite  extinct.  The  fea- 
tures assume  a  distorted  and  frightful  expression  ;  the  temples  and  cheeks 
are  hollowed ;  the  nose  is  twisted  and  pointed,  and  the  nostrils  are 
obstructed  with  dry  and  powdery  crusts  ;  the  eyes  are  also  dry,  dull,  and 
sunken  behind  the  half-closed  and  purple  lids ;  the  conjunctiva  is  no 
longer  moistened  by  its  secretion  and  becomes  bloodshot ;  the  tempera- 
ture in  the  mouth  may  fall  to  79°  or  80°  F.  ;  a  viscid  exhalation  bedews 
the  icy  and  marbled  skin ;  and  the  whole  body  is  so  shrunken  from  its 
natural  proportions  as  to  lose  all  the  marks  by  which  its  identity  has  been 
recognized.  From  this  pulseless,  exhausted,  cold,  and  cyanotic  condition 
there  can  be  but  one  step  to  death.  It  generally  comes  on  gradually,  the 
patient  sinking  into  the  state  of  apparent  insensibility  before  mentioned ; 
on  the  other  hand,  he  may  expire  suddenly  on  attempting  tq  make  some 
unusual  effort. 

At  any  period  in  the  progress  of  cholera,  except  that  of  complete 
asphyxia,  the  contest  between  the  system  and  the  disease  may  be  decided 
in  favor  of  the  former.  If  this  occurs  before  profuse  evacuations  have 
taken  place  or  blueness  of  the  skin  appeared,  the  recovery  may  be  gradual 
and  present  no  special  phenomena.  The  pulse  regains  by  degrees  its 
natural  force  ;  the  skin  grows  warm  again,  first  upon  the  trunk  and  after- 
ward upon  the  extremities ;  the  breathing  becomes  easy,  and,  the  diar- 
rhea having  already  ceased,  convalescence  is  established.  But  in  pro- 
portion to  the  severity  of  the  symptoms,  the  intensity  and  duration  of 
the  cold  stage,  the  cramps,  and  the  evacuations,  will  there  be  a  tendency 
to  febrile  reaction,  with  more  or  less  passive  congestion  of  the  internal 
organs,  and  therefore  a  slower  return  to  health.  If  the  attack  has  been 
very  severe,  and  particularly  if  the  algid  stage  has  been  prolonged,  fever 
of  a  low  type  is  apt  to  occur,  and  indeed  may  terminate  fatally.  This 
fever  presents  all  the  characters  of  the  typhoid  state,  and  is  marked  by 
dryuess  of  the  tongue,  a  brown  crust  upon  the  teeth  and  gums,  jerking 
of  the  tendons,  delirium,  and  coma.  These  symptoms  are  partly  evi- 
dences of  exhaustion,  of  inability  of  the  system  to  resume  its  normal 
action,  and  perhaps  also  they  denote  the  retention  of  the  effete  products 
of  nutrition  in  the  blood ;  but  sometimes  they  appear  to  be  associated 


COMPLICATIONS  AND  SEQUELS.  735 

with  and  caused  by,  a  local  and  latent  inflammation  of  low  grade,  estab- 
lished  usually  in  the  lungs.  Again,  the  nervous  system  seems  to  bear 
the  brunt  of  the  reactionary  effort,  and  the  patient  is  attacked  by  convul- 
sions or  perishes  in  an  apoplectic  fit.  These  phenomena  appear  to  be  dut 
m  most  instances,  if  not  in  all,  to  renal  obstruction,  and,  as  it  is  supposed 
that  their  immediate  cause  is  the  retention  of  urea  in  the  blood  they 
have  received  the  title  of  ursemic.  In  other  cases  a  wasting  diarrhoea  due 
probably  to  the  damaged  state  of  the  intestinal  mucous  membrane  is 
superadded  to  the  already  existing  typhoid  state.  Occasionally  the  parotid 
glands  become  enlarged  and  painful,  and  sometimes  a  measly  or  roseolous 
eruption  appears  upon  the  skin. 

It  frequently  happens  that  the  convalescence  from  cholera  is  slow  and 
irregular.  The  system  seems  to  be  shattered  by  the  trial  it  has  passed 
through  •  the  nervous  susceptibility  is  for  a  long  time  morbidly  increased, 
or,  what  is  still  more  usual,  the  digestive  function  is  greatly  impaired. 
The  appetite  is  capricious  and  the  digestion  feeble.  The  mouth  is  pasty, 
the  abdomen  tympanitic,  the  bowels  are  irregular  and  alternately  confined 
and  relaxed.  Finally,  patients  who  leave  the  bed  too  soon  or  indulge 
prematurely  in  their  ordinary  diet  are  liable  to  a  relapse,  perhaps  fatally, 
into  the  original  disease.  It  has  sometimes  happened  that  such  a  relapse 
has  taken  place  several  days  after  an  apparent  restoration  to  perfect  health. 

COMPLICATIONS  AND  SEQUELAE. — In  a  small  proportion  of  cases,  as 
above  stated,  cutaneous  eruptions  have  been  observed  during  the  attack 
of  cholera,  or  gather  during  its  decline,  for  they  coincide  with  the  reac- 
tion or  follow  it,  and  may  be  regarded  as  indications  of  increasing  vitality. 
They  belong  to  the  exanthematous  class,  and  comprise  roseola,  erythema, 
urticaria,  and  rarely  vesicular  eruptions.1  But,  instead  of  them,  there 
may  occur  destructive  tissue-lesions  in  the  form  of  abscesses  or  ulcers. 
These  affections  are  more  usual  on  the  limbs  than  on  the  trunk  or  face, 
but  some  of  them  may  appear  even  in  the  mouth  or  fauces.  Profuse 
sweats  have  been  noticed  elsewhere,  and  the  important  fact  that  they 
carry  off  large  quantities  of  urea,  which  they  deposit  upon  the  skin. 
Diphtherial  exudation  has  also  been  met  with  upon  tender  parts  of  the 
skin  and  in  the  fauces,  as  well  as  in  the  stomach  and  intestine.  In  some 
epidemics  of  cholera  suppuration  of  the  parotid  gland  is  occasionally 
observed,  while  in  others  it  may  be  entirely  absent.  Instances  have  been 
reported  of  double  parotitis,  and  in  several  of  them  the  termination  of 
the  attack  was  fatal.  Still  more  rarely  suppuration  of  the  submaxillary 
or  the  cervical  glands  has  been  met  with.  Another  sequela  of  cholera  is 
a  tetanic  contraction  of  the  flexor  muscles  of  the  limbs.  Between  the 
tenth  and  fifteenth  days  of  convalescence  the  patient  is  attacked  with  a 
tearing,  rending  pain  in  the  hands  and  forearms,  the  legs  and  feet,  followed 
by  tonic  contraction  of  the  flexor  muscles  of  these  parts.  The  sensibility 
is  not  impaired.  The  attack  lasts  for  one  or  several  days,  and  seems 
always  to  end  in  recovery  (Guterbock). 

Some  of  the  individual  symptoms  of  cholera  call  for  a  more  detailed 
notice  than  they  have  received  in  the  foregoing  epitome,  in  which  the  con- 
tinuity of  the  narrative  could  not  be  interrupted  by  a  description  of  varia- 
tions depending  upon  the  stage  and  grade  of  the  disease. 
1  Compare  London  Hosp.  Reports,  iii.  457. 


736  CHOLERA. 

The  first  to  be  considered  is  the  temperature.  The  animal  temperature 
in  cholera  varies  according  to  the  part  of  the  body  at  which  it  is  taken 
more  than  in  any  other  disease.  In  cases  of  average  severity  it  rarely 
falls  below  95°  F.  in  the  axilla.  The  temperature  under  the  tongue  does 
not  furnish  trustworthy  indications.  In  the  stage  of  asphyxia  it  seldom 
exceeds  87.8°  F.,  and  even  in  cases  that  recover  it  may  fall  to  about  78.8° 
F.  (Wunderlich).  In  the  cold  stage  it  is  not  uncommon  for  a  difference 
of  temperature  to  be  noted  of  nearly  ten  degrees  between  the  axilla  and 
the  rectum.  In  a  female  aged  thirty-two  the  temperature  in  the  axilla 
wa,s  93°  F.,  and  that  in  the  vagina  102.8°  F.  (Mackenzie).  In  other 
cases  a  vaginal  temperature  of  104°  F.,  and  even  of  108.32°  F.,  has  been 
reached  (Guterbock).  Such  high  temperatures  furnish  an  unfavorable 
prognosis.  As  Wuuderlich  has  pointed  out,  during  the  algid  stage  tem- 
peratures taken  in  the  mouth  do  not  give  an  accurate  idea  of  the  general 
temperature ;  the  rectal  and  vaginal  temperatures  are  more  nearly  correct. 
The  following  are  some  results  of  thermometry  in  74  cases  of  cholera : 
Lorain  found  the  minimum  rectal  temperature  in  1  case  93.2°  F.,  in  2 
cases  95°,  and  in  10  cases  96.8°.  In  47  cases  the  normal  temperature 
was  preserved;  in  27  it  rose  to  100.4°;  in  15  cases  to  102.2°;  and  in  1 
to  104°  F.  Leubuscher  gives  the  average  temperature  in  the  armpit 
92.7°  F. ;  under  the  tongue,  90.5°;  upon  the  tongue,  81.5°,  in  the  nos- 
trils, 79.2° ;  and  on  the  palm  of  the  hand,  84°  F.  These  numbers,  how- 
ever, only  represent  averages.  It  should  be  noted  that  the  low  temperature 
of  the  mouth  and  nostrils  is  caused  not  only  by  the  evaporation  from  the 
surface  of  those  cavities,  but  also  by  the  relative  coldness  of  the  expired 
air,  due  to  the  partial  suspension  of  the  passage  of  blood  through  the 
lungs,  and  therefore  to  the  heating  of  the  air  contained  in  them.  Accord- 
ing to  Leubuscher  also,  the  lowest  temperature  is  found  in  the  nostrils, 
and  next  under  the  tongue,  and  at  the  latter  point  it  may  vary  from  79° 
F.  to  90.5°  F.  In  death  by  asphyxia  the  vaginal  and  rectal  tempera- 
tures may  rise  to  104°— 108°  F.  The  axillary  fluctuates  less  than  the 
internal  temperature.  It  is  remarkable  that  during  the  algid  stage  the 
patients,  at  least  before  the  temperature  has  reached  its  minimum,  are  not 
conscious  of  their  coldness,  but,  on  the  contrary,  complain  of  internal 
heat,  precisely  as  happens  in  the  congestive  forms  of  periodical  fever. 
When  the  febrile  reaction  assumes  a  typhoid  type  the  temperature  in 
many  cases  is  normal  or  only  slightly  elevated,  and  it  is  of  serious  import 
if  the  temperature  then  sinks  again  below  the  normal  grade  (Wunderlich). 
On  the  whole,  the  maintenance  of  a  uniform  temperature,  neither  much 
above  or  below  90°  F.  in  the  axilla  or  under  the  tongue,  may  be  regarded 
as  favorable,  yet  recoveries  have  taken  place  even  when  the  temperature 
at  these  points  has  fallen  to  79°  F.  If  the  temperature  of  the  parts  just 
mentioned  should  rise  rapidly  to  104°  F.,  it  may  be  regarded  as  a  very 
unfavorable  sign. 

The  skin,  as  has  elsewhere  been  described,  is  pallid,  bluish,  shrunken, 
and  cold,  and  quite  destitute  of  its  natural  firmness  and  elasticity,  so  that 
when  it  is  pinched  into  folds  they  subside  very  slowly,  as  if  they  had 
been  made  on  the  skin  of  a  corpse.  It  is  curious  that,  although  the  drain 
of  liquids  through  the  bowels  is  so  great,  the  skin  not  only  remains  moist, 
but  generally  is  bathed  in  a  profuse  cold  sweat.  Although  the  secretion 
of  urine  is  reduced  or  quite  suspended,  that  of  milk  is  said  to  be  not 


COMPLICATIONS  AND  SEQUELAE.  737 

always  so.  Large  quantities  of  urea  have  been  found  in  the  urine,  and 
in  some  cases  it  has  been  visible  upon  the  skin  in  the  form  of  white  scales. 
During  convalescence  the  skin  may  be  the  seat  of  the  various  eruptions 
already  enumerated.  Of  a  graver  nature,  but,  fortunately,  of  rarer  occur- 
rence, are  erysipelas,  boils,  abscesses,  ulcers,  and  gangrene.  These  several 
affections  seem  to  result  from  the  alternate  obstruction  and  freedom  of 
the  cutaneous  circulation.  They  commonly  appear  first  upon  the  limbs, 
and  afterward  upon  the  face  or  trunk ;  they  may  affect  even  the  cavity  of 
the  mouth.  Some  observers  have  noted  a  relatively  frequent  occurrence 
of  diphtheria!  exudations  in  this  disease,  while  others  do  not  allude  to 
their  existence.  The  former  describe  the  false  membrane  as  affecting  not 
only  the  mouth  and  fauces,  but  also  the  stomach,  the  intestine,  and  the 
female  organs  of  generation.  A  case  is  reported  by  Joseph  of  a  young 
man  who,  after  an  attack  of  cholera,  was  affected  with  a  blenorrhcea,  due 
to  a  diphtherial  inflammation  of  the  urethra. 

The  character  of  the  heart-  and  pulse-beats  in  this  disease  is  quite 
peculiar.  Their  rate  does  not  increase  indefinitely,  as  it  does  after  hem- 
orrhage ;  the  pulse  usually  varies  from  90  to  1 10,  and  indeed  seldom 
exceeds  120,  but  its  volume,  tension,  and  force  progressively  decline  until 
the  beats  become  imperceptible  at  the  wrist,  and  even  in  the  brachial  and 
femoral  arteries.  At  the  same  time,  the  rhythm  of  the  heart  is  inter- 
rupted, the  energy  of  its  impulse  declines  until  it  can  no  longer  be  felt, 
and  its  sounds  grow  weaker  and  weaker  until  they  become  quite  inaud- 
ible. Sometimes,  it  is  said,  a  pericardial  friction  sound  may  be  heard, 
which  is  attributed  to  the  dryness  of  the  pericardium.  That  the  decline 
and  suspension  of  the  heart's  sounds  and  impulse  are  due  not  only  to  the 
weakness  of  the  cardiac  muscle,  but  also  to  the  lessened  volume  of  the 
circulating  blood,  is  proved  by  the  fact  that  they  persist,  sometimes  for 
many  hours,  after  reaction  has  commenced,  and  only  become  audible 
again  when  the  arteries  have  been  replenished  with  blood. 

In  the  description  of  the  symptoms  of  cholera  it  has  been  mentioned 
that  the  cyauotic  color  of  the  skin  is  produced  by  an  accumulation  of 
blood  in  the  veins.  Many  years  ago  Magendie,  and  after  him  Dieffen- 
bach,  on  examining  the  arteries  of  persons  in  the  advanced  stage  of 
cholera,  found  those  vessels  empty  of  blood.  It  might  be  supposed  that, 
under  the  circumstances,  not  only  the  right  side  of  the  heart,  but  also  the 
lungs,  would  be  gorged,  with  blood,  and  that  extreme  dyspnoea  would 
result.  But,  in  point  of  fact,  the  respiration  in  cholera  is  hurried  and 
shallow  rather  than  oppressed  and  labored,  while  after  death  the  lungs 
are  not  engorged  with  blood,  but  rather  in  a  bloodless  condition.  The 
pulmonary  artery  and  its  branches  are  also  empty,  although  the  right 
side  of  the  heart  may  be  filled  with  dark  and  soft  coagula.  These  singu- 
lar conditions  seem  to  be  due,  on  the  one  hand,  to  the  greatly  diminished 
mass  of  the  blood  in  the  vessels,  and  to  its  accumulating  and  stagnating 
in  various  parts  of  the  venous  system,  and,  on  the  other  hand,  to  the 
weakness  of  the  heart,  which  is  shown  by  its  suppressed  impulse  and 
sounds,  and  which  lessens  its  power  to  propel  the  venous  blood  into  the 
lungs.  The  infarction  of  the  systemic  veins  and  the  threatening  suspen- 
sion of  the  circulation  necessarily  impair  the  activity  of  all  the  functions, 
including  those  of  nutrition  and  disintegration,  so  that  the  effete  detritus 
of  the  economy  tends  to  accumulate  in  the  blood.  This  tendency  is 

VOL.  I.— 47 


738  CHOLERA. 

doubtless  counterbalanced  not  only  by  the  diarrhoea,  but  also,  more  or 
less,  by  the  almost  total  suspension  of  nutrition,  due  to  the  inability  of 
the  cholera  patient  to  digest  or  even  to  retain  food,  as  well  as  by  the 
diminished  oxidation  of  the  blood  in  the  lungs.  It  has  already 
been  observed  that,  to  a  certain  extent,  the  impediment  to  the  passage 
of  the  blood  from  the  right  side  of  the  heart  into  the  ramifications  of  the 
pulmonary  artery  tends  to  prevent  congestion  and  infarction  of  the  lungs. 
But  this  obstruction  is  precisely  what  occurs  during  the  stage  of  reaction 
in  many  cases,  which  then  terminate  fatally  by  asphyxia,  as  in  the  pre- 
vious stage  still  more  perish  by  apnoea. 

In  the  milder  attacks  of  cholera  vomiting  may  not  occur,  and  in  the 
most  severe  it  not  unusually  is  suspended  for  some  time  before  death, 
although  the  diarrhoea  may  continue.  In  the  most  malignant  cases, 
indeed,  there  may  be  no  vomiting  at  all,  in  consequence  of  the  extreme 
muscular  exhaustion,  although  the  stomach  may  be  distended  with 
liquid.  When  rejected,  the  liquid  has  the  general  aspect  of  rice-water, 
which  the  stools  also  present.  Its  reaction  is  alkaline  or  neutral,  and  it 
is  said  to  contain  a  less  proportion  than  the  stools  of  solid  matter,  but  a 
larger  proportion  of  urea.  The  act  of  vomiting  is  strictly  one  of  regur- 
gitation,  which  is  performed  without  effort  or  pain.  Sometimes,  indeed, 
it  seems  to  relieve  the  sense  of  weight  caused  by  the  accumulated  con- 
tents of  the  stomach.  It  is  readily  excited  by  attempts  to  drink,  and 
even  by  slight  changes  of  posture.  The  vomited  liquid  at  first  contains 
the  various  articles  of  food  the  patient  may  have  eaten.  Their  half- 
digested  remains  have  sometimes  suggested  the  announcement  of  strange 
specific  forms  of  cholera  germs.  The  liquid,  after  ceasing  to  be  colored 
brownish  or  greenish,  becomes  gray,  and  subsequently,  in  favorable  cases, 
more  or  less  green  again ;  while  during  the  stage  of  reaction  in  grave 
and  ultimately  fatal  cases  it  is  more  or  less  reddened  by  an  admixture  of 
blood.  Its  most  usual  and  characteristic  appearance  is  that  of  a  grayish 
liquid  containing  whitish  flocculi.  The  nature  of  this  liquid,  whether 
discharged  by  vomiting  or  by  purging,  has  been  variously  estimated. 
Formerly,  some  persons  held  the  white  granules  to  be  leucocytes,  but  the 
greater  number  agree  that  they  are  mainly  epithelial  fragments.  When 
the  vomited  liquid  is  allowed  to  stand,  a  sediment  forms  in  it  which  is 
composed  almost  entirely  of  epithelial  scales,  more  or  less  modified  in 
their  appearance  by  the  accidental  contents  of  the  stomach,  and  a  film 
covers  its  surface  in  which-  globules  of  fat  and  phosphatic  crystals  may 
be  detected.  They  are  frequently  associated  with  sarcina?,  produced  by 
fermentation  in  the  contents  of  the  stomach,  and  after  standing  for  some 
time  the  liquid  becomes  crowded  with  vibrios  (Lindsay). 

Although  the  propensity  of  the  sick  to  discover  a  cause  for  every 
symptom  often  leads  cholera  patients  to  attribute  their  diarrhoea  to  some 
particular  exposure  to  cold,  error  of  diet,  etc.,  yet,  in  fact,  this  symptom, 
so  far  as  it  belongs  to  cholera,  is  primarily  an  effect  of  the  cholera  poison 
alone,  although  it  may  be  aggravated  by  causes  like  those  mentioned.  It 
is  of  great  practical  importance  to  bear  in  mind  that  a  specific  choleraic 
diarrhoea — that  is  to  say,  a  diarrhoea  produced  by  the  cholera  poison 
alone — may  continue  to  be  very  slight  as  long  as  it  lasts,  which  may  be 
for  several  weeks ;  and  hence,  as  elsewhere  insisted  upon,  a  person  who  is 
not  suspected  of  being  affected  with  cholera  may,  quite  ignorantly,  sow 


COMPLICATIONS  AND  SEQUELS.  739 

the  seeds  of  a  deadly  epidemic  of  the  disease.  The  danger  in  cholera  is 
proportioned  to  the  volume  of  the  discharges  rather  than  to  their  frequen- 
cy, just  as  a  single  profuse  hemorrhage  is  more  serious  than  the  loss  of 
an  equal  amount  of  blood  divided  among  several  successive  days.  The 
special  danger,  however,  is  not,  as  in  hemorrhage,  from  syncope,  "but  from 
the  progressive  loss  by  drainage  of  the  water  of  the  blood,  rendering  it 
unfit  to  circulate,  and  therefore  causiug  it  to  stagnate  in  the  veins.  The 
spoliative  operation  of  the  diarrhoea  has  occasionally  been  productive  of 
benefit  instead  of  injury,  as  in  the  following  case  of  Barlow :  A  man 
suffering  from  dropsy  was  attacked  with  cholera,  "  and  passed  gallons  of 
liquid  by  stool,  had  cramps,  and  became  livid  and  clammy,  but  his  pulse 
did  not  disappear,  as  in  profound  collapse,  and  he  eventually  rallied,  and 
left  the  hospital  apparently  well.  When  he  began  to  recover  from  cholera 
his  appearance  was  almost  ludicrous,  from  the  manner  in  which  the  integu- 
ment hung  loosely  about  him." 

The  stools  pass  through  a  series  of  changes  corresponding  to  those  of 
the  matters  vomited,  being  fecal  at  first,  and  then  becoming  colorless  and 
watery.  During  reaction,  if  that  Occurs,  they  regain  more  or  less  of  their 
proper  color,  but  if  typhoid  febrile  symptoms  prevail  they  are  usually 
bloody.  Decomposed  blood  sometimes  renders  them  dark,  tarry,  and 
fetid ;  this  'condition  has  caused  them  sometimes  to  be  described  as  being 
composed  of  vitiated  bile,  which  is,  however,  a  product  not  of  the  liver, 
but  of  the  imagination. 

In  the  intestine  after  death  considerable  quantities  of  epithelium  are  found 
floating  in  the  contained  liquid  or  else  loosely  adherent  to  the  mucous 
membrane.  It  is  usually  in  flocculi,  but  sometimes  in  fragments  large 
enough  to  form  a  continuous  membrane.  A  microscopic  examination  of 
cholera  stools  shows  that  their  turbidness  depends  chiefly  upon  desqua- 
mated epithelium,  with  which  is  mixed  white  corpuscles  and  bacteria. 
It  is  remarkable  that  although  the  stools  are  drained  directly  and  so 
rapidly  from  the  blood-vessels,  they  nevertheless  contain  but  little  albu- 
men, indeed  hardly  more  than  a  trace  of  it.  If,  however,  blood  is  mixed 
with  the  stools,  as  happens  in  rare  instances,  more  albumen  is  present. 
Oil-globules  are  most  abundant  in  cases  that  have  passed  beyond  the 
stage  of  collapse  into  that  of  reaction  with  fever.  In  these  it  is  said  that 
oily  matter  may  be  found  either  in  concrete  masses  or  as  a  scum  of  liquid 
oil.  Of  inorganic  constituents  they  contain  crystals  of  the  triple  phos- 
phate of  ammonium  and  magnesium  and  chloride  of  sodium  in  greatest 
abundance,  but  the  proportion  of  ammonium  and  potassium  salts  is  small. 
Indeed,  the  total  amount  of  solids  does  not  exceed  2  per  cent.  As  the 
quantity  of  water  in  the  blood  and  solids  is  limited,  and  as  in  this  dis- 
ease the  stomach  will  not  receive  nor  retain  any  liquid,  it  follows  that  the 
more  profuse  the  evacuations  are,  the  shorter  must  be  the  duration  of  the 
attack,  for  the  sooner  then  does  the  blood  become  too  thick  to  circulate. 

It  has  several  times  been  stated  that  in  cholera  the  urine  is  diminished, 
and  that,  therefore,  the  blood  retains  a  larger  proportion  of  effete  prod- 
ucts than  in  health.  But  it  has  also  been  remarked  that  the  amount  of 
these  products  is  abnormally  small,  on  account  of  the  interference  with 
nutrition  of  the  abnormal  state  of  the  circulation.  Doubtless,  as  in  other 
cases  of  renal  obstruction,  an  increased  proportion  of  effete  matter  is 
eliminated  by  the  skin,  if  not  by  the  bowels.  When  the  amount  of 


740  CHOLERA. 

urine  excreted  is  only  diminished,  its  specific  gravity  may  vary  between 
remote  extremes,  as  1.012  and  1.030.  Usually,  however,  when  its 
quantity  is  very  greatly  reduced,  symptoms  which  are  described  as  uraemic 
are  apt  to  arise,  and  the  urine  is  found  to  contain  the  usual  products  of 
renal  congestion — viz.  albumen,  sometimes  traces  of  blood,  hyaline  and 
granular  casts,  and  epithelial  scales,  with  less  chloride  of  sodium  and 
more  urea  than  normal.  It  is  remarkable  that  at  the  beginning  of  con- 
valescence the  urine,  which  had  been  suppressed  or  greatly  diminished, 
may  become  for  a  time  abnormally  abundant.  Rarely,  if  ever,  does  the 
derangement  of  the  kidneys  now  described  denote  or  produce  an  organic 
lesion  in  those  organs.  Like  the  disorders  elsewhere,  these  are  due  to  the 
loss  of  balance  between  the  arterial  and  the  venous  sides  of  the  circula- 
tion ;  both,  indeed,  have  lost  their  functions  more  or  less,  the  one  by  lack 
of  blood,  the  other  by  an  excess  of  blood  unfit  for  circulation. 

The  occurrence  of  cramps  in  cholera,  which  has  bestowed  upon  the  dis- 
ease one  of  its  titles,  spasmodic,  has,  however,  no  distinctive  relation 
to  the  Asiatic  disease.  Spasmodic  phenomena  occur  in  many  cases  of 
poisoning  by  corrosive  and  irritant  agents  and  in  ordinary  cholera  morbus, 
and  in  cholera  iufantum  they  are  among  the  most  alarming  symptoms, 
assuming,  as  they  often  do,  the  character  of  general  convulsions.  In 
most  of  these  cases  they  are  clonic  and  general,  and  therefore  probably  of 
central  origin,  primary  or  reflected ;  but  the  spasms  of  cholera  are  tonic, 
and  affect  the  muscles  of  the  upper  and  lower  limbs,  and  most  frequently 
the  flexor  muscles  of  these  pails,  and  especially  those  of  the  fingers  and 
toes,  which  become  rigidly  bent.  The  larger  muscles  contract  into  hard 
lumps,  and  even  those  of  the  chest  and  abdomen  do  not  escape  the  terri- 
ble spasms.  When  they  are  severe  they  extort  cries  from  patients  who 
at  other  times  seem  quite  apathetic.  It  is  stated  by  Macnamara  that  the 
natives  of  Southern  Bengal  and  other  people  of  relatively  loose  fibre  are 
much  less  apt  to  be  attacked  by  them  than  the  natives  of  the  upper 
country  or  than  Europeans.  It  may  be  debated  whether  their  immediate 
cause  is  a  reflex  irritation  emanating  from  the  gastro-iutestiual  mucous 
membrane;  or  whether  it  is  due  to  the  rapid  diminution  of  the  supply 
of  blood  to  the  nervous  centres,  or  to  the  infarction  of  those  centres 
with  thick  and  imperfectly  oxygenated  blood ;  or,  finally,  whether  it  is 
occasioned  by  a  diminished  supply  of  blood,  and  that  blood  of  bad 
quality,  to  the  muscles  themselves.  Probably  all  of  these  factors  are 
associated  causes  in  producing  the  spasmodic  phenomena  of  cholera.  It 
is  well  worthy  of  notice,  however,  that  spasms,  which  are  so  frequent  in 
all  infantile  diseases,  and  especially  in  those  affecting  the  stomach  and 
bowels,  rarely  attack  children  suffering  from  cholera.  This  would  seem 
to  prove  that  the  spasms  in  question  are  not  reflex,  but  either  central  and 
spinal,  or  else  muscular — an  inference  which  is  strengthened  by  their  being 
tonic  and  not  clonic.  As  stated,  the  spasms,  or  cramps,  frequently  affect 
the  limbs,  but  comparatively  seldom  involve  the  muscles  of  the  chest  or 
abdomen,  and  those  of  the  face  hardly  ever.  They  are  almost  the  only 
causes  of  pain  in  the  disease,  which  in  not  a  few  instances  runs  its  whole 
course,  even  to  a  fatal  termination,  without  their  occurrence. 

As  a  rule,  the  abdomen  is  not  so  much  retracted  as  might  be  ex- 
pected from  the  profuse  discharges.  Probably  in  some  degree  its  form 
is  maintained  by  the  constantly  recurring  accumulation  of  liquid  in  the 


MORBID  ANATOMY  AND  PATHOLOGY.  741 

gastro-intestinal  cavity.  In  protracted  cases,  however,  the  abdomen 
becomes  sunken  and  hollowed.  At  all  stages  of  the  disease  it  is  some- 
what sore  under  pressure,  especially  at  the  epigastrium,  and  it  generally 
has  a  doughy  feel.  As  to  the  functions  of  the  digestive  organs,  they  are 
completely  suspended  during  a  typical  attack  of  the  disease.  Not  only 
are  these  organs  incompetent  to  digest  food,  but  they  cannot  even 
retain  it. 

Throughout  such  an  attack  not  only  rs  sleep  apt  to  be  prevented  by 
the^  pain  of  the  cramps  and  the  frequent  evacuations,  but,  as  a  rule,  the 
patient  is  wakeful,  and  yet,  apart  from  the  restlessness  which  accompanies 
the  paroxysms  of  pain,  there  is,  on  the  whole,  a  tendency  to  a  placid 
quietness.  ^  Mental  excitement  and  delirium  are  probably  unknown  dur- 
ing the  primary  attack,  but  sometimes  a  degree  of  somnolence  or  of  apa- 
thetic tranquillity  exists,  which,  however,  is  quite  distinct  from  coma. 
When  the  attack  is  prolonged,  and  especially  when  it  merges  into  a 
typhoid  state,  the  eyes  become  inflamed  by  their  exposure  to  the  air.  The 
conjunctiva  then  grows  blood-shot,  and  occasionally  the  cornea  is  ulcer- 
ated. 

MORBID  ANATOMY  AND  PATHOLOGY. — The  appearance  after  death 
of  a  person  who  has  died  in  the  collapse  of  cholera  is  very  characteristic. 
It  comprises  a  shrunken  aspect  of  the  whole  body,  its  prevalent  grayish 
or  leaden  pajlor  contrasting  with  the  livid  hue  of  the  abdomen  and  back, 
the  fingers  and  toes,  the  lips  and  eyelids,  and  ears;  the  eyes  are  sunken 
deeply  in  their  orbits ;  the  nose  is  sharp  and  bent,  the  temples  are  hollow, 
and  the  skin  seems  to  cling  tightly  to  the  bones  beneath  it.  The  connec- 
tive tissue  is  very  dry,  and  the  muscles  are  hard  as  well  as  dry,  and, 
owing  to  the  wasting  of  the  softer  parts,  stand  prominently  out.  In  con- 
sequence of  the  absence  of  moisture  decomposition  takes  place  very  slowly. 
Cadaveric  rigidity  is  very  marked  and  persistent.  A  very  notable  phe- 
nomenon is  the  occurrence  of  muscular  contraction  after  death.  It  may 
be  excited  mechanically  or  may  occur  spontaneously.  A  case  is  related 
(Eichhorst)  in  which  three  hours  after  death  the  fibres  of  the  biceps  were 
observed  to  move  tremulously,  and  then  the  entire  muscle  contracted, 
causing  flexion  of  the  forearm.  Even  the  fingers  performed  movements 
like  those  made  in  piano-playing.  The  lower  jaw  has  also  been  observed 
to  move,  causing  the  mouth  to  open  and  shut  repeatedly.  The  late  Sir 
Thomas  Watson  long  ago  described  this  singular  phenomenon  as  follows : 
"A  quarter  or  half  an  hour,  or  even  longer,  after  the  breathing  had  ceased, 
and  all  other  signs  of  animation  had  departed,  slight,  tremulous,  spas- 
modic twitchings  and  quiverings  and  vermicular  motions  of  the  muscles 
would  take  place,  and  even  distinct  movements  of  the  limbs,  in  conse- 
quence of  these  spasms."1  It  was  carefully  studied  by  Barlow,  from 
whose  narrative  the  following  is  taken :  The  patient  was  a  strong  man ;  the 
course  of  his  attack  was  rapid,  and  he  suffered  most  cruelly  from  cramps. 
"  Within  two  minutes  of  his  ceasing  to  breathe  muscular  contractions  began, 
becoming  more  and  more  numerous.  The  lower  extremities  were  first 
affected.  Not  only  were  the  sartorius,  rectus,  vasti,  and  other  muscles 
thrown  into  violent  spasmodic  movements,  but  the  limbs  were  rotated 
forcibly  and  the  toes  were  frequently  bent.  The  motions  ceased  and 
returned ;  they  varied  also :  now  one  muscle  moved,  now  many.  Quite 

1  Lectures,  Am.  ed.  of  1872. 


742  CHOLERA. 

as  remarkable  were  the  movements  of  the  arm :  the  deltoid  and  biceps 
muscles  were  peculiarly  influenced;  occasionally  the  forearm  was  flexed 
upon  the  arm — flexed  completely,  and  when  I  straightened  it,  which  I 
did  several  times,  its  position  was  recovered  instantly.  The  fingers  and 
thumbs  were  now  and  then  contracted,  and  at  times  the  thumbs  were 
separately  moved.  The  fibres  of  the  pectoral  muscles  were  often  in  full 
action;  distinct  bundles  of  them  were  seen  at  intervals  beneath  the  skin. 
....  After  I  had  taken  leave-of  the  body  the  nurse  was  horrified  by  a 
movement  of  the  lower  jaw,  which  was  followed  by  others ;  and  I  thought 
for  a  moment  that  the  man  was  alive.  The  facial  muscles  became  gen- 
erally affected,  and  at  length  all  was  still." *  These  muscular  contractions 
succeed  one  another  in  a  regular  order,  beginning  in  one  lower  extremity 
and  extending  to  the  other,  then  to  the  upper  limbs,  and  finally  to  the 
face.  Their  degree  varies  from  a  slight  quivering  to  a  powerful  contrac- 
tion, and  their  duration  from  a  minute  or  less  to  an  hour  and  a  quarter. 
Cases  have  occurred  in  which  the  legs  were  so  forcibly  retracted  that  they 
could  with  difficulty  be  straightened  again.  In  one  case,  six  hours  after 
death  movements  took  place  in  one  leg,  and  the  hand  was  drawn  across 
the  chest;  in  another,  "the  forearms  were  powerfully  flexed,  and  the 
hands,  approximating,  gave  the  attitude  of  praying  to  the  body."2 
Again,  Mr.  Ward  reports:  "I  saw  the  eyes  of  my  dead  patient  open  and 
move  slowly  in  a  downward  direction.  This  was  followed,  ,a  minute  or 
two  subsequently,  by  the  movement  of  the  right  arm  (previously  lying  by 
the  side)  across  the  chest."  In  the  same  paper  Barlow  says :  "  Mr.  Law- 
rence mentioned  to  me  that  a  gentleman  who  died  in  1832  of  rapid  chol- 
era was  turned  after  death  completely  on  the  side  by  a  strange  and  forcible 
combination  of  muscular  contractions." 3  These  muscular  phenomena 
after  death  form  an  interesting  feature  in  the  history  of  cholera,  but  they 
are  by  no  means  peculiar  to  that  disease.  They  have  been  observed  in 
other  diseases,  and  especially  in  yellow  fever — an  affection  in  which  the 
pathological  condition  is  quite  unlike  that  of  cholera.  In  both  diseases 
they  have  been  manifested  in  robust  persons  and  when  the  course  of  the 
fatal  attack  was  both  rapid  and  severe.  Thus,  Dr.  Dowler  of  New  Orleans 
not  only  found  that  they  could  be  developed  in  such  cases  of  yellow  fever 
by  striking  the  muscles,  but  he  observed  their  spontaneous  occurrence  in 
several,  of  which  the  following  is  a  remarkable  example:  "Not  long  after 
the  cessation  of  the  respiration  the  left  hand  was  carried  by  a  regular 
motion  to  the  throat,  and  then  to  the  crown  of  the  head ;  the  right  arm 
followed  the  same  route  on  the  right  side ;  the  left  arm  was  then  carried 
back  to  the  throat,  and  thence  to  the  breast,  reversing  all  its  original 
motions,  and  finally  the  right  hand  and  arm  did  exactly  the  same."4  In 
1860,  Drasche  alleged  that  not  unusually  the  skin  covering  the  contract- 
ing muscles  became  reddish,  while  the  local  temperature  rose  f  °,  and  that 
a.*;  soon  as  the  contractions  ceased  the  temperature  fell  below  the  normal 
and  cadaveric  rigidity  set  in.  According  to  the  same  observer,  analogous 
contractions  affect  the  unstriped  muscular  fibres,  in  those  of  the  skin 
producing  a  projection  of  the  papillte,  and  in  the  genital  organs  a  discharge 
of  semen.  This  phenomenon  is  said  to  have  occurred  an  hour  and  a  half 
after  death. 

1  London.  Med.  Qaz.,  Nov.,  1849,  p.  798.  2  Ibid,  Jan.,  1850,  p.  185. 

*  Ibid.,  pp.  185,  186.  4  Experimental  Researches,  1846. 


MORBID  ANATOMY  AND  PATHOLOGY,  743 

On  opening  the  abdominal  cavity  of  persons  who  have  died  in  the  col- 
lapse of  cholera  one  is  struck  by  the  general  pink  or  rose  tint  of  the  peri- 
toneal coat  of  the  intestines.  It  is  produced  by  a  repletion  of  the  minute 
branches  of  the  portal  venous  system.  Sometimes  the  color  is  rendered 
very  dark  by  the  pitchy  blood  contained  in  the  veins.  The  surface  of 
the  peritoneum,  like  all  the  tissues,  is  singularly  dry,  and  often  has  a  soapy 
or  sticky  feel,  caused  by  a  layer  of  albuminous  matter,  which  forms  a 
lather  when  rubbed  between  the  fingers,  and  causes  the  intestinal  folds  to 
adhere  to  one  another.  If  death  takes  place  during  the  stage  of  reaction, 
these  appearances  are  less  distinct,  and  the  intestines,  which  in  collapse 
are  usually  retracted,  are  then  somewhat  distended. 

The  stomach  generally  contains  a  thin,  partially  transparent  liquid  of  a 
greenish  or  grayish  color,  and  occasionally  reddish,  holding  in  suspension 
portions  of  coagulated  mucus  and  an  unctuous  substance  of  an  albumin- 
ous nature,  which  adheres  to  the  walls  of  the  cavity.  Fatty  globules 
may  be  observed  floating  in  the  liquid,  which  under  the  microscope 
reveals  epithelial  debris,  granular  corpuscles,  and  fragments  of  gastric 
glands.  Under  heat  and  nitric  acid  coagulation  of  the  liquid  occurs,  and 
on  chemical  examination  it  is  found  to  contain  urea.  The  gastric  mucous 
membrane  is  of  a  dark  violet  or  pale  pink  color,  according  to  the  stage 
of  the  disease ;  its  follicles  are  enlarged,  and  patches  of  superficial  abra- 
sion may  be  observed  on  it. 

The  intestinal  canal  of  those  who  die  during  the  collapse  of  cholera  is, 
in  the  majority  of  cases,  partially  filled  with  liquid  which  has  the 
aspect  of  turbid  serum,  more  or  less  mixed  with  the  previous  contents  of 
the  bowel  if  death  has  taken  place  very  rapidly,  but  otherwise  it  is 
almost  colorless.  On  the  whole,  however,  it  is  less  pale  and  watery  than 
the  stools.  It  contains,  like  these  discharges,  more  or  less  epithelial 
flocculi,  and  generally  more  than  were  observed  during  life  in  the 
dejections.  The  mucus  scraped  from  the  lining  membrane  of  the 
intestine  and  mixed  with  water  renders  it  turbid  with  epithelial  debris. 
The  same  mucus  examined  microscopically  contains  fragments,  larger  or 
smaller,  of  epithelium.  These  conditions  are  said  to  predominate  in  the 
large  intestine.  Indeed,  the  proportion  of  liquid  increases  from  above 
downward.  Hence  in  the  more  prolonged  cases  the  contents  of  the  bowel 
at  its  upper  part  are  less  liquid  and  are  darker  in  color.  There  is,  indeed, 
a  striking  contrast  between  the  appearance  of  the  intestine  in  cases  which 
have  terminated  in  collapse  and  its  aspect  in  persons  who  have  died  during 
the  stage  of  reaction.  It  has  been  clearly  presented  by  Dr.  Sutton.1 
When  death  took  place  in  "  the  cold  stage  the  mucous  membrane  was 
unusually  pale  in  three  cases ;  in  two  it  .was  healthy-looking ;  in  other 
two  it  was  pale  throughout,  excepting  that  one  or  two  of  Peyer's  patches 
were  congested ;  and  in  the  remaining  three  there  was  more  or  less  con- 
gestion of  the  mucous  membrane.  When  the  mucous  membrane  was 
pale  throughout  the  entire  intestine,  the  valvulse  conniventes  looked 
swollen  and  oedematous,  and  the  color  of  the  membrane  was  dead  white. 
The  solitary  glands  were  very  distinct  and  prominent.'  Those  of  the 
duodenum  were  remarkably  so.  In  cases  of  imperfect  reaction  the 
mucous  membrane  of  the  intestine  was  usually  found  very  much  con- 
gested and  ecchymosed.  The  congested  portions  were  sometimes  granu- 

1  I,ondon  Hasp.  Clin.  Lect.  and  Reports,  iv.  497. 


744  CHOLERA. 

lar,  and  apparently  denuded  of  epithelium.  The  mucous  surlace  had 
often  a  dark  port-wine  color,  due  to  the  extravasated  blood  and  the 
hypersemia,  and  here  and  there  the  surface  was  covered  with  a  dirty  gray 
membranous  substance,  likened  to  a  diphtheritic  deposit.  I  have,  how- 
ever, seen  no  decided  false  membrane,  such  as  could  be  peeled  off,  as  in 
diphtheria.  The  surface  was  also  occasionally  bile-stained,  and  the 
greenish-yellow  color  of  the  bile  and  the  deep  red  color  of  the  congested 
surface  presented  a  very  striking  appearance.  The  solitary  glands  were 
very  prominent,  and  in  some  cases  apparently  enlarged."  The  general 
paleness  of  the  intestinal  mucous  membrane  in  the  stage  of  collapse,  and 
its  congestive  redness  whenever  the  signs  of  reaction  have  existed  before 
death,  have  a  very  important  bearing  upon  the  pathology  of  this  disease, 
for  they  demonstrate  conclusively  that  the  gastro-intestmal  evacuations 
in  cholera  have  no  relation  whatever  to  inflammation.  On  the  other 
hand,  they  render  it  altogether  probable  that  the  serous  flux  is  in  the 
nature  of  a  sweat,  an  intestinal  ephidrosis. 

The  nature  of  the  exfoliation  found  in  the  intestinal  canal  has  been 
the  subject  of  much  discussion.  As  long  ago  as  the  first  American 
epidemic  of  cholera  (1832-35)  Dr.  W.  E.  Horner,  Professor  of  Anatomy 
in  the  University  of  Pennsylvania,  described  an  exfoliation  of  the  epi- 
thelial lining  of  the  alimentary  canal,  whereby  the  extremities  of  the 
venous  system  of  the  part  are  denuded,  as  being  characteristic  of  cholera 
alone.  In  1849,  Dr.  Samuel  Jackson,  Professor  of  the  Institutes  of 
Medicine,  and  Dr.  John  Neill,  Demonstrator  of  Anatomy  in  the  Univer- 
sity, in  conjunction  with  Dr.  William  Pepper  and  Dr.  Paul  B.  Goddard, 
presented  a  report  to  the  College  of  Physicians  of  Philadelphia,  in  which 
they,  too,  showed  that  the  "  epithelial  layer  of  the  intestinal  mucous  mem- 
brane was  either  entirely  removed  or  was  detached,  adhering  loosely." 
This  important  fact — the  most  important,  perhaps,  in  the  mechanism  of 
cholera — was  confirmed  seventeen  years  later  by  the  eminent  pathologist 
Dr.  Lionel  S.  Beale,1  who,  when  referring  to  "  the  remarkable  characters 
of  the  matter  discharged  from  the  intestinal  tube,  and  to  the  fact  that  the 
small  intestines  almost  always  contain  a  considerable  quantity  of  pale 
almost  colorless  gruel-,  rice-,  or  cream-like  matter,"  added :  "  This  has 
been  proved  to  consist  almost  entirely  of  columnar  epithelium,  and  in  very 
many  cases  large  flakes  can  be  found,  consisting  of  several  uninjured 

epithelial  sheaths  of  the  villi In  bad  cases  it  is  probable  that 

almost  every  villus,  from  the  pylorus  to  the  ilio-csecal  valve,  has  been 

stripped  of  its  epithelial  coating  during  life These  important 

organs,  the  villi,  are,  in  a  very  bad  case,  all  or  nearly  all  left  bare,  and 
a  very  essential  part  of  what  constitutes  the  absorbing  apparatus  is  com- 
pletely destroyed It  is  probable  that  the  extent  of  this  process 

of  denudation  determines  the  severity  or  mildness  of  the  attack 

It  seems  probable  also  that  the  epithelium  may  become  detached  in  con- 
sequence of  the  almost  complete  cessation  of  the  circulation  in  the  capil- 
laries beneath,  but  the  death  of  the  cells  may  occur  in  consequence  of 
their  being  exposed  to  the  influence  of  certain  matters  in  the  intestine 
or  in  the  blood,  in  which  case  they  would  simply  fall  off." 

In  this  connection,  and  as  complementary  of  the  statements  now  made, 
should  be  considered  the  further  description  by  the  same  author — viz. : 
1  Med.  Times  and  Gazette,  Aug.,  1866,  p.  109. 


MORBID  ANATOMY  AND  PATHOLOGY.  745 

"  Remarkable  changes  have  occurred  in  the  smaller  vessels,  especially  in 
the  capillaries  and  small  veins  of  the  villi  and  submucous  tissue.  The 
blood-corpuscles  appear  to  have  in  a  great  measure  been  destroyed  in  the 
smaller  vessels,  and  in  their  place  are  seen  clots  containing  blood-coloring 
matter,  minute  granules,  and  small  masses  of  germinal  matter  evidently 
undergoing  active  multiplication.  Some  of  the  arteries  are  contracted, 
but  here  and  there  small  clots  destitute  of  blood-corpuscles  may  be  seen 
at  intervals."  Hence,  the  gastro-intestiual  lesions  in  cholera,  according 
to  their  extent  and  degree,  they  remove  the  natural  obstacles  to  exhala- 
tion in  the  mucous  membrane,  and  also,  and  in  the  same  degree,  pre- 
vent the  absorption  of  the  contents  of  the  alimentary  canal.  It  must 
not,  however,  be  forgotten  that  this  lesion  is  not  altogther  peculiar  to  the 
intestinal  mucous  membrane.  Dr.  Beale  long  ago  called  attention  to  the 
fact  that  in  this  disease  there  seems  to  be  a  tendency  to  the  removal  of 
epithelium  from  the  surface  of  all  soft,  moist  mucous  membranes,  but  not 
from  the  follicles  of  the  glands.  The  first  statement  appears  to  be  explic- 
able by  the  shrinkage  of  all  the  mucous  membranes  during  cholera  col- 
lapse, for  by  this  merely  mechanical  agency  the  inelastic  epithelium  must 
necessarily  become  detached.  As  to  the  second  statement,  the  remark 
may  be  made  that  the  whole  follicular  structure  furnished  with  columnar 
epithelium  is  an  absorbing  and  not  an  eliminating  apparatus,  and  that, 
since  its  functional  activity  is  from  the  beginning  of  the  disease  dimin- 
ished by  an  inadequate  blood-supply,  it  can  have  but  a  small  and  indirect 
share  in  generating  the  phenomena  of  the  disease. 

In  1884,  Dr.  Koch,  during  his  investigations  of  cholera  in  India, 
found  bacilli  in  the  bowel  which  he  believed  to  be  peculiar  to  the  disease, 
and  which  presented  the  following  characters :  they  were  not  straight, 
like  other  bacilli,  but  curved  or  comma-shaped ;  they  proliferated  rapidly 
and  displayed  very  active  movements.  Bodies  of  persons  who  died  of  va- 
rious other  diseases  did  not  present  them,  although  abounding  in  different 
bacteria.  The  bacilli  were  not  found,  or  only  exceptionally,  in  the 
stomach,  but  abundantly  in  the  intestine,  and  most  so  in  the  diarrhoeal 
discharges  that  occurred  at  the  height  of  the  disease.  As  soon  as  the 
stools  began  to  be  fecal  the  specific  bacilli  disappeared  from  them.  After 
death  at  the  height  of  the  disease  they  were  most  abundant  in  the  intes- 
tinal contents,  and  especially  in  the  lower  part  of  the  small  intestine. 
"When  death  took  place  at  a  later  period  none  of  them  might  be  detected 
in  the  liquids  in  the  bowel,  but  they  would  still  be  present,  in  consider- 
able numbers,  in  the  tubular  glands.  They  were  not  found  at  all  in 
cases  fatal  from  some  sequela  of  the  disease.1 

Other  abdominal  lesions  in  cholera  possess  a  very  subordinate  import- 
ance. The  isolated  and  the  agminated  glands  are  both  prominent,  chiefly 
because  they  are  swollen  by  the  liquid  imbibed  from  the  bowel.  A 
whitish  substance  which  they  sometimes  contain  may  perhaps  be  the 
albumen  or  fat  which  they  have  taken  from  the  intestinal  liquid.  _  A 
very  similar  condition  of  the  mesenteric  glands  is  probably  due  to  a  like 
cause.  The  liver  is  pale  and  flaccid  when  death  takes  place  in  collapse, 
and  it  is  also  described  as  presenting  a  "  dirty  grayish-red,  homogeneous 
appearance,  and  indistinctness  of  the  lobular  structure,  as  if  some  glu- 
tinous matter  had  been  poured  throughout  the  tissues  of  the  organ " 
1  Times  and  Gaz.,  Mar.,  1884,  p.  398. 


746  CHOLERA. 

(Sutton).  This  appearance  would  seem  to  be  due  to  the  total  suspension 
of  the  blood-supply  through  the  portal  vein. 

At  all  stages  of  the  disease  the  gall-bladder  is  usually  found  full  of 
bile,  which  is  apt  to  be  dark  during  the  collapse  and  more  watery  after 
reaction  has  commenced. 

The  spleen  is  small,  pale,  and,  as  a  rule,  firm,  but  occasionally  it  is 
soft. 

The  kidneys  present  no  marked  changes  when  death  has  taken  place 
early  in  the  attack,  or  at  most  only  exhibit  a  lighter  color  than  usual  of 
the  cortical  substance  and  a  darker  one  of  the  pyramids.  They  show 
that  the  arteries  are  comparatively  empty  and  that  the  veins  are  con- 
gested. Similarly  contrasted  appearances  are  met  after  death  from 
obstructive  disease  of  the  heart  and  other  causes  that  produce  obstruc- 
tion of  the  venae  cavse.  In  the  tubules,  later  on,  fatty  degeneration  of 
the  epithelium  has  been  observed,  and  some  cylindrical  casts.  These 
alterations,  especially  of  the  tubules,  are  most  marked  when  death  occurs 
in  the  stage  of  reaction,  and  are  then  apt  to  be  accompanied  by  more  or 
less  hemorrhagic  trausudation.  The  urinary  bladder  is  always  contracted 
after  death  in  collapse ;  after  febrile  reaction  its  mucous  membrane  may 
be  more  or  less  coated  with  false  membrane. 

The  brain  and  the  spinal  marrow  offer  nothing  peculiar ;  their  venous 
systems  are  everywhere  more  or  less  engorged,  and  sometimes  effused 
blood  has  been  found  in  the  spinal  canal. 

In  the  state  of  the  respiratory  organs  the  most  important  facts  are  that 
in  algid  cholera  the  lungs  are  always  more  or  less  collapsed,  "  shrunk 
and  small,  and  lying  back  in  the  chest,  toward  the  spine,"  and  that,  so 
far  from  being  congested,  they  are  (with  the  exception  of  a  small  portion 
of  their  posterior  part  rendered  dense  by  hypostasis)  singularly  bloodless, 
dry,  and  tough.  As  might  be  inferred  from  these  conditions,  they  are 
also  lighter  in  weight  than  natural.  To  Dr.  Parkes  belongs  the  credit 
of  having  first  described  this  very  important  fact  in  the  morbid  anatomy 
of  cholera,  as  follows :  "  In  fourteen  cases  the  lungs  were  completely 
collapsed,  appearing  in  some  cases  like  the  lungs  of  a  foetus.  In  three 
cases  they  were  considerably,  in  eight  slightly,  collapsed,  and  in  the 
remaining  fourteen  cases  the  collapse  was  in  some  altogether,  and  in  some 
partially,  prevented  by  old  adhesions."1  So  Dr.  Sutton  found  that  the 
average  weight  of  the  two  lungs  during  collapse  was  about  twenty 
ounces,  and  after  reaction — that  is,  after  the  passage  of  the  blood  into 
the  pulmonary  artery  had  become  completely  re-established — about  forty- 
five  ounces.  In  the  latter  condition  also  the  lungs  presented  the  usual 
signs  of  congestion  of  those  organs,  being  dark-red  throughout  or  in 
portions  only.  Sometimes  also  they  contained  masses  or  nodules  of 
apparent  hepatization,  and  of  these  some  may  have  undergone  partial 
softening. 

In  absolute  conformity  with  the  condition  of  the  lungs  that  has  been 
described  is  that  of  the  heart.  If  the  lungs  are  bloodless,  it  follows 
necessarily  that  the  left  side  of  the  heart  must  be  empty,  and  almost  as 
necessarily  that  the  right  side  of  the  heart  must  be  distended  with  blood. 
All  careful  investigators  of  the  subject  agree  that  such  is  the  condition 
of  the  heart  when  death  takes  place  in  cholera  during  the  stage  of 

1  Med.  Times,  1848,  p.  378. 


MORBID  ANATOMY  AND  PATHOLOGY.  747 

asphyxia.  All  report  that  the  pulmonary  artery  is  either  empty  01  that 
it  contains  a  small  quantity  of  dark  and  usually  of  thick  blood ;  that 
the  right  side  of  the  heart  and  the  coronary  veins  are  distended  with 
blood  of  the  same  description,  while  numerous  ecchymoses  exist  along 
the  course  of  the  coronary  veins ;  that  the  venae  cavae  are  filled  with 
half-coagulated  blood  of  a  tarry  aspect ;  and  that  even  the  femoral  and 
splenic  veins  contain  similar  blood.  On  the  other  hand,  the  left  ventricle 
of  the  heart  is  usually  contracted,  and  contains  a  very  little  semi-fluid 
blood,  with  perhaps  a  small  and  pale  clot.  This  engorged  condition  of 
the  right  cavities  and  emptiness  of  the  left  cavities  of  the  heart  diminish 
very  slowly  during  the  passage  from  collapse  to  reaction,  during  which 
time  the  pulmonary  blood-vessels  are  being  gradually  replenished.  Be- 
sides the  thick  and  tarry  aspect  of  the  blood  above  described,  it  has  been 
observed  that  when  the  blood  is  withdrawn  by  means  of  a  pipette,  its  glob- 
ules rapidly  subside  and  are  surmounted  by  a  transparent  serum,  and  that 
such  blood  may  remain  for  a  long  time  uncoagulated.  The  red  corpuscles 
are  said  to  be  pale  and  viscous,  but  not  adhesive,  and  the  white  corpus- 
cles abnormally  numerous  and  easily  crushed.  In  the  free  intervals  are 
observed  "  very  pale  little  objects,  slightly  elongated  and  constricted  in 
their  middle,"  which  multiplied  in  blood  kept  for  one  or  two  days  at  a 
temperature  of  38°  C.  (100.4°  F.).1  If  death  does  not  take  place  until 
reaction  is  far  advanced  or  has  merged  into  a  febrile  condition,  the  left  ven- 
tricle is  usually  found  not  contracted,  and  it  contains  a  quantity  of  blood. 
The  term  "  usually  "  is  employed  to  show  that  even  to  this  rule  there  are 
some  exceptions,  and  that,  as  in  all  other  diseases,  the  issue  does  not 
depend  absolutely  and  exclusively  upon  a  definite  degree  of  any  anatom- 
ical lesion,  but  upon  the  aggregate  condition  of  all  the  functions  upon 
which  life  depends.  The  pericardium,  like  the  pleura  and  the  perito- 
neum, may  be  covered  with  a  saponaceous  film  which  is  albuminous. 

In  looking  now  over  the  field  that  has  been  traversed  in  the  foregoing 
pages,  and  searching  for  some  link  that  will  unite  in  a  consistent  whole 
the  causes,  symptoms,  and  lesions  of  cholera,  it  is  evident  that  only  one 
factor  can  possibly  be  so  described.  That  factor  is  the  gastro-intestinal 
flux.  This  it  is  that  produces  the  vomiting  and  the  purging ;  that  pros- 
trates the  patient  and  wastes  away  in  a  few  hours  the  fullest  and  the  firm- 
est form  ;  that  chills  the  limbs  and  afterward  the  trunk ;  that  thickens 
the  blood  so  that  the  capillary  vessels  can  no  longer  convey  it,  and  that 
spreads  a  cyanotic  shadow  over  the  whole  surface  of  the  body  ;  that  cuts 
off  the  supply  of  blood  from  the  lungs  and  heart ;  that  paralyzes  the 
nervous  system,  ganglionic  as  well  as  cerebro-spiual ;  that  obstructs  the 
kidneys  and  arrests  their  secretion ;  and  that,  acting  through  the  several 
links  of  this  pathological  chain,  becomes  the  cause  of  death.  But  the 
question  still  recurs,  What  is  the  cause  of  the  gastro-intestinal  flux  ?  To 
this  also,  in  the  light  of  observation,  it  is  possible  to  give  only  one 
answer.  It  is  a  specific  poison  which  originates  in  Hindostan,  and, 
being  taken  into  the  stomach  and  bowels,  not  only  produces  in  the  indi- 
vidual the  symptoms  and  lesions  of  cholera,  but  is  capable  of  multiply- 
ing itself  and  rendering  infectious  the  discharges  from  the  stomach  and 
bowels  of  the  subjects  of  the  disease,  so  that  it  may  be  transmitted  from 
1  Rapport  sur  le  Cholera  d'figypte  en  1883,  par  M.  le  Dr.  Strauss,  etc. 


748  CHOLERA. 

one  person  to  another  round  the  whole  circumference  of  the  globe.  Re- 
garding the  form  and  nature  of  that  poison  little  or  nothing  is  definitely 
established,  beyond  what  has  already  been  stated  as  the  result  of  Koch's 
observations.  As  far  as  they  go,  they  harmonize  with  a  long-prevalent 
opinion  that  the  cholera  poison  consists  of  certain  microscopic  germs, 
which,  on  being  received  into  the  bowels,  propagate  their  kind  and 
destroy  the  epithelium.  It  is  believed  by  some  that  these  bodies  are 
products  of  the  rice-plant  on  the  banks  of  the  Ganges,  and  that,  having 
once  originated  the  disease,  the  germs  contained  in  the  discharges  become 
mixed  with  water  or  are  borne  upon  the  wind,  and  enter  the  system  of 
new  victims,  who,  in  their  turn,  disseminate  the  plague.  This  theory 
will  be  further  considered  below. 

Another  view,  that  of  B.  W.  Richardson,  is  that,  "  as  pus  undergoes 
changes  which  convert  it  into  a  septic  poison,  so  the  excreted  matter  from 
the  alimentary  canal  is  equally  capable,  under  peculiar  conditions  of  oxi- 
dation, of  producing  an  alkaloidal  organic  poison,  which,  soluble  in  water, 
but  admitting  of  deposit  on  desiccation,"  becomes  the  agent  for  dissemi- 
nating the  disease.  In  these  theories  a  false  datum  and  a  hypothesis  are 
offered  us  in  place  of  the  fact  which  we  seek.  The  cryptogamous  nature 
of  the  essential  cause  of  the  disease  has  no  positive  proof,  but  only  the 
probability  of  coincidence  in  its  favor.  There  is  no  proof,  because  one 
after  another  organic  form  has  been  alleged  to  be  the  essential  generator 
of  the  disease,  and  each  has  been  proved  to  be  either  not  peculiar  to 
cholera  or  has  been  shown  to  be  present  in  other  diseases  than 
cholera. 

At  the  present  time  (1884)  it  is  the  fashion  to  trace  every  disease  to 
specific  bacteria  or  analogous  organisms.  But  it  may  be  that  the 
occurrence  of  cholera  only  furnishes  the  occasion  for  the  development 
of  these  organisms,  just  as  a  certain  temperature,  hygrometric  condi- 
tion, and  deficient  light  and  air  will  cause  mould  to  form  on  bread  and 
other  organic  substances.  The  judgment  pronounced  by  Dr.  Beale 
in  this  question  as  long  ago  as  1866  appears  now,  as  it  did  then,  to  ap- 
proach the  truth  upon  this  point :  "  There  is  no  good  reason  for  suppos- 
ing that  the  bacteria  in  such  numbers  in  the  alimentary  canal  in  cholera 
have  anything  to  do  with  this  disease  or  with  the  falling  off  of  epithe- 
lium from  the  intestinal  and  other  mucous  membranes.  Bacteria  are 
developed  in  organic  matter  which  is  not  traversed  and  protected  by  the 
normal  fluids  of  the  body,  and  they  invade  the  cells  and  textures  in 
cholera  after  those  cells  and  textures  have  undergone  serious  prior  changes, 
just  as  they  would  invade  textures  removed  from  the  body  altogether. 
Nor  would  it  be  in  accordance  with  known  facts  to  infer  that  cholera  was 
due  to  the  invasion  of  some  peculiar  form  or  species  of  bacterium."  l 

We  repeat,  then,  that  while  nothing  can  be  simpler  than  the  mechan- 
ism of  cholera  viewed  as  a  gastro-intestinal  hyperidrosis,  nothing  is  more 
mysterious  than  the  mechanism  of  the  primary  cause  which  gives  rise  to 
it.  That  its  real  nature  has  been  correctly  described  is  rendered  all  the 
more  probable  by  the  fact,  presently  to  be  insisted  upon,  that  sporadic 
cholera  morbus,  which  is  always  the  consequence  of  a  direct  irritation  of 
the  gastro-intestinal  mucous  membrane,  is  often  with  difficulty  distin- 
guishable from  Asiatic  cholera,  which,  indeed,  differs  from  the  former 
1  Times  and  Gazette,  Aug.,  1866,  p.  167. 


MORBID  ANATOMY  AND  PATHOLOGY.  749 

disease  chiefly  by  the  intensity  of  its  cause  as  measured  by  the  gravity 
of  its  symptoms  and  by  the  nature  of  the  special  agent  that  produces  it. 
The  above  views  regarding  the  essential  cause  of  cholera  were  substan- 
tially indited  before  the  Egyptian  epidemic  of  1883,  but  they  are  in 
accord  with  the  more  definite  conclusions  arrived  at  by  the  German  and 
French  commissions  on  the  subject.  Before  their  reports  appeared,  how- 
ever, a  communication  was  made  by  Dr.  Kartulis  of  the  Greek  hospital 
in  Alexandria,  setting  forth  that  the  drinking-water  and  the  stools  and 
blood  of  the  cholera  patients  contained,  the  first  a  mass  of  micro-organ- 
isms, and  the  others  bacteria  and  micrococci,  which,  however,  presented 
no  distinctive  characters.1  The  German  report  was  prepared  by  Dr.  Koch, 
the  French  by  Dr.  Strauss.2  The  former,  alluding  to  the  enormous  quan- 
tity of  micro-organisms  found  in  the  contents  of  the  bowels  and  in  the 
stools,  did  not  perceive  any  connection  between  them  and  the  phenomena 
of  the  disease.  On  the  other  hand,  he  did  assign  this  relation  to  a  species 
of  bacterium  found  in  the  walls  of  the  intestine,  and  which  he  compared 
to  the  bacilli  of  glanders.  They  were  lodged  in  great  quantities  within 
the  intestinal  glands  and  behind  their  epithelium,  as  well  as  upon  the  sur- 
face of  the  villi  and  within  them,  and  sometimes  even  in  the  muscular 
coat.  They  were  most  numerous  at  the  lower  end  of  the  small  intestine. 
Dr.  Koch  concluded  that  although  these  bacilli,  beyond  doubt,  are  in 
some  manner  associated  with  the  development  of  cholera,  they  are  by  no 
means  shown  to  be  its  cause,  and  may  indeed  be  themselves  the  product 
of  the  morbid  conditions  belonging  to  cholera.  All  his  attempts  at  that 
time  to  develop  cholera  in  animals  by  inoculating  them  with  the  organisms 
gave  only  negative  results.  The  conclusions  of  Dr.  Strauss  were  in  entire 
conformity  with  those  of  Dr.  Koch,  but  involved  an  additional  and  very 
important  statement — viz.  that  the  shorter  and  the  more  violent  were  the 
fatal  attacks  of  cholera  the  fewer  were  the  bacteria  found  in  the  intestine. 
It  is  evident  that  this  fact  is  the  very  opposite  of  what  should  have  been 
found  had  bacteria  been  essential  in  the  causation  of  cholera.  The  more 
recent  investigations  conducted  in  Calcutta  by  Dr.  Koch,  which  have 
already  been  cited,  led  him,  however,  to  attribute  to  bacilli  of  a  specific 
form  the  absolute  origination  of  the  disease.  He  poses  the  question  in 
the  following  manner:  Either  these  "comma  bacilli"  are  a  product  of 
the  cholera  process,  or  "the  disease  only  arises  when  these  specific  organ- 
isms have  found  their  way  into  the  bowel."  The  former  alternative  he 
rejects,  because,  in  his  judgment,  it  assumes  that  the  bodies  in  question 
must  be  pre-existent  in  every  person  who  becomes  affected  with  the  dis- 
ease— a  hypothesis  which  he  rejects,  because  they  have  never  been  found 
except  in  cholera.  He  therefore  concludes  that  they  are  the  cause  of 
cholera.  He  points  out  that  their  first  appearance  coincides  with  the  com- 
mencement of  the  disease,  that  they  increase  with  it,  and  that  they  disap- 
pear with  its  decline.3  The  statement  of  Strauss  quoted  above  does  not,  how- 
ever, appear  to  harmonize  with  this  conclusion,  since  the  bacteria  are  said  by 
him  to  have  been  fewest  in  the  more  violent  and  fatal  attacks  of  the  disease. 
Another  of  Dr.  Koch's  remarks  is  also  open  to  criticism.  After  showing  how 
rapidly  the  cholera  bacteria  multiply  when  kept  moist,  he  states  that  they 
die  after  drying  more  quickly  than  almost  any  other  form  of  bacteria,  "As 

1  Medical  News,  xliii.  377.  '  Archives  gen.,  Dec.,  1883,  pp.  713,  722. 

3  Times  and  Gaz.,  Mar.,  1884,  p.  398. 


750  CHOLERA. 

a  rule,  even  after  three  hours'  drying  every  vestige  of  life  has  disappeared.'' 
It  is  evident  that  this  statement  is  not  in  harmony  with  the  numerous 
facts,  several  of  which  have  been  cited,  that  cholera  fomites  have  pre- 
served their  infectious  qualities  after  several  weeks.  Dr.  Koch  endeav- 
ored to  produce  in  animals,  artificially,  with  these  bacteria,  a  disease 
analogous  to  cholera,  but  without  success;  and  he  adds,  "If  any  species 
of  animal  whatever  could  take  the  cholera,  it  would  surely  have  been 
observed  in  Bengal,  but  all  inquiries  directed  to  this  point  met  with  a 
negative  result."  Dr.  Vincent  Edwards,  who,  however,  is  of  opinion 
that  the  cholera  poison  is  "  not  an  organism,  but  of  the  nature  of  a  chemical 
compound  of  comparatively  unstable  nature,"  reports  that  he  produced 
fatal  cholera  in  pigs  by  giving  them  the  dejections  of  cholera  patients.1 
But  the  Times  and  Gazette  inclines  to  question  that  the  pigs  employed  in 
Dr.  Edwards'  experiments  were  affected  with  true  cholera. 

DIAGNOSIS. — The  most  characteristic  symptoms  of  Asiatic  cholera 
have  repeatedly  been  mentioned  in  the  foregoing  pages.  They  are  rice- 
water  evacuations  by  vomiting  and  purging,  rapid  emaciation  of  the 
whole  body,  a  cadaverous  hollowness  of  the  cheeks  and  eyes,  a  livid  color 
of  the  face,  hands,  and  feet,  a  feeble,  thready,  and  at  last  absent  pulse,  an 
icy  coldness  of  the  extremities,  face,  and  even  the  breath,  a  loss  of  the 
elasticity  of  the  skin,  a  thin  and  feeble  voice,  and  intense  thirst.  But 
every  one  of  these  symptoms  may  occur  in  cholera  morbus  produced  by  a 
direct  irritation  of  the  stomach  and  bowels.  It  is  rathor  their  nature,  we 
repeat,  than  their  phenomena  that  distinguishes  these  two  affections 
from  each  other.  In  attempting  to  separate  Asiatic  cholera  from  other 
forms  of  cholera  we  must  endeavor  to  dismiss  from  the  mind  the  erro- 
neous notion  that  the  term  cholera  denotes  a  definite  disease  identical  in  its 
cause,  phenomena,  and  results.  It  is  no  more  a  disease  than  dropsy  or 
fever  is  a  disease.  It  is  a  complex  group  of  symptoms  which  have  in 
common  the  fact  that  they  proceed  directly  from  gastro-intestinal  irrita- 
tion, whose  degree  of  severity — i.  e.  the  presence  or  absence  of  certain 
grave  symptoms — and,  above  all,  its  issue,  depend  chiefly  upon  the  nature 
and  intensity  of  the  cause  of  the  attack,  and  also,  necessarily,  upon  the 
degree  of  resistance  opposed  to  it  by  the  subjects  of  the  disease.  Noth- 
ing has  led  to  more  error  in  regard  to  epidemic  cholera  than  the  ignor- 
ance of  this  pathological  fact  by  some  and  the  disregard  of  it  by  others. 

In  the  first  portion  of  this  article  it  was  shown  that  the  Greek,  Roman, 
and  Arabian  conceptions  of  cholera  morbus  included  a  discharge  of  bile, 
the  very  symptom  for  the  absence  of  which  Asiatic  cholera  is  notorious ; 
and  also  that  the  classical  cholera,  or  cholera  morbus,  ended  in  recovery 
even  more  frequently  than  Asiatic  cholera  terminates  in  death.  But 
local  epidemics  of  cholera  morbus  sometimes  take  place  which  are  of  a 
severe  and  even  of  a  grave  type,  and  which  also  appear  to  originate  in 
some  peculiar  atmospheric  influence,  for  they  prevail  to  a  limited  extent 
and  in  connection  with  vicissitudes  of  weather.  Still  more  circumscribed 
epidemics  have  been  traced  to  unwholesome  food  and  drink,  and  innu- 
merable instances  of  individual  attacks  have  been  caused  by  irritants  that 
are  ranked  as  poisons  and  others  which  are  reckoned  as  food  or  medicines. 
Now,  under  these  various  circumstances,  which  have  in  common  gastro- 
intestinal irritation,  there  may  be  produced,  if  the  irritation  is  excessive, 

1  Notes  on  ihr  Poison  contained  in  Choleraic  Atomic  Discharges. 


DIAGNOSIS.  75] 

a  series  of  symptoms  closely  resembling,  if  not  identical  with,  those  of 
Asiatic  cholera. 

In  illustration  may  be  cited  the  comparatively  familiar  description  of 
Sydenham.1  These  are  his  words :  "  There  is  vomiting  to  a  great  degree, 
and  there  are  also  foul,  difficult,  and  straining  motions  from  the  bowelh. 
There  is  intense  pain  in  the  belly,  there  is  wind,  and  there  are  distension, 
heartburn,  and  thirst.  The  pulse  is  quick  and  frequent,  at  times  small 
and  unequal.  The  feeling  of  sickness  is  most  distressing,  and  is  accom- 
panied with  heat  and  disquiet.  The  perspiration  sometimes  amounts  to 
absolute  sweating.  The  legs  and  arms  are  cramped  and  the  extremities 
cold.  To  these  symptoms,  and  to  others  of  a  like  stamp,  we  may  add 
faiutness."  .  ..."  As  the  summer  came  to  a  close  the  cholera  morbus 
raged  epidemically,  and,  being  promoted  by  the  unusual  heat  of  the 
weather,  it  brought  with  it  worse  symptoms,  in  the  way  of  cramps  and 
spasms,  than  I  had  ever  seen.  Not  only,  as  is  generally  the  case,  was 
the  abdomen  afflicted  with  horrible  cramps,  but  the  arms  and  legs,  indeed 
the  muscles  in  general,  were  afflicted  also."  ....  At  the  risk  of  repeti- 
tion an  additional  passage  may  be  quoted  from  Sydenham's  later  defini- 
tion of  cholera  morbus  :  "  This  is  limited  to  the  month  of  August  or  the 
first  week  or  two  of  September.  Violent  vomiting,  accompanied  by  the 
dejection  of  depraved  humors,  difficulty  on  passing  them,  vehement  pain, 
inflation  and  distension  of  the  bowels,  heartburn,  thirst,  quick,  frequent, 
small,  and  unequal  pulse,  heat  and  anxiety,  nausea,  sweat,  cramps  of  the 
legs  and  arms,  faintiugs,  and  coldness  of  the  extremities,  constitute  the 
true  cholera — and  it  kills  within  twenty-four  hours." 

In  spite  of  the  general  likeness  between  this  description  and  the  symp- 
toms of  Asiatic  cholera,  there  are  differences  of  considerable  importance 
which  have  been  italicized  in  the  quotations.  These  differences  are  such 
as  may  be  attributed  to  the  action  of  a  harsh  irritant  in  the  case  of 
cholera  morbus,  while  in  the  epidemic  (Asiatic)  disease  the  distinctive 
phenomena  are  the  result  of  a  sudden  and  profuse  intestinal  flux.  Mac- 
pherson,  who  had  a  long  and  extensive  experience  of  epidemic  cholera  in 
India,  after  contrasting  in  detail  its  phenomena  with  those  of  cholera  nos- 
tras,  sums  up  the  discussion  in  these  words :  "  Cholera  indica  is  essentially 
a  very  fatal  disease,  while  cholera  nostras  is  usually  a  mild  affection  and 
is  seldom  fatal,  although  it  was  called  atrocissimus  et  peracutus,  and  has 
undoubtedly  killed  in  from  eight  to  twenty-four  hours." 2  In  regard^to 
the  individual  symptoms  this  very  competent  reporter  does  not  recognize 
a  single  one  as  being  absolutely  peculiar  to  either  disease;  Even  the 
ancients,  already  referred  to,  after  describing  bilious  evacuations  as  being 
characteristic  of  cholera  nostras,  add  that  sometimes  also  they  are  whitish ; 
and  modern  writers,  both  before  and  since  the  advent  of  Asiatic  cholera 
in  Europe,  have  made  a  similar  observation.  Thus,  Quinquaud,  in  his 
description  of  cholera  nostras,  of  which  a  slight  epidemic  occurred  in 
1869  at  the  Hospital  St.  Autoine  in  Paris,  says  :  "  The  principal  symp- 
toms were  vomiting  and  purging,  sometimes  of  a  bilious  and  sometimes 
of  a  rice-water  liquid ;  a  shrivelled  and  cyanotic  skin,  the  latter  appear- 
ance being  sometimes  strongly  marked ;  anxiety,  coldness,  cramps,  altered 
voice,  and  suppression  of  urine.3  In  1875  thirty-three  cases  of  this 

*  Works,  Sydenham  Soc.  ed.,  i.  163 ;  ii.  8,  266. 

8  Times  and  Gaz.,  Dec.,  1870,  p.  725.  8  Archives  gen.,  Mars,  1870,  p.  308. 


752  CHOLERA. 

disease  occurred  at  Valenciennes,  near  Paris,  and  its  symptoms  were  thus 
summarized  by  Manouvriez  r1  "  Repeated  vomiting,  first  of  food,  and 
then  of  a  dark-green  liquid ;  diarrhoaa,  which  was  at  first  fecal  and  then 
bilious,  but  afterward  serous  and  like  rice-water;  painful  tension  of  the 
epigastrium  and  tenderness  of  this  part ;  headache,  cramps  in  the  legs, 
suppression  of  urine;  pallor,  coldness,  and  dryness  of  the  skin,  especially 
of  the  limbs;  pinched  features,  a  blue  circle  around  the  eyes,  a  small  and 
scarcely  perceptible  pulse,  and  a  faltering  and  whispering  voice."  Yet 
of  the  thirty-three  cases  only  two  were  fatal — the  one  a  child  of  four 
years  and  the  other  an  infant  of  as  many  months.  The  substantial 
identity  of  nature  of  these  two  local  epidemics,  and  the  almost  equally 
close  relation  of  their  symptoms  to  those  of  epidemic  cholera,  must  be 
quite  apparent. 

Yet  the  contrasts  are  neither  slight  nor  unimportant;  and  the  most 
striking  and  significant  is  the  trifling  mortality  of  the  European  as  com- 
pared with  the  Asiatic  disease,  notwithstanding  the  grave  symptoms 
present  in  the  former.  It  may  be  regarded  as  certain,  we  think,  that  the 
reason  of  this  difference  of  danger  lies  in  a  corresponding  difference  in 
the  nature  of  the  causes  of  the  two  forms  of  disease.  The  rapid  recovery 
from  cholera  morbus  produced  by  changes  of  weather,  acid  fruits,  and 
indigestion  renders  it  certain  that  no  material  lesion  of  the  gastro-intes- 
tinal  mucous  membrane  has  been  produced ;  while,  on  the  other  hand, 
inspection  after  death  from  epidemic  cholera  or  by  corrosive  poisoning 
renders  it  equally  certain  that  the  damage  to  that  membrane  is  substantial 
and  widespread,  as  well  as  often  irreparable,  and  that,  therefore,  "the 
powers  of  life  that  resist  death  "  must  be  engaged  in  a  very  unequal  and 
often  fruitless  struggle.  The  cramps  in  cholera  nostras  are,  as  a  rule, 
less  severe  than  in  epidemic  cholera,  while  the  colicky,  and  in  general  the 
abdominal,  pains  are  greater  in  the  former  than  in  the  latter  disease. 
The  reason  of  this  difference  appears  to  be  that  muscular  spasm  is  the 
natural  result  of  depletion,  whether  sanguine  or  serous,  while  colic  is  an 
effect  of  irritation  of  the  surface  of  the  mucous  coat  of  the  bowel,  and 
not  of  its  destruction,  such  as  occurs  in  epidemic  cholera. 

It  is  true  only  in  a  limited  degree,  and  indeed  only  upon  a  super- 
ficial survey  of  the  symptoms,  that  the  effects  of  irritant  poisoning  are 
like  those  produced  by  Asiatic  cholera.  The  analogy  between  the  two 
was  pointed  out,  among  others,  by  Sedgwick  in  1867.2  The  resem- 
blance appeared  so  striking  to  the  vulgar  eye  that  in  Paris,  and  per- 
haps elsewhere,  a  popular  tumult  followed  the  first  violent  outbreak 
of  epidemic  cholera,  and  it  was  charged  that  the  wells  had  been  poisoned. 
The  cases  that  most  resemble  cholera  are  the  following :  "  Acute  poison- 
ing by  corrosive  sublimate,  by  arsenic,  and  by  mineral  acids,  especially 
nitric  acid  ;  the  effects  which  follow  the  eating  or  drinking  of  poisonous 
animal  matters,  such  as  tainted  or  simply  unwholesome  meat  or  fish,  and 
milk  which  has  undergone  some  injurious  but  yet  unknown  change, 
decomposing  vegetables  and  some  of  the  poisonous  fungi,  and  the  exces- 
sive action  of  certain  drugs,  for  the  most  part  belonging  to  the  class  of 
drastic  purgatives,"  as  elaterium  and  croton  oil.  The  effects  produced  by 
these  agents  constitute  a  cholera  morbus,  and  therefore  resemble  cholera, 
and  have  been  occasionally,  and  almost  unavoidably,  mistaken  for  it.  It 

1  Archives  g&n.,  Sept.,  1877,  p.  298.  2  Med.-Chir.  Trans.,  li.  1. 


PROGNOSIS.  753 

is  remarkable  that  suppression  of  urine  may  occur  among  them,  as  well 
as  _  vomiting,  purging,  and  collapse.  As  Griesinger  and  others  have 
pointed  out,  the  order  in  which  the  symptoms  occur  is  a  valuable,  and 
generally  an  available,  ground  of  diagnosis.  In  cholera,  diarrhoea  always 
occurs  before  vomiting,  while  in  the  various  irritant  poisonings  mentioned 
vomiting  precedes  diarrhoea.  In  irritant  poisoning  also  there  is  generally 
severe  abdominal  pain — not  so  much  colicky  and  paroxysmal  as  constant 
and  burning ;  the  stools  are  not  so  copious  as  in  cholera,  and  they  do  not 
possess  the  rice-water  aspect,  but  are  rather  dark,  bloody,  and  fetid,  and 
are  voided  with  teuesmus  or  with  heat  in  the  anus ;  and  even  when  the 
urine  is  suppressed  it  is  less  persistently  and  completely  so  than  in 
cholera,  and  attempts  to  void  it  are  attended  with  vesical  tenesmus  and 
strangury.  In  a  doubtful  case  it  is  important  to  ascertain  whether  a 
metallic  or  other  unpleasant  taste  is  perceived  in  the  mouth,  whether 
this  cavity  or  the  throat  bears  marks  of  corrosion,  whether  any  unusual 
article  of  food  has  been  used,  etc.  Moreover,  it  is  of  extreme  importance 
to  learn  whether  Asiatic  cholera  prevails,  not  merely  in  the  immediate 
neighborhood,  but  at  any  place  from  which  diseased  persons  or  infected 
goods  may  have  arrived.  The  instances  should  not  be  forgotten  in  which 
cholera-infected  clothing  from  Europe  has  developed  the  disease  in  the 
valley  of  the  Mississippi.  Nor  should  those  still  more  numerous  cases 
be  overlooked  in  which  travellers  affected  with  choleraic  diarrhoea  have 
disseminated  the  disease  at  great  distances  from  their  starting-point, 
although  unconscious  of  the  nature  of  their  own  ailment,  whose  seed 
they  were  sowing  along  their  route. 

PROGNOSIS. — Like  the  diseases  called  septic,  of  which  the  eruptive 
fevers  may  be  taken  as  examples,  and  also  like  the  eifects  of  irritant  poi- 
sons, the  gravity  of  cholera  must  mainly  depend  upon  the  amount  and  the 
activity  of  the  specific  poison  that  is  received  into  the  system.  It  is  most 
probable  that  the  cholera  poison  is  organic,  and  that  it  has  a  limited  power 
of  reproduction  and  term  of  existence,  a  period  also  of  intense  activity 
and  a  period  of  exhaustion ;  in  a  word,  that  either  by  progressive  dilution 
as  an  inorganic  substance  or  by  organic  senescence  it  finally  ceases  to  exist. 
By  no  other  theory  is  it  possible  to  explain  the  numerous  degrees  of  sever- 
ity which  cholera  exhibits,  from  a  mild  indisposition  to  a  malignant  and 
rapidly  fatal  disease.  On  the  one  hand,  the  patients,  if  they  may  so  be 
called,  are  hardly  prevented  from  attending  to  their  customary  occupa- 
tions. They  may  even  be  able  to  travel  and  carry  the  disease  to  distant 
places,  and  so  appear  to  justify  the  erroneous  and  irrational  doctrine  of 
the  atmospheric  or  spontaneous  origin  of  cholera.  On  the  other  hand, 
the  entire  apparent  duration  of  an  attack  may  not  exceed  two  or  three 
hours,  during  which  all  the  distinctive  symptoms  of  the  disease  may  be 
crowded  together  in  the  most  appalling  forms.  Such  grave  cases  are 
always  most  numerous  at  the  commencement  of  an  epidemic.  These 
statements  are  true  not  only  in  regard  to  individual  cases  in  the  greater 
number  of  epidemics,  but  they  represent  the  distinctive  character  of  par- 
ticular epidemics,  some  of  which  are  as  remarkable  for  their  benignity  as 
others  are  for  their  extreme  malignity.  For  such  contrasts  no  plausible 
reason  can  be  suggested,  unless  it  be  a  difference  either  in  the  essential 
virulence  of  the  morbid  poison  or  in  the  dose  of  it  imbibed.  That  they 
are  due  to  the  activity  rather  than  to  the  quantity  of  the  poison  seems  to 

VOL.  I.— 48 


754  CHOLERA. 

be  proved  by  the  progressive  weakening  iu  the  gravity  of  the  cases ;  for 
if  the  quantity  of  the  poison  remained  the  same  some  malignant  cases 
might  be  expected  to  occur  even  during  the  decline  of  an  epidemic. 

These  considerations  help  to  explain  the  extreme  diversities  of  mortal- 
ity in  different  epidemics.  The  extremes  may  be  stated  at  10  and  90  per 
cenl.,  and  they  would  perhaps  be  still  wider  apart  if  all  the  mild  cases, 
which  are  never  reported — many  of  which,  indeed,  do  not  even  fall  under 
medical  observation — were  included  in  the  reckoning.  The  general  or 
average  mortality  of  cholera  is  about  50  per  cent.  According  to  Allbu, 
the  epidemics  in  Berlin  from  1831  to  1873  gave  a  total  of  28,753  cases 
and  18,916  deaths;  that  is,  a  mortality  of  65.8  per  cent.  (Eichhorst).  It 
should  be  noted  that,  as  in  other  epidemic  diseases,  there  is  no  uniform 
proportion  between  the  extent  and  the  mortality  of  cholera  epidemics. 
Some  of  very  limited  extent  have  been  proportionally  the  most  destruc- 
tive. It  should  also  be  remembered  that  the  disease  is  far  more  fatal 
in  infancy  and  old  age  than  at  any  other  period  of  life,  and  for  a  similar 
reason  it  is  very  dangerous  to  all  who  are  weakened  by  any  cause,  such 
as  an  inherited  morbid  diathesis,  a  chronic  debilitating  disease,  etc.  There 
seems  to  be  a  doubt  whether  its  male  or  female  victims  are  the  more 
numerous.  In  this  connection  it  may  be  suggested  that  while  males  are 
more  likely  to  contract  the  disease  by  drinking  contaminated  water,  etc., 
more  women  are  exposed  to  its  contagion  by  their  intimate  relations  with 
the  sick,  by  their  handling  and  washing  infected  fomites,  by  carrying 
away  the  cholera  discharges,  etc. 

Undoubtedly,  the  class  of  society  to  which  cholera  patients  belong  is 
not  without  influence  on  its  prognosis.  Not  only  is  the  total  mortality 
greater  among  the  laboring  classes,  but  the  individual  belonging  to  those 
classes  has  a  less  chance  of  recovery,  because  he  is  not  apt  to  resort  to 
treatment  on  the  appearance  of  the  premonitory  signs  of  the  disease,  and 
because  the  treatment  he  receives  is  less  intelligently  and  sedulously  pur- 
sued by  his  physicians  and  friends. 

In  regard  to  the  particular  symptoms  which,  are  favorable  or  unfavor- 
able, nothing  need  be  added  to  what  has  already  been  stated  in  detail, 
unless  it  be  that  during  the  height. of  the  attack  the  danger  is  to  be  meas- 
ured by  the  degree  of  prostration  and  of  the  stasis  of  the  blood,  and, 
during  reaction,  by  the  grade  of  the  typhoid  state.  Gradual  reaction,  as 
denoted  by  the  state  of  the  skin  and  the  pulse  and  a  more  natural  aspect 
of  the  stools,  is  generally  indicative  of  improvement. 

Finally,  a  word  of  caution  may  be  given  to  those  who  are  apt  to  attri- 
bute all  the  favorable  changes  in  the  conditions  of  an  epidemic  to  the 
sanitary  or  medicinal  measures  they  have  instituted.  Cholera  epidemics 
are  remarkable  for  the  comparatively  short  period  of  their  duration,  which 
may  be  stated  at  less  than  a  mouth  in  the  same  place.  Doubtless,  judi- 
cious sanitation  and  timely  treatment  save  a  great  many  lives,  but  the 
qualifying  fact,  already  insisted  upon,  must  not  be  overlooked,  that  the 
mortality  occasioned  by  the  disease  in  a  given  place  is  greatest  during  the 
first  period  of  its  prevalence,  and  that  thenceforth  it  gradually  declines. 
Yet  it  is  of  essential  significance  that  the  disea.se  rarely  attacks  a  large 
number  of  persons  simultaneously;  the  epidemic  proper  is  usually  pre- 
ceded by  a  few  scattering  cases  which  are  apt  to  become  foci  of  ignition 
that  presently  unite  to  form  a  widespread  conflagration.  The  recognition 


PREVENTION.  755 

of  these  cases,  their  isolation,  and  the  proper  treatment  of  the  localities 
where  they  occurred  have  frequently  stamped  out  what  might  have  l>een 
the  commencement  of  a  deadly  epidemic. 

PREVENTION. — The  history  of  cholera  demonstrates  conclusively  that 
since  the  disease,  outside  of  India,  never  arises  spontaneously,  it  must  be 
more  or  less  preveutible,  partly  by  excluding  its  seeds  and  partly  by  ren- 
dering the  soil  in  which  they  are  planted  more  or  less  unfit  'for  their 
development ;  in  other  words,  by  quarantines  and  sanitary  cordons  and  by 
various  measures  of  local  sanitation. 

In  regard  to  the  former  there  would  be  comparatively  little  difference 
of  opinion,  at  least  theoretically,  if  both  measures  were  "alike  efficacious. 
But  there  would  seem  to  have  prevailed  a  tendency  in  official  quarters  to 
undervalue  the  efficiency  of  both.  Those  who  made  and  administered 
the  sanitary  laws  relating  to  cholera  seem  to  have  forgotten  the  emphatic 
question,  "What  will  not  a  man  give  for  his  life?"  or  at  least  to  have 
considered  that  whatever  value  some  men  may  set  upon  their  own  lives, 
the  Jives  of  other  men  become  of  no  account  when  balanced  against  the 
needs,  or  even  the  conveniences,  of  commerce.  The  ethics  which  justi- 
fied the  introduction  of  opium  into  China  by  the  English  and  the  Ameri- 
can gift  of  alcohol  to  the  Indian  to  gratify  a  lust  for  lucre  or  for  land  is 
only  paralleled  by  those  contained  in  the  official  protests  against  cholera 
quarantines.  At  the  International  Medical  Congress  held  in  1873  at 
Constantinople,  it  was  almost  unanimously  resolved  that  "the  practice 
of  (laud)  quarantine  as  now  carried  out  ought  not  to  be  maintained, 
because,  on  the  one  hand,  it  does  not  constitute  a  real  protection,  and,  on 
the  other  hand,  it  is  directly  opposed  to  the  interests  of  commmerce  and 
industry."  A  leading  critic,  in  commenting  upon  this,  remarks  that 
if  a  quarantine  were  possible  it  would  give  no  real  security,  because  it 
would  be  evaded,  just  as  customs  laws  are  evaded  by  smuggling.1  A  logi- 
cal deduction  from  this  curious  argument  would  be  that  customs  laws 
should  be  abrogated.  In  1880  was  published  the  report  of  the  German 
Imperial  Commission  on  the  cholera  epidemic  of  1873  in  Germany,  edited 
by  Hirsch,  from  which  we  learn  that  "all  the  German  medical  experts 
agree  in  condemning  the  employment  of  quarantine,  for,  while  largely 
detrimental  to  the  interests,  welfare,  convenience,  and  happiness  of  a  com- 
munity, it  is  quite  inert  and  inefficient  as  a  safeguard  against  the  further 
diffusion  of  cholera." 2  Whether  this  opinion  refers  only  to  land  quaran- 
tine or  not  is  left  in  doubt,  but  the  spirit  of  subordinating  the  lives  of  the 
people  to  the  commercial  interests  of  a  country  is  just  the  same  as,  and 
is  not  less  worthy  of  condemnation  than,  the  spirit  which  has  more  than 
once  blinded  customs  officials  to  the  disease  on  board  of  vessels  from  which 
it  has  afterward  issued  to  destroy  thousands  of  lives. 

It  seems  to  be  overlooked  that  in  national  as  well  as  in  personal  affairs 
"honesty  is  the  best  policy,"  and  that  if,  instead  of  concealment  or  false 
statements  regarding  the  sanitary  state  of  ships,  their  passengers,  and 
cargoes,  and  equally  false  assertions  respecting  the  contagiousness  of  chol- 
era, and  a  contemptuous  neglect  of  well-tried  preventive  measures, — if, 
instead  of  this  delusive  and  disastrous  policy,  all  nations  had  honestly 
carried  out  the  rules  prescribed  by  experience  for  the  exclusion  of  the 'dis- 
ease, and  for  its  management  after  it  had  passed  the  frontiers  of  a  country, 

1  Practitioner,  xii.  226.  2  Ibid.,  xxvi.  159. 


756  CHOLERA. 

there  can  be  little  doubt  that  its  ravages  would  ere  this  have  been  confined 
to  the  region  in  which  it  originated.  As  we  have  seen,  there  is  urged 
against  the  enforcement  of  a  rigid  quarantine  by  land  or  sea  the  singular 
argument  that  it  has  not  always  excluded  the  disease.  A  more  logical 
inference  would  seem  to  be  that  since  it  succeeded,  not  completely,  but  yet 
partially,  its  inefficiency  should  be  charged  to  its  imperfect  execution ;  or, 
even  granting  that  the  absolute  exclusion  of  cholera  is  impracticable  in 
every  instance,  including  cases  of  choleraic  diarrhoea,  contaminated  cloth- 
ing and  merchandise,  does  it  therefore  follow  that  the  transit  of  men  and 
things  should  be  unimpeded?  As  well  might  it  be  maintained  that  because 
one  or  more  houses  cannot  escape  destruction  by  fire,  therefore  no  effort 
should  be  made  to  save  the  remainder  of  a  threatened  city;  as  well  might 
it  be  argued  that  because  some  men  must  be  killed  in  battle,  no  precau- 
tions should  therefore  be  used  to  preserve  the  rest  of  the  army ;  as  well 
abstain  from  all  local  sanitation  intended  to  mitigate  the  ravages  of  the 
disease,  because,  do  what  we  may,  some  victims  it  will  surely  have.  This 
is  taking  counsel  from  despair;  is  a  stupid  fatalism  which  one  might 
imagine  to  have  been  imported  with  the  disease  from  the  East ;  or  it  may 
be  a  sign  of  the  unconscious  blindness  of  Mammon-worshippers,  who, 
neither  fearing  God  nor  regarding  man,  have  as  little  pity  for  the  victims 
of  cholera,  permitted,  if  not  invited,  by  them  to  scourge  the  nations,  as 
devout  Christians  once  felt  for  the  negroes  who  were  bought  or  kidnapped 
in  Africa  to  toil  and  die  under  the  lash  of  the  slave-driver. 

Probably  no  sanitary  cordon  nor  any  quarantine  will  invariably  and 
completely  exclude  cholera,  since  it  is  transmissible  by  living  men  and  by 
water  and  by  fomites  of  various  descriptions,  and,  worst  of  all,  by  men 
who  neither  exhibit  its  characteristic  symptoms  nor  are  conscious  of  the 
poison  which  they  conceal  and  disseminate.  But,  as  has  already  been 
urged,  it  is  no  argument  against  preventive  measures  that  they  are  not 
absolutely  perfect  in  their  efficiency.  If  they  sometimes  succeed  in  arrest- 
ing the  progress  of  cholera,  and  if  they  always,  when  honestly  executed, 
lessen  the  number  of  channels  through  which  the  infection  can  be  con- 
veyed, and  thereby  reduce  to  a  minimum  its  fatal  effects,  they  ought  to  be 
maintained  and  perfected,  and  not  decried  or  abolished.  It  is  difficult  to 
characterize  that  state  of  mind  which  concludes  against  the  use  of  a  salu- 
tary measure  because  its  efficiency  is  not  absolute,  the  more  so  when  it  is 
admitted  that  its  inefficiency  is  not  intrinsic,  but  due  to  negligent,  and 
even  fraudulent,  administration.  The  preponderance  of  official  and  per- 
sonal authority  is  altogether  on  the  side  of  the  necessity  of  a  quarantine, 
not  in  its  literal,  but  in  its  technical,  sense.  The  International  Medical 
Congress  of  1874  declared  as  follows:  "Quarantine  ought  to  be  limited 
to  the  time  requisite  for  the  examination  and  disinfection  of  the  ship,  the 
crew,  and  the  passengers ;  and  if  there  be  no  disease  on  board  the  latter 
should  be  released  immediately  after  disinfection.  But  if  there  be  chol- 
era or  sickness  of  a  doubtful  nature  on  board,  it  will  be  necessary  to  iso- 
late and  disinfect  the  ship  also."  The  same  congress,  however,  wholly 
condemned  land  quarantines,  apparently  upon  the  sole  ground  of  the 
extreme  difficulty  of  rendering  them  efficient — an  argument,  as  before 
remarked,  that  touches  not  the  principle  of  the  measure,  but  only  the 
manner  of  its  execution.  In  this  respect  the  congress  occupied  a  lower 
position  than  its  predecessor  of  1866,  which  held  that  the  futility  of  quar- 


PREVENTION.  757 

antine  in  "arresting  the  march  of  cholera"  arose  "rather  from  the  unin- 
telligent application  of  the  measure  than  from  any  fallacy  in  its  prin- 
ciple." l 

It  would  burden  this  narrative  even  to  enumerate  the  instances  in  which 
a  strict  quarantine  has  protected  places  to  which  cholera  has  been  carried 
by  sea.  In  the  United  States  numerous  examples  might  be  given  of 'sea- 
ports into  which  cholera  was  brought  from  foreign  countries,  and  within 
whose  quarantine  stations  it  was  confined  by  rigid  sanitary  regulations ; 
but  it  is  sufficient  to  cite  the  case  of  New  York,  through  whose  quaran- 
tine at  Staten  Island  nine-tenths  of  all  emigrants  to  America  have  passed. 
Writing  in  1867,  Dr.  Peters  said:  "There  have  been  fourteen  epidemics 
of  cholera  at  Staten  Island,  and  only  four  have  reached  New  York." 
A  large  number  of  illustrations  has  been  collected  by  Dr.  Smart,  Inspec- 
tor-General, R.  N.,2  who  sums  up  the  matter  as  follows:  "Believing  that 
cholera  has  frequently  been  excluded  from  islands  by  quarantine,  and  as 
often  introduced  by  its  non-observance,  I  regard  it  as  a  truly  preventive 
measure ;  but,  recognizing  the  impracticability  of  exacting  it  under  many 
circumstances,  I  would  insist  on  the  most  strict  isolation  of  all  the  first 
cases  or  units  of  disease,  whether  introduced  from  without  or  originating 
from  relationship  to  introduced  cases,  or  persons  or  goods  imported  from 
infected  countries." 

While  experience  demonstrates  the  efficacy,  and  therefore  the  necessity, 
of  quarantine  against  cholera  in  seaports,  it  has  also  shown  that  the  same 
agent  of  prevention  need  not  be  invariably  and  rigidly  applied.  When 
quarantine  meant  literally  a  detention,  and  almost  an  incarceration,  for 
forty  days,  it  often  failed  through  its  very  rigor  at  a  time  when  proper 
methods  of  disinfecting  ships,  cargoes,  crews,  and  passengers  were  either 
unknown  or  inefficiently  applied.  It  is  now  certain  that  quarantine 
may  be  reduced  to  a  fraction  of  its  original  duration,  and  yet  possess  a 
much  greater  degree  of  efficiency,  its  length  depending  upon  the  number 
and  the  sanitary  condition  of  the  crew,  etc.,  the  nature  of  the  cargo,  etc. 
It  is  evident  that  a  ship  carrying  only  cabin  passengers  is  less  open  to 
suspicion  than  one  crowded  with  filthy  emigrants,  although  both  may 
have  sailed  from  the  same  cholera-infected  port.  A  more  liberal  rule 
may  govern  the  one  than  the  other;  and  in  the  second  case  a  rigid  inspec- 
tion and  cleansing  of  luggage  may  be  imperative  which  would  be  super- 
fluous as  well  as  vexatious  in  the  first  case.  The  importance  of  such  a 
treatment  of  emigrants'  effects  has  already  been  illustrated  by  cases  in 
which  they  caused  an  outbreak  of  cholera  after  having  been  carried  from 
a  seaport  into  an  interior  town  many  hundreds  of  miles  distant. 

In  regard  to  the  time  during  which  a  vessel  that  has  had  cholera  on 
board  within  a  week  or  ten  days  should  be  detained  under  sanitary  inspec- 
tion and  treatment,  including  a  thorough  cleansing  of  the  passengers  and 
their  effects,  no  absolute  rule  can  be  laid  down ;  but  it  would  appear  that 
if  no  suspicious  cases  arise  within  a  week,  there  need  be  little  apprehen- 
sion that  any  will  occur. 

The  sanitary  measures  which  should  be  undertaken  wherever  there  is 
reason  to  fear  an  invasion  of  cholera  are,  in  the  first  place,  such  as  are 

1  Practitioner,  xxviii.  393. 

7  Lancet,  April,  1873,  pp.  555,  659;  Times  and  Gazette,  April,  1874,  p.  387.  Compare 
also  Colin,  Brit,  and  For.  Med.-Chir.  Rev.,  July,  1874,  pp.  42-44. 


758  CHOLERA. 

equally  appropriate  in  anticipation  of  any  infectious  and  contagious  epi- 
demic disease,  and  relate  especially  to  the  removal  of  all  sources  of  putrid 
emanations,  whether  in  stagnant  ponds,  in  streets,  markets,  shambles, 
sewers,  privies,  cellars,  or  inhabited  rooms ;  for  these  influences,  although 
they  do  not  cause  cholera,  yet,  by  lowering  the  vitality  of  persons  exposed 
to  them,  create  an  abnormal  susceptibility  to  disease.  Many  instances  in 
Europe  might  be  cited  to  prove  that  whole  cities,  which  in  the  earlier 
epidemics  were  devastated  by  cholera,  were  either  spared  entirely  in  the 
later  ones  or  suifered  in  a  far  less  degree.  The  measures  which  proved 
most  efficient  were  an  improved  water-supply  and  a  better  system  of  sew- 
erage ;  and  this  fact  strongly  corroborates  the  belief  that  contaminated 
water  and  fecal  emanations  are  the  principal  agents  in  propagating  this 
disease.  Cleanliness  is  the  best  disinfectant,  but  during  epidemics  of 
cholera,  as  of  other  diseases,  the  popular  faith  is  very  strong  in  numer- 
ous articles  called  by  that  name.  The  real  value  of  these  preparations 
is  commercial  rather  than  sanitary,  but,  indirectly,  they  are  useful  by 
prompting  those  who  use  them  to  be  more  diligent  in  searching  out  and 
removing  many  sources  of  air-contamination  that  perhaps  invite  and 
intensify  attacks  of  cholera. 

The  disinfectants  in  common  use  comprise  chlorine  gas,  chlorinated 
soda,  chloride  of  zinc,  sulphate  of  iron,  permanganate  of  potassium,  car- 
bolic acid,  and  the  fumes  of  burning  sulphur.  Some  of  them — and  espe- 
cially the  chloride  of  zinc,  sulphate  of  iron,  the  permanganate  of  potas- 
sium, and  carbolic  acid — are  supposed  to  be  capable  of  destroying  the 
infectious  principle  of  the  vomit  and  stools.  -  Another  method  is  to 
receive  such  matters  in  vessels  containing  saw-dust,  which,  after  being 
dried,  is  consumed  by  fire ;  and  still  another  is  to  mix  them  with  dry 
earth  and  bury  them.  If  they  are  thrown  into  water-closets  or  privies, 
they  should  have  added  to  them  a  portion  of  sulphate  of  iron.  What- 
ever has  been  used  by  cholera  patients  should  be  destroyed,  unless  of 
value,  and  in  that  case  it  should  be  thoroughly  purified  by  hot  air  or 
boiling  water  and  long  exposure  to  the  sun.  The  importance  of  having 
large  and  well-ventilated  rooms  for  cholera  patients  is  very  great,  but 
less,  perhaps,  for  the  patients  themselves  than  for  their  medical  attend- 
ants and  nurses.  All  persons  should  be  excluded  from  them  who  are  not 
required  by  the  duties  of  the  sick  chamber,  and  in  case  of  death  funeral 
assemblages  ought  not  to  be  allowed ;  nor,  during  a  cholera  epidemic, 
ought  crowded  assemblies  for  any  purpose  to  be  permitted. 

During  epidemics  of  cholera,  as  of  some  other  diseases,  the  liability  to 
be  attacked  is  greatest  when  the  vital  powers  are  depressed  by  mental  or 
by  physical  causes.  Hence  it  is  desirable  that  one's  courage  and  con- 
fidence should  repose  upon  a  consciousness  of  having  done  whatever  is 
recognized  as  proper  to  ward  off  the  disease — not  by  a  minute,  watchful, 
and  anxious  attention  to  rules  at  every  step,  but  by  such  a  general  care 
of  the  health  as  good  sense  and  experience  enjoin.  Undoubtedly,  other 
things  being  equal,  the  weak,  sickly,  careless,  and  imprudent  are  more 
liable  to  suffer  than  the  strong  and  cautious,  and  therefore  it  is  incumbent 
upon  all  to  maintain  as  high  a  degree  of  health  as  possible,  avoiding  not 
only  all  probable  sources  of  contagion,  direct  or  indirect,  but  excessive 
fatigue,  catching  cold,  depressing  emotions,  sexual  excesses,  etc.  During 
the  first  cholera  epidemics  in  this  country  it  was  considered  so  dangerous 


TREATMENT.  759 

to  eat  fruit  and  fresh  vegetables  that  many  persons  lived  entirely  upon 
meat,  rice,  and  bread.  Such  a  regimen  intensified  cholfraphobia,  and 
was  also  an  unsuitable  midsummer  diet.  There  is  no  reason  to  believe 
that  any  intrinsically  wholesome  food  need  be  prohibited  during  the  prev- 
alence of  cholera. 

The  one  article  of  diet  about  which  the  greatest  and  most  peculiar  care 
should  be  taken  is  water.  It  is  the  first  duty  of  towns  supplied  with 
water  from  a  common  source  to  be  sure  that  it  is,  and  continues  to  be, 
uncontaminated.  Well-water  should  be  used  as  little  as  possible  after 
the  disease  has  made  its  appearance,  and,  as  an  additional  precaution,  no 
water  should  be  drunken  that  has  not  previously  been  boiled.  Where 
ice  can  be  procured  it  may  be  used  to  restore  the  boiled  water  to  an  agree- 
able temperature  for  drinking.  Filtered  water,  provided  that  it  be  prop- 
erly filtered,  may  likewise  be  regarded  as  innocuous. 

TREATMENT. — If  regard  be  had  to  the  various  methods  and  particular 
medicines  which  have  been  used  in  the  treatment  of  cholera,  it  will  appear 
that  in  hardly  any  other  acute  disease  has  a  greater  number  or  variety 
been  employed.  If,  on  the  other  hand,  we  endeavor  to  learn  what  meas- 
ures have  been  really  and  generally  curative  in  cholera,  and  what  are 
they  to  which,  on  the  occurrence  of  an  epidemic  of  the  disease,  we  may 
turn  with  confidence  in  their  power  to  cure,  the  result  of  the  investiga- 
tion is  disheartening,  and  adds  to  the  accumulated  proofs  that  the  power 
of  medical  art  is  exceedingly  restricted.  To  this  conclusion  we  must 
assent  at  whatever  cost  to  a  faith  which  is  strong  in  proportion  to  the 
ignorance  out  of  which  it  grows.  Nor,  if  we  consider  the  matter  ration- 
ally, ought  we  to  be  surprised  or  humiliated  on  account  of  the  compara- 
tive helplessness  of  medicine  in  this  disease,  since,  if  wre  reflect  upon  it, 
the  case  is  by  no  means  peculiar  or  exceptional.  Every  disease  that  may 
become  mortal  occurs  more  or  less  frequently  with  phenomena  which 
place  it  beyond  the  resources  of  therapeutics  as  completely  as  cholera  is 
in  its  most  malignant  forms;  and  yet  no. one  lays  it  to  the  charge  of 
medicine  that  the  various  fevers,  for  example,  are  at  times  utterly  unin- 
fluenced by  the  most  rational  and  judicious  treatment.  Nor  does  any  one 
bring  a  railing  accusation  against  medicine  when  accident  fatally  damages 
a  part  essential  to  life. 

One  accident  of  frequent  occurrence  presents  a  certain  analogy  to 
cholera  in  its  effects,  and  that  is  a  burn  or  scald  involving  a  very  large 
portion  of  the  skin.  In  cases  of  this  sort  experience  assures  us  that 
death  is  almost  inevitable,  and  that  the  duty  of  the  physican  is  to  avoid 
officious  and  meddlesome  treatment,  and  address  himself  to  soothe  the 
patient's  suffering  and  maintain  his  strength,  if  haply  the  powers  of 
nature  may  triumph  over  the  effects  of  the  injury.  This,  too,  is  the 
lesson,  substantially,  which  experience  has  taught  respecting  cholera.  It 
is  certain  that  in  this  disease  the  function  of  the  whole  gastro-intestinal 
mucous  membrane  is  reversed,  and  that  it  is  no  longer  a  secreting  and 
absorbing  organ,  but  one  almost  exclusively  exhaling,  and  that  through 
it  the  liquid  which  is  essential  to  carrying  on  the  functions  is  rapidly  run- 
ning away.  If  the  lesion  on  which  this  symptom  depends  is  complete, 
if  the  gastro-intestinal  mucous  membrane  has  entirely  lost  its  natural 
function,  evidently  it  is  quite  futile  to  address  any  treatment  to  this  organ. 
But  if,  as  probably  happens  in  a  great  majority  of  the  cases,  the  disorgau- 


760  CHOLERA. 

ization  takes  place  gradually,  it  is  evident  that  there  is  more  to  hope  from 
remedies  when  the  disease  is  gradually  developed  than  when  it  reaches  its 
acme  at  a  single  bound  and  leaves  no  time  for  medical  intervention.  The 
one  unmistakable  lesson  that  experience  teaches  respecting  the  treatment 
of  cholera  is,  that  its  success  depends  upon  its  prompt  and  early  appli- 
cation. Almost  as  distinctly  does  observation  teach  that  subsequently  to 
the  first  (or  diarrhceal)  stage  the  comparative  value  of  different  methods 
and  individual  medicines  is  very  uncertain.  And,  finally,  it  would  seem 
that  in  this,  as  in  other  acute  diseases,  intelligent  and  careful  nursing  and 
regimen  are  quite  as  important  as  any  medicinal  treatment  whatever.  How- 
ever a  false  notion  of  the  power  of  medicine  may  blind  us  to  the  fact,  it 
is  none  the  less  a  fact,  that  if  different  methods  of  treatment  are  com- 
pared, that  method  gives  the  best  results  which  is  least  perturbative.  For 
example,  in  England,  on  board  of  a  hospital  ship,  were  85  cases,  of 
which  19  treated  by  quinine  gave  12  deaths,  12  by  calomel  gave  2 
deaths,  12  by  carbolic  acid  gave  3  deaths,  and  37  by  "  Nil "  gave  1  death.1 
Or,  again,  in  1865,  at  the  London  Hospital,  159  patients  were  treated — 48 
with  a  mixture  containing  logwood,  ether,  aromatic  sulphuric  acid,  cam- 
phor, and  capsicum,  of  whom  31  died ;  56  with  sweetened  water,  of 
whom  28  died ;  21  with  castor  oil,  of  whom  14  died  ;  and  20  with  "  saline 
lemonade,"  of  whom  6  died.2  In  the  last  example  the  deaths  during  the 
use  of  the  astringent  mixture  were  twice  as  great  as  under  sugar  and  water, 
and  under  castor  oil  twice  as  great  as  under  "  saline  lemonade." 

We  shall  first  give  an  account  of  the  management  of  cholera  in  general, 
and  then  consider  some  of  the  particular  medicines  used  in  its  treatment. 

The  essential  elements  of  all  plans  of  treatment  for  this  disease,  as  for 
so  many  others,  are  rest  and  abstinence.  Whatever  else  may  be  done, 
nothing  avails  without  them.  This  remark  applies  emphatically  to  the 
premonitory  diarrhoea ;  if  it  is  neglected  it  may  readily  be  converted  into 
the  full-formed  disease.  It  is  therefore  essential,  during  the  prevalence 
of  cholera,  that  whoever  is  attacked  with  diarrhoea  should  at  once  give 
up  all  active  occupation,  and  confine  himself  to  a  recumbent  posture  and 
to  the  use  of  food  of  the  blandest  quality,  such  as  mucilages  and  similar 
preparations,  especially  of  rice,  which,  less  than  any  other  vegetable  food, 
is  liable  to  fermentation  during  digestion.  It  is  prudent  to  drink  no 
water  that  has  not  been  boiled.  If  there  is  reason  to  believe  that  the 
bowels  retain  feces  from  before  the  attack,  it  is  generally  thought  advis- 
able to  administer  a  laxative  dose  of  castor  oil,  to  procure  the  discharge 
of  matters  which  would  act  as  irritants.  Except  for  this  purpose  purga- 
tives are  neither  indicated  nor  expedient.  In  a  large  number  of  cases 
nothing  more  is  necessary  than  the  use  of  means  to  check  the  action  of 
the  bowels,  and  which  should  consist  of  absorbents  or  antacids,  astring- 
ents, and  opiates  as  they  are  contained  in  the  officinal  chalk  mixture,  with 
the  addition  of  tincture  of  kino  or  catechu  and  a  small  proportion  of 
laudanum.  This  medicine  should  be  given  in  dessertspoonful  doses  at 
intervals  of  not  more  than  an  hour. 

If,  instead  of  a  diarrhoea  which  differs  from  ordinary  dyspeptic  diarrhoea 
chiefly  by  its  watery  character,  there  shoidd  also  be  colic  and  profuse  dis- 
charges, it  is  proper  to  add  to  the  medicines  just  suggested  some  which 
are  of  a  decidedly  stimulant  character,  such  as  the  essential  oils  of  caje- 

1  Times  and  Gas.,  Dec.,  1866,  p.  590.  s  London  Hosp.  Reports,  iii.  444. 


TREATMENT.  761 

put,  cloves,  cinnamon,  peppermint,  etc.,  with  which  chloroform,  ether,  or 
Hoffman's  anodyne  may  be  associated.  At  the  same  time  rubefacient 
embrocations  may  be  applied  to  the  abdomen,  which  should  also  be  com- 
pressed slightly  with  a  broad  flannel  bandage.  Instead  of  these  stimu- 
lants, and  perhaps  more  efficiently,  may  be  used  a  simple  epithem  made 
by  dipping  a  large  towel  several  times  folded  in  cold  or  cool  water, 
applying  it  so  as  to  cover  the  whole  abdomen,  and  then  enveloping  it 
and  the  body  with  a  dry  towel.  This  application  is  more  soothing  than 
any  liniment  and  its  action  is  more  constant.  Instead  of  any  of  these 
agents  dry  heat  may  be  used,  obtained  from  bags  of  hot  salt  or  sand,  or 
moist  heat  from  thick  poultices  of  flaxseed  meal  or  Indian  corn  meal  or 
similar  substances  enclosed  in  flannel  bags  and  applied  to  the  abdomen 
while  they  are  as  hot  as  can  be  borne.  It  is  difficult  to  determine  which 
of  these  applications  is  the  most  useful.  But,  on  the  whole,  heat  is  pre- 
ferable to  rubefacients,  and  moist  to  dry  heat.  The  cold-water  dressing  is 
probably  best  suited  to  young  and  robust  persons. 

It  must  be  remembered  that  between  choleraic  diarrhoea  and  cholera  in 
its  complete  form  there  are  several  grades,  in  one  of  the  most  common 
of  which  a  tendency  to  vomit,  and  even  a  certain  amount  of  vomiting, 
accompanies  the  diarrhoea.  Anti-emetic  remedies  are  then  indicated. 
They  may  consist  externally  of  rubefacient  and  aromatic  applications  to 
the  epigastrium  (especially  the  spice  poultice) ;  and  it  is  claimed  that  a 
hypodermic  injection  of  morphia  in  this  part  is  very  efficient.  Inter- 
nally, the  best  remedies  are  ice  swallowed  in  small  pieces  and  small  but 
frequent  draughts  of  iced  carbonated  water  or  iced  champagne.  Where 
these  liquids  cannot  be  procured,  effervescing  powders  used  in  the  same 
way  form  a  very  good  substitute  for  them.  If,  notwithstanding  such 
remedies,  the  diarrhoea  continues  or  if  it  tends  to  increase,  astrin- 
gent and  absorbent  medicines  may  be  substituted  for  them ;  for  exam- 
ple, bismuth  may  be  given  instead  of  chalk,  and  if  this  also  fails  acetate 
of  lead  may  be  prescribed.  The  last  may  be  used  by  the  rectum  as 
well  as  by  the  mouth,  but  with  very  questionable  advantage.  Mean- 
while, especial  care  should  be  taken  to  avoid  giving  so  much  of  any 
opiate  as  will  induce  sopor  or  excite  nausea. 

Whoever  has  had  the  care  of  cholera  patients  has  probably,  at  first, 
felt  sanguine  of  success  in  their  treatment,  even  after  the  characteristic 
discharges  and  the  symptoms  of  collapse  had  set  in;  but  a  little  more 
experience  has  proved  their  hope  to  be  deceptive,  and  revealed  the  reason 
of  it  in  the  absolute  suspension  of  the  sensibility  and  absorbent  function 
of  the  digestive  canal.  Hence  the  dismal  unanimity  of  all  medical 
authors,  who  from  actual  observation  of  cholera  have  declared  that  no 
treatment  avails  to  arrest  the  fully-developed  disease.  And  yet  there  is 
some  encouragement  in  the  fact  that  recoveries  sometimes  occur  from 
even  the  most  desperate  state  of  collapse  and  under  the  most  dissimilar 
methods  of  treatment ;  so  that  the  physician  is  warranted  in  not  yielding 
to  discouragement  and  in  cheering  his  patients  with  hope  even  to  the  end 
of  life.  The  popular  dread  of  this,  and  indeed  of  all  epidemics,  is  sure 
to  be  exaggerated,  and  it  therefore  behooves  the  physician  to  combat  the 
fears  of  his  patients,  and  by  a  cheerful  manner  as  well  as  encouraging 
words  administer  the  cordial  of  hope,  which  often  proves  stronger  than 
phannaceutic  elixirs. 


762  CHOLERA. 

It  may  be  well  to  enumerate,  as  many  do,  the  indications  of  treatment 
in  the  active  stage  of  cholera,  but  they  really  need  no  such  specification. 
It  is  evident  that  they  consist  in  combating  the  symptoms — the  vomiting, 
the  purging,  the  debility,  the  cyajQOsis,  the  cramps,  etc.;  and  the  only 
means  by  which  the  carrying  out  of  such  indications  can  even  be 
attempted  are  neither  more  nor  less  than  would  be  used  to  relieve  the 
same  symptoms  in  other  affections.  If  the  evacuations  could  be  con- 
trolled, evidently  the  cramps  and  the  collapse  would  not  occur ;  but  this 
essential  and  preliminary  step  cannot  be  secured.  The  medicines  intro- 
duced into  the  stomach  or  rectum  are  not  absorbed,  but  are  speedily 
rejected ;  those  which  are  administered  subcutaneously  are  not  taken  up 
by  the  stagnant  blood  as  freely  as  in  other  diseases ;  the  nervous  system 
gives  little  or  no  response  to  the  mechanical  and  physiological  stimulants 
applied  to  the  skin.  Yet,  in  spite  of  these  obstacles,  the  physician  must 
persist  in  the  use  of  rational  methods,  in  the  hope,  however  faint  it  may 
be,  that  he  may  succeed  in  restraining,  and  possibly  in  arresting,  the  fatal 
course  of  the  attack.  For  this  end  he  has  hardly  any  means  at  command 
except  those,  or  such  as  those,  which  were  recommended  in  the  first  stage 
of  the  disease — the  anti-emetic  and  anti-diarrhoeal  medicines,  which  he  is 
only  too  likely  to  see  rejected  as  soon  as  administered.  Yet  he  must  not 
cease  to  allay  the  thirst  by  the  repeated  administration  of  small  quantities  of 
carbonated  and  cold  liquids,  water,  or  champagne  wine,  or  morsels  of  ice 
swallowed  whole.  The  application  of  pounded  ice  in  a  bladder  to  the 
epigastrium  is  a  measure  of  an  analogous  sort,  and  is  sometimes  as 
efficient  as  generally  it  is  soothing.  In  other  cases  the  aromatic  poultice 
seems  to  answer  better.  Of  irritants  little  can  be  said  that  is  favorable, 
but  the  combined  irritant  and  anaesthetic  action  of  chloroform  is  useful, 
and  morphia  should  be  applied  to  the  epigastrium  as  well  as  given  hypo- 
dermicaUy. 

If  the  vomiting  tends  to  become  less  frequent,  acetate  of  lead  may  be 
prescribed,  in  the  hope  that  it  will  exert  some  constringing  action  upon 
the  gastro-intestinal  mucous  membrane.  The  distressing  symptom,  hic- 
cough, cannot  with  any  certainty  be  controlled  by  medicine,  but  perhaps 
the  inhalation  of  chloroform  is  more  efficient  than  any  other  remedy,  as 
it  also  is  for  the  cramps  in  the  limbs.  For  the  latter  purpose  it  is  prefer- 
able to  the  frictions  with  flannel  or  with  stimulating  liniments  which  are 
generally  employed.  If  such  liniments  are  used,  care  should  be  taken 
that  they  do  not  contain  ingredients  that  may  disorganize  the  skin  either 
immediately  or  subsequently.  A  dangerous  compound  of  the  latter  sort 
introduced  during  the  first  epidemic  of  cholera  in  this  country  became 
officinal  under  the  name  of  liniment  of  cantharides. 

The  loss  of  the  water  and  of  the  salts  it  holds  in  solution  in  the  blood 
is.  as  has  now  been  frequently  repeated,  the  chief  pathological  element  of 
the  disease,  next  after  the  conjectural  cause  which  injures  the  mucous  mem- 
brane of  the  stomach  and  bowels.  It  was  rationally  indicated,  and  there- 
fore a  method  was  early  practised,  to  supply  this  loss  by  injecting  into  the 
veins  a  solution  of  sodium  salts.  The  method  was  seductive  as  well  as 
rational,  for  its  primary  effects  were  extremely  encouraging;  it  neverthe- 
less failed,  and  probably  for  the  very  reason  that  suggested  its  use. 
Indeed,  there  is  no  more  reason,  if  there  is  as  much,  to  suppose  that  a 
liquid  artificially  introduced  into  the  blood-vessels  will  be  retained  when 


TREATMENT.  763 

the  natural  liquor  sanguinis  cannot  be  so.      Necessarily,   the   one    will 
escape  where  the  other  has  escaped. 

Certain  systematic  writers  prescribe  a  method  intended,  on  the  one 
hand,  for  reviving  the  animal  heatx  and  on  the  other  for  restoring  the 
movement  of  the  circulation.  It  need  hardly  be  remarked  that  the  two 
form  essentially  but  one  and  the  same  indication.  If  the  circulation  is 
restored  the  animal  heat  will  revive,  but  not  otherwise.  The  same  treat- 
ment leads  to  both  ends,  and  it  consists  partly,  as  already  stated,  in  the 
use  of  stimulants,  such  as  alcohol,  camphor,  coffee,  ether,  etc. ;  but  their 
efficacy  depends  upon  their  being  taken  into  the  blood,  and  with  it  reach- 
ing the  various  nervous  centres  upon  which  the  renewal  of  functional 
activity  depends.  Little,  therefore,  can  be  expected  from  them  at  the 
height  of  the  disease — that  is,  in  the  stage  of  collapse — but  as  soon 
as  any  signs  of  reaction  are  manifested  they  tend  to  promote  it,  and 
hence  may  enable  the  functions  to  revive.  For  this  reason  they  are 
adapted  to  persons  who  are  feeble  by  reason  of  their  tender  or  their 
advanced  age,  or  who  have  previously  suffered  from  ill-health.  But  if 
they  act  at  all,  and  the  more  they  tend  to  act,  they  must  be  employed 
with  circumspection,  lest  they  outrun  the  purpose  of  their  adminis- 
tration and  produce  a  violent  or  excessive  reaction.  Instead  of,  or  in 
conjunction  with,  these  internal  remedies  the  local  stimulants  of  the- 
skin,  already  enumerated,  may  be  used  with  the  due  precautions,  and,  in 
addition,  baths  at  a  temperature  of  105°  F.  of  water  alone  or  with  the 
addition  of  salt  or  mustard ;  but  all  such  remedies  are  of  little  avail  until 
reaction  has  commenced.  Before  that  event  there  is  reason  to  believe  that 
the  cold  bath  is  preferable,  or,  still  better,  frictions  of  the  whole  body  with 
cold  water,  or  even  with  ice,  after  which  the  patient  should  be  wrapped 
in  dry  and  warm  blankets.  Yet  the  efficacy  of  this  powerful  agency  is 
by  no  means  comparable  to  that  which  it  produces  in  the  algid  forms,  of 
malarial  fever.  The  two  conditions,  although  apparently  analogous,  are, 
in  reality,  very  different.  In  the  cold  stage  of  fever  the  mechanism  is 
indeed  paralyzed,  but  none  of  its  mechanical  elements  are  wanting;  but 
in  algid  cholera  there  is  an  actual  subtraction  of  water  from  the  blood, 
that  turns  it  from  a  liquid  capable  of  circulating  through  the  narrowest 
channels  into  one  that  stagnates  even  in  the  largest  vessels.  In  the  one 
case  force  is  wanting  to  circulate  the  blood  ;  in  the  other  there  is  no  nor- 
mal blood  to  circulate. 

The  treatment  of  the  stage  of  reaction  when  it  does  not  exceed  a  mod- 
erate degree,  consists  simply  in  strictly  enforcing  the  rules  for  the  patient's 
repose;  that  is  to  say,  in  intelligent'  nursing.  Mental  excitement  must  be 
forbidden,  and  neither  medicine  nor  food  allowed  that  is  likely  to  interfere 
with  the  gradual  and  steady  progress  of  convalescence.  Of  all  articles 
of  food,  cool  water  is  not  only  the  most  urgently  desired,  but  is  the  most 
imperatively  necessary  for  replenishing  the  emptied  blood-vessels  and 
restoring  the  normal  functions.  But  unless  great  caution  is  observed  it 
will  be  taken  too  freely  and  provoke  a  renewal  of  the  discharges.  If  any 
food  besides  water  is  allowed,  it  should  be  of  the  simplest  sort — of  whey 
first,  and  then  of  milk  in  small  quantities  at  a  time,  with  lime-water  if  it 
provokes  nausea  or  retching.  Afterward  thin  broths  may  be  given,  also 
in  great  moderation,  and  by  degrees  farinacea  in  milk  and  in  animal 
broths.  Only  when  the  strength  is  much  improved  should  even  the  mosi 


764  CHOLERA. 

digestible  meats  be  permitted.  In  proportion  as  convalescence  is  marked 
or  interrupted  by  symptoms  of  undue  reaction  is  it  necessary  to  prolong  and 
render  stringent  this  regimen;  and  if  those  symptoms  unfortunately  arise 
which  oftener,  perhaps,  dej)end  upon  an  over-zealous  stimulant  treatment 
than  upon  the  natural  reaction  of  the  system,  they  must  be  combated  by 
measures  which  will  lessen  the  local  congestions,  especially  of  the  brain 
and  the  lungs,  and  also  by  such  as  will  tend  to  prevent  the  system  from 
falling  into  a  typhoid  state.  For  the  former  dry  cups  applied  to  the  back 
of  the  neck,  and  cold  lotions  and  affusions  upon  the  scalp,  are  to  be  recom- 
mended, and  for  the  latter  dry  cups  and  warm  stimulating  poultices  upon 
the  chest  near  the  affected  region.  It  is  probable  that  the  general  warm 
bath,  with -cold  affusion  upon  the  head  at  the  same  time,  would  prove  as 
efficient  as  it  does  in  analogous  states  of  typhoid  affections.  If  the  uri- 
nary secretion  is  suspended  or  remains  scanty,  there  is  not  usually  an 
urgent  need  of  using  means  for  its  restoration ;  for  that  will  generally 
occur  when  the  blood-vessels  become  replenished.  It  should,  however, 
be  mentioned  that,  according  to  Macnarnara,  if  the  patient  does  not  pass 
any  urine  within  thirty-six  hours  of  reaction  coming  on,  ten  minims  of 
the  tincture  of  cantharides  in  an  ounce  of  water  should  be  given  every 
half  hour  until  six  doses  have  been  taken,  and  the  patient  encouraged  to 
drink  freely  of  water.  If  this  treatment  does  not  cause  urine  to  pass,  we 
must,  after  the  sixth  dose,  discontinue  the  medicine  for  twelve  hours,  and 
then  repeat  it  in  precisely  the  same  way.  The  dose  here  referred  to  is  of 
the  British  preparation,  and  if  the  use  of  it  were  not  recommended  by  so 
competent  an  authority  its  propriety  might  very  properly  be  challenged. 

After  the  cholera  patient  has  become  convalescent  his  restoration  is  very 
apt  to  be  retarded  by  dyspeptic  disorders,  for  which,  perhaps,  the  best 
remedy  is  a  judicious  use  of  condiments  with  the  food  and  of  bitter 
tonics,  especially  quinine,  Colombo,  quassia,  etc.,  before  meals.  If  there 
is  constipation,  it  should  be  corrected  by  the  cautious  use  of  fruits,  and, 
if  these  prove  insufficient,  of  mild  saline  laxatives  or  small  doses  of  castor 
oil  or  rhubarb.  On  the  other  hand,  if  there  is  a  tendency  to  diarrhoea, 
it  should  be  met  by  the  use  of  a  mild  laxative,  such  as  castor  oil,  magne- 
sia, or  rhubarb,  followed  by  chalk  or  bismuth,  and  the  use  for  a  time  of 
simpler  food  and  in  less  than  the  usual  quantities. 

Having  thus  furnished  a  sketch  of  the  plan  of  treatment  of  cholera 
which  we  regard  as  dictated  by  experience,  it  may  be  not  without  some 
interest  to  consider  certain  elements  of  the  method  a  little  more  fully, 
and  criticise,  in  passing,  some  other  remedies  which  have  from  time  to 
time  been  proposed.  The  first  of  these  is  venesection.  There  was  a 
time  when  certain  physicians,  carried  away  by  conceptions  of  the  disease 
evolved  from  their  inner  consciousness,  maintained  that  it  consisted  essen- 
tially of  a  spasm  of  the  blood-vessels,  and  that  the  natural  and  legitimate 
cure  for  it  was  to  be  found  in  bleeding.  No  theory  is  so  gratuitous  or 
absurd  but  cases  may  be  found  which  appear  to  justify  it,  and  in  this 
instance  also  examples  were  not  wanting  to  illustrate  at  once  the  truth  of 
the  theory  and  its  successful  application.  Longer  experience,  however, 
and  a  more  correct  conception  of  the  disease,  have  long  since  condemned 
this  method,  which  was  almost  as  dangerous  as  it  was  irrational.  If  any 
additional  argument  against  it  were  required,  it  would  be  found  in  the 
condition  of  the  lungs  after  death.  These  organs,  we  have  seen,  are  not 


TREATMENT.  765 

only  not  engorged,  but  they  are  empty  of  blood,  and  death  is  due  not  to 
asphyxia,  but  to  apno3a,  when  it  takes  place  in  collapse. 

If  ever  there  existed  any  reason  for  the  administration  of  an  emetic — 
and  ipecacuanha  has  generally  been  used  at  the  commencement  of  an 
attack  of  cholera — it  must  be  looked  for,  not  in  any  clinical  experience 
of  its  virtues,  but  simply  in  the  deplorable  routine  that  required  the 
administration  of  an  emetic  at  the  commencement  of  nearly  all  acute 
diseases,  so  that,  whatever  else  was  prescribed,  the  lancet  and  an  emetic 
seldom  failed  to  be  so.  In  this  case  also  the  proofs  of  the  successful 
administration  of  ipecacuanha  were  not  wanting,  and  one  might  be 
tempted  to  suppose,  in  view  of  the  alleged  facts  in  its  favor,  that  it  was 
useful  by  causing  an  evacuation  of  the  material  cause  of  the  disease. 
Physicians  were  even  to  be  found,  of  high  station  and  character,  who 
contended  that  cholera  is  a  species  of  fever,  and  to  be  treated  by  an 
emeto-cathartic  composed  of  tartar  emetic  and  epsom  salts.  If  the  treat- 
ment had  been  efficient,  the  absurdity  of  the  reasons  for  it  might  have 
been  overlooked ;  but  the  one  was  as  disastrous  as  the  other  was  false. 
But,  as  usual,  the  facts  had  been  misstated  or  misinterpreted,  and  emetics 
ceased  to  form  a  part  of  the  systematic  treatment  of  cholera.  The  idea 
which  possessed  those  who  advocated  the  use  of  evacuants  was  that 
there  was  either  a  poison  to  be  eliminated  from  the  blood  or  one  to  be 
expelled  from  the  bowels.  Apparently,  the  method  was  not  efficacious, 
for  the  latest  phase  of  it,  the  use  of  castor  oil  in  acute  stage  of  cholera, 
was  of  short  duration. 

When  cholera  first  appeared  in  Europe  the  tendency  naturally  arose  to 
follow  in  its  treatment  the  example  of  the  British  practitioners  in  India. 
It  then  appeared  that  one  of  the  most  eminent  among  them,  Annesley, 
gave  a  scruple  of  calomel,  with  two  grains  of  opium,  at  the  commence- 
ment of  the  attack,  and  repeated  the  dose  in  six  or  eight  hours,  and  again 
upon  the  following  day.  In  the  decline  of  the  disease  he  ordered  scruple 
doses  of  calomel  for  the  removal  of  a  "  cream-colored,  thick,  viscid,  and 
tenacious  matter  exactly  like  old  cream  cheese,  which  glues  the  gut 
together  and  obstructs  its  passage."  Three,  four,  and  even  five,  scruples 
of  calomel  were  usually  taken  before  this  effect  was  produced.  "When  it 
is  added  that  this  practitioner  held  depletion  to  be  the  capital  element  of 
the  treatment,  and  that  he  was  equally  lavish  of  his  patient's  blood  and 
of  his  own  drugs,  we  can  only  wonder  that  any  subjects  of  his  heroic 
method  survived.  It  is  now  conceded  by  all  enlightened  physicians  that 
mercurials  in  large  or  in  ordinary  doses  are  worse  than  worthless  in  epi- 
demic cholera.  In  1832,  Dr.  Ayre  of  Hull,  Eng.,  proposed  another 
method  of  using  calomel,  to  which  he  adhered  in  treating  this  disease. 
It  consisted  in  the  administration  of  very  small  doses  of  calomel  at  short 
intervals,  and  with  each  of  the  first  doses  a  few  drops  of  laudanum. 
Such  a  method,  if  not  carried  too  far,  certainly  has  the  merit  of  sparing 
the  patient  a  great  deal  of  the  perturbative  treatment  against  which  we 
have,  in  the  preceding  pages,  protested.  But  that  was  not  at  all  the 
notion  of  its  proposer.  He  claimed  for  it  positive  and  active  virtues. 
Ho  stated,  as  the  fundamental  ground  of  his  plan,  that  "the  primary  and 
leading  object  of  the  treatment  must  be  to  restore  the  secretion  of  the 
liver."  He  did  not  in  the  least  doubt  that  he  was  able  to  do  this  by  the 
administration  of  mercury — not,  indeed,  by  a  direct  action  upon  the  liver 


766  CHOLERA. 

itself,  but  indirectly  and  sympathetically  through  the  stomach,  and  by 
the  healthy  and  specific  stimulus  imparted  to  it,  by  which  the  due  secre- 
tion of  the  bile  is  promoted.  It  is,  indeed,  difficult  to  conceive  of  any 
-tinmlus  that  calomel  could  impart  to  the  stomach  that  would  not  be 
equally  given  by  any  other  non-irritant  and  insoluble  powder — subni- 
trate  of  bismuth,  for  example.  Indeed,  Ayre  himself  relates  the  case 
of  a  man  who  in  an  attack  of  cholera  took  during  three  days  no  less  than 
five  hundred  and  eighty  grains  of  calomel,  and  recovered  without  any 
soreness  of  the  mouth.  But  the  plan  which  he  finally  elaborated  was 
different.  It  was  to  give  small  doses  of  calomel  repeatedly — in  the  pre- 
monitory stage  one  grain  every  half  hour  or  hour  for  six  or  eight  suc- 
cessive times,  or,  if  this  failed,  every  five  or  ten  minutes — and  in  the  stage 
of  collapse  one  grain  and  a  half  every  five  minutes.  In  a  few  cases  of 
extreme  severity  two  grains  of  calomel  were  given  every  five  minutes  for 
an  hour  or  two,  and  then  the  ordinary  dose  of  one  grain  was  resumed. 
But  this  was  not  all :  with  every  dose  of  calomel  was  associated  one,  two, 
or  three  drops  of  laudanum,  so  that  if  these  doses  were  repeated  fre- 
quently the  patient  received  a  very  efficient  amount  of  the  narcotic  dur- 
ing the  attack.  Indeed,  Ayre  attributed  to  it  the  virtue  of  sustaining 
the  vital  powers  under  the  depressing  influence  of  the  disease,  and  of 
removing  or  abating  the  cramps,  as  well  as  of  detaining  the  calomel  in 
the  stomach.1  From  the  preceding  account  it  follows  that  the  treatment 
of  cholera  by  small  doses  of  calomel  with  laudanum  is  founded  on  an 
erroneous  assumption  of  the  mode  of  action  of  calomel,  and  that  what- 
ever efficacy  the  plan  of  treatment  may  possess  may  with  more  justice  be 
attributed  to  the  opium,  whose  effects  we  know,  than  to  the  calomel, 
whose  action,  so  far  as  it  is  known  at  all,  has  no  conceivable  relation  to 
the  disease  for  which  it  was  given.  However  this  may  be,  if  the  results 
of  Ayre's  treatment  are  compared  with  those  of  other  plans,  it  exhibits 
very  little  if  any  superiority.  In  the  report  of  the  cholera  committee  of 
the  College  of  Physicians,  London,  made  in  1853,  we  find  the  statement 
that  in  725  unequivocal  cases  treated  on  Ayre's  plan  the  deaths  were  365, 
or  about  50  per  cent.,  and  also  the  following  commentary  :  "  In  general, 
no  appreciable  effects  followed  the  administration  of  calomel,  even  after  a 
large  amount  in  small  and  frequently-repeated  doses  had  been  adminis- 
tered. For  the  most  part,  it  was  quickly  evacuated  by  vomiting  or  purg- 
ing, or,  when  retained  for  a  longer  period,  was  passed  from  the  bowels 
unchanged.  Salivation  but  very  rarely  occurred,  and  then  only  in  the 
milder  cases.  We  conclude  that  calomel  was  inert  when  administered  in 
collapse,  and  that  the  cases  of  recovery  following  its  employment  at  this 
period  were  due  to  the  natural  course  of  the  disease,  as  they  did  not  sur- 
pass the  ordinary  average  obtained  when  the  treatment  consisted  in  the 
use  of  cold  water  only." 2  It  is  of  interest  to  ceiupare  the  mortality  of 
50  per  cent,  above  stated  to  have  occurred  under  this  sort  of  calomel 
treatment  with  the  mortality  noted  at  the  London  Hospital  under  various 
kinds  of  treatment,  including  the  administration  of  calomel  in  doses 
varying  "  from  five  to  ten  and  twenty  grains  every  quarter,  half,  one 
hour,  two,  four,  etc."  Out  of  509  cases,  281  were  fatal,  or  54.9  per  cent.2 
Every  disease  in  which  exhaustion  and  coldness  occur  is  sure  to  be 

1  A  Report  on  the  Treatment  of  the  Malignant  Cholera,  Lond.,  1833. 

*  Dr.  Gull's  Report,  p.  177.  3  Lond.  Hosp.  Report*,  iii.  43?,  -±41. 


TREATMENT.  767 

treated  more  or  less  actively  with  alcohol,  but  iu  the  collapse  of  cholera, 
as  in  tlue  cold  stage  of  fevers,  it  is  generally  useless,  and  sometimes  hurt- 
ful. We  believe  that  the  following  protest  of  Macnamara  is  sustained  by 
almost  universal  experience :  "  I  would  here  enter  an  earnest  protest 
against  the  use  of  brandy  or  any  alcoholic  stimulant  in  this  [the  second] 
stage  of  cholera.  I  believe  these,  both  theoretically  and  practically,  to 
be  the  cause  of  unmitigated  evil.  I  simply,  therefore,  mention  brandy, 
champagne,  and  the  like  in  order  to  condemn  their  use  most  emphatically 
in  cholera ;  according  to  my  ideas  and  experience,  it  is  almost  impossible 
to  hit  on  a  more  detrimental  plan  of  treatment  than  that  usually  known 
as  '  the  stimulant '  in  this  form  of  disease."  l  It  is  true  that  apparent 
dissidents  from  this  judgment  may  be  found,  like  Play  fair,  a  deputy 
inspector  of  hospitals  in  Bengal,  who  even  circulated  printed  directions 
for  the  treatment  of  the  first  stage  of  the  disease  by  means  of  brandy 
or  strong  rum,  cayenne  pepper,  and  laudanum,  and  had  entire  confi- 
dence in  the  efficacy  of  the  method.2  Dr.  Macpherson,  inspector-general 
of  hospitals,  also,  after  comparing  the  results  of  a  stimulant  treatment  with 
those  of  other  methods,  reaches  the  conclusion  that  the  mortality-rate  of  chol- 
era is  affected  neither  by  the  moderate  nor  by  the  excessive  use  of  alcohol.3 
Upon  no  other  point  in  the  treatment  of  cholera  is  the  agreement  of 
physicians  more  complete  than  upon  the  use  of  opiates  in  the  early  stage 
of  the  disease.  The  premonitory  diarrhoea  has  always  been  treated  by 
opiates  alone  or  associated  with  astringents.  Probably  the  best  rule  is  to 
give  from  twenty  to  thirty  drops  of  laudanum,  or  an  equivalent  dose  of 
some  other  liquid  preparation  of  opium,  in  a  little  brandy  and  water,  and 
repeat  the  dose  as  often  as  a  stool  is  voided.  Opiates  have  also  been 
generally  employed  to  mitigate  the  symptoms  of  the  fully-developed  disease. 
But,  like  all  other  medicines  introduced  into  the  stomach  or  rectum,  they 
are  apt  to  be  rejected,  and  even  if  they  are  not,  their  absorption  is  very 
doubtful,  so  that  at  the  height  of  the  attack  they  must  be  considered  as 
nearly  if  not  quite  useless.  When  the  vomiting  and  purging  begin  to 
subside  and  reaction  is  about  to  commence,  small  and  repeated  doses  of 
opiates  undoubtedly  tend  to  lessen  the  evacuations;  but  great  caution 
must  be  observed  not  to  exceed  the  due  degree  of  stimulation,  lest  a 
dangerous  state  of  narcotism  or  collapse  be  induced.  It  might  be  sup- 
posed that  the  hypodermic  use  of  morphia  would  be  less  open  to  objec- 
tion than  its- administration  by  the  stomach;  but  it  is  to  be  remembered 
that  the  suspension  of  gastric  absorption  is  only  a  part  of  the  similar  con- 
dition affecting  the  whole  circulatory  system,  and  that  the  stagnation  of 
the  blood  in  the  systemic  veins  prevents  the  absorption  of  medicines 
administered  subcutaneously  perhaps  as  completely  as  the  state  of  the 
gastric  blood-vessels  interferes  with  their  absorption  from  the  stomach 
itself.  In  point  of  fact,  the  utility  of  opiates  at  any  stage  of  cholera 
after  the  first  is  not  easily  determined,  for  nearly  always  they  are  asso- 
ciated with  other  medicines,  and  especially  with  astringents.  In  this  dis- 
ease, as  in  others  that  involve  life,  we  are  seldom  at  liberty  to  test  the 
powers  of  individual  medicines,  but  are  bound  to  endeavor  to  save  life  by 
associating  those  which  seem  to  be  required  for  the  purpose.  Opiates,  then, 
are  nearly  always  given  in  conjunction  with  astringents  or  stimulants  dur- 

1  Op.  cit.,  p.  456.  *  Edinburgh  Med.  Jour.,  xix.  471. 

8  Med.  Times  and  Qaz.,  Jan.,  1870,  p.  62. 


768  CHOLERA. 

ing  the  first  (or  diarrhceal)  stage  of  the  attack,  but  after  vomiting  is  added 
to  diarrhoea  and  a  tendency  to  collapse  is  manifested  they  are  at  least  useless. 

The  patient,  it  has  already  been  said,  should  be  disturbed  as  little  as 
possible,  and  hence,  if  he  becomes  restless,  and  especially  if  he  is  ren- 
dered so  by  pain,  he  should  be  tranquilized  by  means  of  anaesthetics. 
Chloroform  has  generally  been  employed,  and  is  best  administered  on  the 
first  accession  of  cramps.  Much  pain,  with  muscular  fatigue  and  depres- 
sion, is  thus  saved,  and  the  inhalation  of  the  medicine  may  be  repeated  as 
often  as  the  pain  threatens  to  return.  No  doubt  other  anaesthetics,  and 
especially  ether,  would  answer  the  same  purpose. 

Camphor  has  been  claimed  to  be  a  valuable  medicine  in  cholera,  but 
there  is  no  clinical  evidence  that  it  is  so.  Indeed,  the  only  series  of  cases 
in  which  it  was  mainly  depended  upon  gave  a  large  mortality. 

Acids  have  been  employed  in  cholera,  but  chiefly  on  theoretical  grounds, 
"  in  the  hope  of  destroying  the  specific  cholera  process  going  on  in  the 
intestinal  canal "  (Macnamara).  It  is  hardly  necessary  to  discuss  so  vague 
a  reason.  What  specific  process  is  going  on  ?  What  relation  to  it  has  the 
administration  of  acids?  And,  after  all,  only  the  hope  is  held  out  of 
destroying  the  hypothetical  morbid  process.  The  reaction  of  normal 
stools  is  usually  acid,  but  sometimes  it  is  neutral  or  even  alkaline.  In 
other  acute  bowel  complaints  with  profuse  diarrhoea  they  are  acid,  as  in 
cholera  infantum,  but  in  epidemic  cholera  they  are  alkaline,  because  they 
consist  chiefly  of  the  water  of  the  blood.  It  is  far  from  proven  that 
mineral  acids  can  be  useful  -merely  by  reversing  the  reaction  of  the  stools. 
Far  more  probable  is  it  that,  in  so  far  as  they  are  of  use,  it  is  because  they 
act  as  astringents  upon  the  digestive  mucous  membrane.  This  may  be 
inferred  from  the  fact  that,  according  to  the  advocates  of  these  medicines, 
it  is  always  difficult,  and  is  often  impossible,  to  acidify  the  stools  in 
cholera.  Moreover,  it  must  be  remembered  that,  like  other  medicines, 
the  greater  part  of  them  are  rejected  by  vomiting.  If,  then,  mineral 
acids  tend  to  lessen  the  diarrhoea  of  cholera,  they  act  by  their  astringency 
and  not  by  their  acidity.  Diluted  or  aromatic  sulphuric  acid  may  be 
given  in  the  dose  of  from  two  to  thirty  minims,  at  intervals  of  an  hour, 
in  acid  water  or  carbonated  water,  or  diluted  nitric  acid,  in^doses  of  from 
twenty  to  fifty  minims,  at  the  same  or  somewhat  longer  intervals. 

Intravenous  injections  were  used  in  England  during  the  first  epidemic 
of  cholera  in  1832—33,  but  their  results  were  regarded  as  unfavorable ;  sub- 
sequently, in  1849,  they  were  tried  with  somewhat  better  success,  and  in 
1867  the  effects  were  still  more  encouraging.  The  liquid  employed  on  the 
last-mentioned  trial  consisted  of  chloride  of  sodium  60  gr.,  chloride  of 
potassium  6  gr.,  phosphate  of  sodium  3  gr.,  carbonate  of  sodium  20  gr., 
alcohol  2  drachms,  and  distilled  water  20  ounces.  The  alcohol  was  added 
only  when  the  liquid  was  about  to  be  used,  and  the  temperature  of  the 
latter  was  not  allowed  to  exceed  110°  F.  or  fall  below  100°  F.  The 
liquid  was  contained  in  a  zinc  vessel  holding  about  eighty  ounces,  with  a 
lamp  underneath,  a  thermometer  hanging  within,  and  a  tap  near  the  bot- 
tom, from  which  proceeded  an  india-rubber  tube  four  feet  long,  with  a 
silver  nozzle  at  its  end.  The  fluid  was  allowed  to  enter  the  vein  by  the 
force  of  gravity.  If  difficulty  was  experienced  in  introducing  the  nozzle, 
the  vein  was  freely  exposed,  supported  on  a  probe,  and  incised  longitudi- 
nally. It  was  found  that  the  success  of  the  operation  depended  greatly 


TREATMENT.  769 

upon  having  an  ample  supply  of  the  solution  prepared,  so  as  to  repeat 
the  injection  as  often  as  might  be  found  necessary.  Mr.  Little,  who  prac- 
tised this  method  in  numerous  cases,  stated  as  follows  :  "  When  a  patient 
has  been  long  pulseless  clots  form  in  the  heart,  and,  as  I  have  seen, 
extend  into  the  larger  veins.  In  one  case  the  fluid  would  not  flow  in, 
and  only  distended  the  veins  of  the  arm  injected.  After  death  clots  were 
found  extending  from  the  heart  into  the  axillary  vein.1  Five  out  of 
twenty  apparently  hopeless  cases  recovered  under  this  treatment.  The 
first  effect  of  the  injection  was  to  revive  the  pulse,  which  had  ceased  to  be 
felt;  the  voice  also  was  restored,  the  color  and  expression  improved,  the 
cramps  were  relieved,  the  temperature  rose,  and  the  patients  became  con- 
vinced that  their  recovery  was  assured.  A  profuse  perspiration  and  a 
severe  rigor  accompanied  these  symptoms.  The  rigor  was  evidently  a  ner- 
vous phenomenon,  and  not  a  chill,  for  it  occurred  when  the  temperature  was 
rising.  Other  cases  might  be  cited  which  unquestionably  owed  their 
recovery  to  this  mode  of  treatment.  It  is  true,  however,  that  much  more 
frequently  it  failed  of  success ;  and  probably  not  only  because  the  injec- 
tion could  not  reach  the  heart,  but  because,  having  permeated  the  blood- 
vessels of  the  whole  body,  it  escaped,  as  the  serum  of  the  blood  had  done, 
from  the  damaged  intestine.  Nevertheless,  it  would  seem  that  an  expedient 
which  in  a  certain  proportion  of  cases  has  been  quite  successful  might  yet  be 
rendered  more  certain  in  its  results  if  the  operative  procedure  were  perfected. 

Cramps  in  the  limbs  may  be  lessened  by  active  friction  and  sham- 
pooing, but  there  is  no  clinical  reason  for  believing  that  these  measures 
tend  to  restore  the  circulation.  Equally  ineffectual  are  other  means  used 
for  communicating  heat  to  the  algid  body  and  thereby  reviving  its  func- 
tions. It  is  true  that  some  physicians  found  that  warm  baths,  at  from 
90°  to  104°  F.,  gave  relief  to  the  cramps  and  restored  the  failing  pulse. 
In  most  cases  the  calming  influence  of  the  bath  was  noted,  but  it  does  not 
seem  to  have  been  curative  or  to  have  diminished  the  mortality-rate.2  It 
should  not  be  forgotten  that  the  patient  has  no  perception  of  his  coldness. 
In  all  analogous  conditions,  as  has  already  been  remarked,  such  as  frost- 
bite and  the  cold  stage  of  periodical  fevers,  cold,  and  not  heat,  promotes 
reaction.  Still  more  injurious,  if  possible,  than  hot  applications  are  irri- 
tants and  stimulants  after  the  stage  of  collapse  has  set  in.  Not  only  are 
they  absolutely  futile  for  restoring  the  animal  temperature,  but  they  are 
liable,  unless  very  cautiously  used,  to  produce  intractable  sores  upon  the 
skin  if  recovery  ensues.  It  should  also  be  remembered  that  the  cholera 
patient's  exhaustion  is  exceptionally  great,  and  is  apt  to  be  increased  by 
the  officiousness  implied  in  the  use  of  many  stimulating  agents. 

As  early  as  1832  a  marked  advantage  was  ascribed  to  the  use  of  cold 
affusions  in  cholera.3  One  of  the  physicians  of  the  cholera  hospital  of 
Berlin  said:  "In  these  living  corpses  which  are  struck  with  asphyxia, 
lying  cold  and  powerless,  external  and  internal  medicines  cease  to  stimu- 
late; no  steam  apparatus,  no  warm  bathing,  no  friction,  no  irritant,  avails." 
The  condition  is  comparable  to  that  in  approaching  death  by  cold,  in  which 
friction  with  snow  is  well  known  to  be  the  proper  remedy.  Cold  affusions 
were  employed  in  the  second  stage  of  the  disease.  If  the  pulse  revived, 
the  affusions  were  continued  in  a  tepid  bath,  after  which  the  patient  was 

1  London  Hosp.  Reports,  iii.  470.         2  Tbid.,  iii.  445 ;  St.  Bartholomews  Reports,  iii.  190. 
"Ainsworth,  Pestilential  Cholera,  1832. 
VOL.  I.— -19 


770  CHOLERA. 

put  to  bed  and  gently  rubbed  with  cold  flannels.  Internally,  ice-water 
was  freely  administered.  Labadie-Lagrave1  refers  to  forty  cases  treated 
in  this  manner,  with  only  seven  deaths.  Yet  the  cold-water  treatment 
does  not  appear  to  have  commended  itself  to  physicians  generally.  Evi- 
dently it  does  not  meet  the  prime  indication,  which  is  to  restore  the 
wasted  waters  of  the  blood  and  retain  it  in  the  blood-vessels. 

Cold  water  ought  to  be  given  as  freely  as  possible  to  assuage  the  thirst 
that  exists  in  every  stage  of  cholera,  and  especially  in  collapse.  Nor 
should  it  be  withheld  because  it  will  presently  be  rejected,  for  not  only 
does  it  produce  a  grateful  sensation  in  the  mouth  and  throat,  but  it  ren- 
ders the  act  of  vomiting  easier.  Yet,  to  some  extent  at  least,  the  thirst  may 
be  allayed  by  rinsing  the  mouth  and  throat  with  cold  water.  Iced  water 
is  preferable  to  ice  used  for  the  same  purpose,  for  the  latter,  by  its  rela- 
tively intense  coldness,  irritates  and  dries  the  mouth.  Fragments  of  ice 
swallowed  whole  allay  the  burning  heat  in  the  stomach. 

On  the  hypothesis  that  the  cholera  poison  consists  of  organic  germs 
various  antiseptics  have  been  employed  in  this  disease.  Permanganate  of 
potassium  was  fortunately  excluded  from  the  list,  on  account  of  its  corro- 
sive action,  but,  unfortunately,  carbolic  acid  was  conceived  to  possess  vir- 
tues that  rendered  it  an  eminently  suitable  remedy,  and  creasote,  which 
resembles  it  very  closely,  was  presumed  to  possess  corresponding  virtues. 
Then  sulphurous  acid  and  the  sulphites,  which  for  a  time  were  warranted 
to  destroy  every  species  of  germ,  were  confidently  appealed  to  to  stay  the 
progress  of  cholera,  and  it  was  at  one  time  even  a  matter  of  dispute  whether 
sulphite  of  sodium  or  sulphite  of  potassium  was  the  more  efficacious.  In  truth, 
all  of  these  medicines  were  useless,  even  when  they  were  not  mischievous. 

Cholera  has  never  prevailed  in  any  country  without  giving  rise  to  extra- 
ordinary theoretical  and  practical  divagations.  One  physician  in  the 
earliest  American  epidemic  gravely  proposed,  as  the  best  mode  of  check- 
ing the  diarrhrea,  to  plug  the  anus  with  a  soft  velvet  cork.  Another,  in 
England,  suggested  that  the  "blood  may  be  kept  circulating  by  putting 
the  patient  on  his  back  on  a  board  and  keeping  up  a  rocking,  see-saw,  to- 
and-fro  movement  from  eighty  to  one  hundred  times  a  minute."  Another 
had  the  revelation  that  the  disease  is  essentially  a  "  paralysis  of  the  sym- 
pathetic nerve  and  want  of  performance  of  the  organic  functions,  with 
deficient  vitality  of  the  mucous  membranes,"  and  that  its  proper  remedies 
are  "  bleeding,  turpentine,  and  cool  drinks,  without  heat  and  stimulants ; " 
and  to  this  remarkable  doctrine  a  well-known  physician  gives  his  adhe- 
sion, thus:  "The  cause,  I  firmly  believe,  is  an  union  of  the  poison  with 
the  sympathetic."2  Still  another  discovered  that  the  disease  is  a  spinal 
disorder,  and  is  to  be  treated  by  the  application  of  ice-bags  to  the  spine. 
Were  not  the  evidence  so  palpable,  it  would  hardly  be  believed  that  such 
irrational  ideas  should  have  been  published  concerning  a  disease  which  had 
then  been  under  observation  by  the  whole  medical  profession  in  Europe  and 
America  for  more  than  thirty  years,  and  in  Asia  for  a  much  longer  period. 

The  most  important  lesson  to  be  drawn  from  this  history  of  the  treat- 
ment of  epidemic  cholera  is,  that  the  arrest  of  the  disease  in  the  diarrhreal 
stage  is  comparatively  easy,  and  that  in  the  stage  of  collapse  its  cure  by 
any  means  whatever  is  altogether  an  exceptional  occurrence. 

1  Du  Froid  en  Therapeutique,  1878. 

'Times  and  Gazette,  Aug.,  18G6,  p.  209;  ibid.,  Nov.,  1866,  p.  555. 


THE  PLAGUE. 

BY   JAMES    C.  WILSON,  M.  D. 


DEFINITION. — An  acute  specific  fever  of  short  duration  and  very 
fatal,  endemic  in  certain  Oriental  countries,  and  frequently  epidemic ;  it 
is  characterized  by  buboes,  carbuncles,  and  petechiae. 

SYNONYMS. — (/T^T?,  plaga,  a  stroke);  the  Pest;  Pestilence;  the 
Bubonic,  Glandular,  Inguinal  Plague ;  the  Oriental,  Levantine,  Levant 
Plague ;  the  Indian,  Pali  Plague ;  Mahamari ;  Septic  or  Glandular  Pes- 
tilence ;  Pestilential  Fever,  Adeno-uervous  Fever ;  Typhus  Pestilentialis, 
Gravissimus,  Bubonicus,  Anthracicus,  etc.  Gr.  6  loi/wt; ;  Lat.  Pestis; 
FT.  La  Peste ;  Ger.  die  Pest,  Beulcnpest. 

CLASSIFICATION. — The  plague,  pest,  pestilence,  and  their  equivalents 
in  various  tongues,  are  terms  that  have  been  used  from  the  earliest  his- 
torical times  to  designate  every  epidemic  disease  attended  by  great  mor- 
tality. As  knowledge  of  diseases  becomes  clearer  the  terms  by  which 
they  are  designated  become  more  definite ;  those  which  did  service  for  a 
class  are  restricted  to  particular  groups,  and  new  names  are  found  for 
other  maladies  only  allied  to  such  groups  by  superficial  resemblances. 
Hence  by  degrees  the  term  plague  has  become  more  restricted  in  its  use. 
To-day  it  is  understood  as  designating  exclusively  the  specific  affection 
defined  above,  the  bubo  plague. 

The  student  of  medical  history  meets  with  insurmountable  difficulties 
in  attempting  to  classify  the  recorded  epidemics  which  have  been  described 
under  this  term.  Even  when  used  in  its  more  restricted  signification, 
difficulties  as  to  the  propriety  of  its  application  to  certain  epidemics  arise. 
Thus,  nosologists  are  not  in  agreement  as  to  whether  the  great  plague — 
the  black  death — which  swept  over  Europe  in  the  fourteenth  century  and 
destroyed  in  three  years  twenty-five  millions  of  inhabitants,  was  a  modi- 
fication of  the  bubo  plague  or  an  essentially  different  disease.  A  like 
difference  of  opinion  exists  in  regard  to  the  relationship  between  the 
Indian  or  Pali  plague  which  has  from  time  to  time  prevailed  in  North- 
western India  during  the  present  century  and  the  true  plague. 

The  black  death  of  the  fourteenth  century  and  the  Pali  plague,  though 
presenting  many  of  the  characteristics  of  bubo  plague,  differ  from  it, 
while  they  resemble  each  other,  in  one  important  particular.  Among  the 
earlier  and  more  common  symptoms  of  note  are  those  dependent  upon 
gangrenous  inflammation  of  the  lungs,  a  lesion,  according  to  Hirsch,1 
extremely  rare  in  bubo  plague.  This  author  informs  us  that  recent 
observations  have  fully  confirmed  the  early  opinion  that  the  Pali  plague 

1  Handbuch  der  historisch-geographischen  Pathologic,  Dr.  August  Hirsch,  1860. 

771 


772  THE  PLAGUE. 

differs  from  that  of  the  Levant  chiefly  in  this  modification,  and  cites 
Pearson  and  Francis  as  saying  of  the  former  disease  that  "  the  collective 
symptoms  are  more  like  those  of  plague  than  of  any  other  known 

disease We  believe  it  to  be  in  all  essential  particulars  identical 

with  the  plague  of  Egypt." 

The  three  forms  of  plague — (a)  the  grave  (or  ordinary),  (6)  the  ful- 
minant (pestis  siderans),  and  (c)  the  larval  or  abortive,  observed  in  epi- 
demics and  hereafter  to  be  described — do  not  represent  distinct  varieties 
of  the  disease,  but  are  merely  expressions  of  differences  in  the  intensity 
of  the  action  of  the  infecting  principle  upon  different  groups  of  individ- 
uals in  given  communities — differences  to  be  explained  here,  as  in  the  other 
infectious  diseases,  in  part  by  variations  in  the  activity  of  the  poison  itself, 
in  part  by  the  individual  peculiarities  and  susceptibilities  of  those  exposed 
to  it. 

HISTORICAL,  SKETCH. — Upon  the  authority  of  Rufus  of  Ephesus, 
quoted  by  Oribasius,1  it  is  stated  that  the  bubo  plague  prevailed  as 
an  endemic,  and  at  times  as  an  epidemic  disease,  in  Libya,  Egypt,  and 
Syria  prior  to  the  beginning  of  the  Christian  era. 

In  the  year  542  A.  D.,  according  to  Procopius,2  the  plague  appeared  in 
Egypt,  at  Pelusium ;  extended  westward  to  Alexandria ;  eastward  to 
Palestine,  Syria,  and  Persia ;  passed  from  Asia  Minor  to  Europe,  where 
it  first  invaded  Constantinople,  whence  it  spread  in  all  directions  with 
such  fury  that  before  the  close  of  the  sixth  century  one-half  the  inhabit- 
ants of  the  Eastern  empire  had  perished,  either  of  the  plague  itself  or  of 
the  universal  destitution  that  followed  in  its  train. 

With  this  epidemic,  known  in  history  as  the  Justinian  plague,  this 
disease  established  itself  for  the  first  time  in  Europe,  where  it  maintained 
foothold  for  more  than  a  thousand  years. 

About  the  middle  of  the  seventeenth  century  the  wide  prevalence  of 
the  plague  in  Europe  began  to  draw  to  an  end.  In  Spain  it  was  epi- 
demic for  the  last  time  from  1677  to  1681  ;  in  Italy  the  last  general  epi-. 
demic  came  to  a  close  in  1656,  although  local  outbreaks  continued  to 
occur  till  the  beginning  of  the  following  century.  In  France  it  still  pre- 
vailed in  several  provinces  in  1668,  although  it  had  for  the  most  part  dis- 
appeared some  years  before.  In  Switzerland  we  encounter  it  for  the  last 
time  in  1667-68  ;  in  the  Netherlands  in  1677 ;  from  England  the  plague 
disappeared  with  the  great  outbreak  of  1665.  In  the  early  part  of  the 
eighteenth  century  two  important  epidemics  occurred  within  the  bound- 
aries of  Europe.  The  first  spread  from  Turkey,  through  Hungary  and 
Poland,  to  Russia,  thence  to  Norway  and  Sweden,  and  along  the  shores 
of  the  Baltic  Sea  to  the  Low  Countries.  This  epidemic  came  to  an  end 
in  1714.  Six  years  later  the  last  great  outbreak  of  the  plague  on 
European  soil  took  place.  It  prevailed  with  great  fury  in  Marseilles  in 
1720-21,  and  overran  the  whole  of  Provence.  From  this  date  till  the 
close  of  the  century  Europe  remained  free  from  the  plague,  with  the 
exception  of  Turkey  and  the  contiguous  countries.  During  the  second 
and  third  decades  of  the  present  century  repeated  epidemics  occurred  in 
the  Balkan  Peninsula  and  the  regions  bordering  on  the  Lower  Danube 
and  the  Black  Sea.  The  plague  appeared  also  in  Malta  in  1813,  and  pre- 
vailed till  1815,  and  in  1816  it  reached  certain  of  the  Ionian  Islands. 
1  ifedicinalia  Collecta.  *  See  Ilirsch. 


HISTORICAL  SKETCH.  773 

Only  twice  has  this  pest  shown  itself  during  the  present  century  in 
Western  Europe — once,  during  the  epidemic  at  Malta  in  1815,  at  Noja, 
a  town  of  the  Neapolitan  province  of  Bari ;  the  second  time,  in  1820,  at 
Majorca,  whither  it  was  carried  over  from  the  coast  of  Barbary. 

Between  1552  and  1784  the  plague  prevailed  twenty-six  times  in 
Tunis  and  Algiers.  Some  idea  of  the  importance  assumed  by  this 
scourge  in  the  countries  of  North-western  Africa  may  be  found  from  the 
fact  that  many  of  these  epidemics  lasted  continuously  for  years,  that 
which  came  in  1784  not  ceasing  for  fifteen  years.  Between  1816  and 
1821  the  plague  again  prevailed  in  Tunis  and  Algiers,  and  again  in 
1836-37. 

During  the  first  half  of  the  present  century  a  change  took  place  in 
the  prevalence  of  the  disease  elsewhere.  Shortly  before  its  complete  dis- 
appearance from  Europe  it  ceased  to  prevail  in  Western  Africa  (with  the 
exception  of  the  Nile  countries),  in  Mesopotamia,  and  in  Persia.  It  dis- 
appeared from  Asia  Minor,  Syria,  and  Palestine  in  1843,  from  Egypt  in 
1844. 

For  a  short  period  the  plague  seemed  to  have  disappeared  altogether. 
Those  who  cherished  this  hope  were,  however,  destined  to  disappoint- 
ment. In  1853  an  outbreak  occurred  in  the  Assyr  country,  Western 
Arabia  ;  and  from  that  time  till  the  present  unmistakable  local  epidemics 
of  the  bubo  plague  have  occurred  in  isolated  regions  of  Africa  and  Asia ; 
thus,  in  1858  at  Benghazi  in  Tripoli ;  in  1857  in  Mesopotamia;  in  1863 
in  the  district  of  Maku,  Persian  Kurdistan;  in  1867  in  the  marsh  dis- 
trict on  the  right  bank  of  the  Euphrates  ;  in  1870  in  Persian  Kurdistan  ; 
in  1871—73  in  the  Yunnan  province,  Western  China;  in  1873  in  the 
marsh  district  on  the  left  bank  of  the  Euphrates.  During  four  years 
following  the  outbreak  of  1873  the  disease  continued  to  prevail  over  an 
extensive  area  in  the  countries  bordering  on  the  northern  banks  of  the 
Persian  Gulf.  In  1874  it  reappeared  also  in  the  Assyr  district,  Western 
Arabia,  and  in  Benghazi,  Northern  Africa.  In  1876,  whilst  still  infest- 
ing the  regions  about  the  Lower  Euphrates,  the  plague  appeared  in  South-' 
eastern  Persia,  and  during  this  and  the  following  years  it  appeared  at 
several  isolated  points  on  the  borders  of  the  Caspian  Sea.  Early  in  1878 
the  disease  was  reported  as  prevailing  in  the  district  of  Souj-Bulak,  Per- 
sian Kurdistan,  and  it  appeared  in  October  of  the  same  year  at  tjie  Cos- 
sack village  "Vetlanka,  on  the  Lower  Volga,  district  of  Astrakhan,  Russia, 
after  an  absence  from  Europe  of  thirty-seven  years.  It  has  more  recently 
prevailed  in  the  Assyr  district,  Western  Arabia,  and  there  have  been 
rumors  of  its  reappearances  in  Persian  Kurdistan. 

The  Indian  or  Pali  plague  (Mahiimari)  has  prevailed  in  local  epidemics 
of  great  severity  on  several  occasions  during  the  present  century  in  the 
North-western  provinces  of  India.  This  fever  was  first  recognized  in 
Kutch  in  May,  1815,  after  a  season  of  great  scarcity  of  food.  It  spread 
rapidly  over  an  extensive  territory,  and  appeared  in  the  spring  of  the 
following  year  at  various  points  in  Guzerat,  next  in  Merawi,  later  in 
Rhadenpur,  spreading  thence  westward  to  Siudh.  Not  until  the  follow- 
ing year  (1817)  did  the  pest  reach  the  British  possessions.  This  epidemic 
continued  to  prevail  until  1821.  The  disease  did  not  reappear  until  July 
6,  1836,  when  it  broke  out  in  Pali,  the  principal  depot  of  traffic  between 
the  coast  and  North-western  India.  It  spread  with  great  rapidity  to  the 


774  THE  PLAGUE. 

adjoining  provinces.  Toward  the  close  of  the  year  1837  the  disease 
broke  out  anew  in  Pali,  and  raged  until  the  spring  of  the  following  year. 
In  1834—35,  again  in  1837,  there  were  outbreaks  of  this  pest  in  Gurwal, 
and  in  1846  and  1847  in  Karmoun,  provinces  of  the  southern  slopes  of 
the  Himalayas.  This  destructive  pest  has  raged  at  an  altitude  of  10,300 
feet,  and  we  learn  from  Hirsch  that  it  has  never  wholly  disappeared  from 
the  mountain-districts  of  the  Himalayas  since  1823,  and  that  its  ravages 
in  these  regions  have  been  so  great  that  certain  settlements  have  been 
wholly  destroyed. 

The  fever  was  remittent  in  type,  with  a  great  tendency  to  become  con- 
tinued ;  it  was  characterized  by  rapidly  developing  extreme  prostration, 
and  was  very  fatal.  In  most  cases  there  were  glandular  swellings  in  the 
groins,  armpits,  and  neck.  Carbuncles  and  petechiae  are  not  mentioned 
as  having  been  observed.  Dyspnoea,  cough,  and  bloody  expectora- 
tion were  frequent  symptoms.  Vomiting,  at  first  of  bilious  matter,  later 
of  dark,  coffee-colored  fluid,  was  likewise  common. 

The  plague  has  never  appeared  in  the  western  hemisphere. 

ETIOLOGY. — 1.  Predisposing  Influences. — Whilst  the  present  views  as  to 
the  causation  of  the  specific  diseases  compel  us  to  assume  a  specific  infecting 
principle  as  the  real  cause  of  every  outbreak  of  the  plague,  there  are 
certain  circumstances  which  are  recognized  as  so  favoring  the  develop- 
ment and  action  of  that  principle  that  they  have  come  to  be  looked  upon 
as  indirect  or  auxiliary  causes  of  particular  epidemics.  It  is  more  in 
accordance  with  the  facts  to  speak  of  them  as  predisposing  influences. 
Chief  among  these  circumstances  is  that  combination  of  physical  and 
social  wretchedness  which  goes  hand  in  hand  with  poverty  and  over- 
crowding. The  plague  has  been  termed  by  a  recent  observer  (Cabiadis) 
miseries  morbus,  and  he  has  thus  reproduced  in  1878  a  name  applied  to 
the  great  plague  of  London  in  1665 — the  poor's  plague.  All  observers 
of  recent  epidemics  unite  in  ascribing  to  poverty  the  foremost  rank 
among  the  predisposing  influences  of  plague  epidemics.  It  is  only  nec- 
essary to  enumerate  the  evils  which  form  the  train  of  poverty,  whether 
in  cities  or  in  villages,  to  complete  the  list. 

With  poverty  come  ignorance  and  neglect  of  all  sanitary  laws ;  over- 
crowding and  ill  ventilation;  personal  filthiuess;  improper  as  well  as 
insufficient  diet ;  indifference  as  to  the  location  of  dwellings  and  their 
surroundings.  The  condition  of  the  villages  which  have  been  the  scene 
of  some  of  the  recent  epidemics  beggars  description.  All  observers 
unite  in  testifying  to  such  accumulations  of  filth  in  and  around  the 
houses  as  requires  to  be  seen  to  be  believed.  In  these  communities 
latrines  are  unknown,  and  no  such  thing  as  organized  scavenging  has 
ever  existed. 

The  accumulation  of  unburied  or  imperfectly  buried  corpses  has  been 
looked  upon  as  the  real  cause  of  the  plague,  and  some  of  the  recent  epi- 
demics have  followed  the  prevalence  of  distinctive  epizootics.  Whilst 
it  is  not  difficult  to  disprove  that  under  ordinary  circumstances  the  efflu- 
via from  exposed  and  rotting  carcasses  can  give  rise  to  outbreaks  of  the 
plague,  it  is  more  than  probable  that  an  atmosphere  charged  with  such 
emanations  (together  with  other  causes)  can  so  unfavorably  influence  a 
community  as  to  increase  its  susceptibility  to  the  specific  cause  of  this 
or  any  other  infective  disease.  There  can  be  but  little  doubt  that  the 


ETIOLOGY.  775 

dead  bodies  of  the  victims  of  the  plague  are  capable  of  disseminating 
the  disease,  and  that  the  reopening  of  graves  containing  such  bodies^ 
even  after  a  long  period  of  time,  has  given  rise  to  fresh  outbreaks  of  the 
disease. 

The  season  of  the  year  does  not  appear  to  exert  any  very  marked 
influence  upon  the  development  of  epidemics,  if  we  base  our  deductions 
upon  _  observations  made  in  different  countries.  In  northern  countries 
the  disease  has  prevailed  as  severely  in  mid-winter  as  in  summer.  The 
epidemics  of  London  showed  a  rise  during  July  and  August,  their  furi- 
ous prevalence  in  September,  and  a  gradual  decline  during  October  and 
November.  In  Constantinople  the  disease  has  commonly  remained  dor- 
mant during  the  winter  months,  and  become  active  as  the  weather  grew 
hotter.  In  Egypt,  on  the  contrary,  the  activity  of  the  outbreaks  has 
developed  in  winter,  increased  with  the  advance  of  spring,  and  suddenly 
abated  upon  the  advent  of  the  summer.  Such  also  has  been  the  case 
with  the  three  general  epidemics'  in  Mesopotamia  studied  by  Tholozan.1 
"Their  beginning  took  place  in  winter,  their  development  during  the 
spring,  their  decline  and  their  extinction  in  summer.  Their  recrudes- 
cences obeyed  the  same  laws :  after  an  incubation  during  the  summer 
season  ....  revivification  took  place  in  winter  and  in  spring."  It  is 
added  in  this  writer's  account  that  the  exceptional  hot  weather  of  sum- 
mer in  that  country,  and  especially  that  of  the  shores  of  the  Persian 
Gulf,  has  always  moderated  or  directed  the  course  of  epidemics  of  this 
pest.  In  Cairo  the  epidemics  have  usually  ceased  upon  the  recurrence 
of  intense  summer  heat  in  June.  Dampness,  and  particularly  a  thor- 
oughly wet  soil,  are  favorable  to  the  development  and  spread  of  the 
disease.  The  marshy  regions  of  the  Lower  Euphrates,  the  shores  of  the 
Caspian  and  the  Black  Seas,  the  valley  of  the  Nile,  have  been  the  scenes 
of  repeated  visitations.  On  the  other  hand,  the  plague  has  maintained 
its  foothold  in  the  mountainous  districts  of  Western  Arabia,  in  Yunnaia, 
on  the  slopes  of  the  Himalayas  at  a  great  elevation,  and  upon  a  dry,  non- 
alluvial  soil  even  more  firmly  than  in  the  low  and  humid  plains  of  Meso- 
potamia.2 

Individual  predisposition  to  contract  the  disease  seems  to  be  increased 
by  all  depressing  influences,  among  which  may  be  mentioned  excessive 
bodily  or  mental  exertion,  intense  and  prolonged  anxiety,  fear,  and  the 
like.  Previous  debilitating  disease  also  increases  the  liability  to  the 
attack.  Neither  sex  nor  age  exerts  an  influence  in  this  respect,  save  that 
after  the  age  of  fifty  few  contract  the  disease.  Occupation  confers  no 
immunity.  Physicians,  nurses,  and  others  occupied  in  the  care  of  the 
sick,  and  those  who  bury  the  dead,  have  especially  suffered  in  recent3  as 
well  as  in  the  older  outbreaks.  Oil-carriers  and  dealers  in  oils  and  fats, 
and  to  a  less  degree  water-carriers  and  the  attendants  at  baths,  are  said 
to  enjoy  a  comparative  immunity  from  attack.  Those  who  have  suffered 
from  the  disease  and  recovered  also  enjoy  a  relative  immunity.  Second 
attacks  are  usually  of  less  intensity  than  the  first. 

2.  The  Exciting  Cause. — The  exciting  cause  of  the  plague  must,  in 

Histoire  de  la  Peste  Bubonique  en  Mesopotamie,  2d  Mdmoire,  Paris,  1874: 
2  Tholozan,  Histoire  de  la  Peste  Bubonique  en  Perse,  1st  Me"moire,  Paris,  1874. 
8  See  summary  of  a  report  addressed  by  Dr.  G.  Cabiadis  to  the  Constantinople  Board 

of  Health  on  the  outbreak  in  Astrakhan  in  Kussia,  1878-79,  by  E.  D.  Dickson,  M.  D., 

Medical  Times  and  Gazette,  1881,  vol.  i.  pp.  4,  32,  119. 


776  THE  PLAGUE. 

the  present  state  of  our  knowledge,  be  assumed  to  be  a  specific  infecting 
principle.  Upon  no  other  hypothesis  can  the  continued  existence  of  a 
disease  so  specific  in  its  characters,  unchanged  through  the  course  of  cen- 
turies, disappearing  when  the  influences  favorable  to  its  presence  cease, 
reappearing  in  certain  regions  when  they  again  arise,  be  explained. 
Capable  of  being  transmitted  by  the  vehicles  of  commercial  intercourse, 
of  control  by  quarantine  and  cordons  sanitaires,  of  spreading  from  lim- 
ited foci  of  contagion  into  overwhelming  epidemics,  the  plague  is  the 
very  typo  of  the  infective  diseases.  The  nature  of  this  infecting  prin- 
ciple is  wholly  unknown.  It  is  probably  a  microphyte  capable  of  devel- 
opment within  the  human  organism — capable  also  of  a  prolonged  inde- 
pendent existence  under  favorable  circumstances  outside  of  the  body,  and 
of  again  giving  rise  to  the  disease.  The  plague  is  properly  to  be  classed 
as  a  contagious-miasmatic  disease  (Liebermeister)  with  cholera,  dysentery, 
and  enteric  fever.  It  continues  to  exist  by  the  continuous  propagation 
of  its  cause,  and  it  spreads  by  the  transportation  of  that  cau.se. 

It  is  conceded  on  all  hands  that  the  plague  has  never  arisen  autochtho- 
nously  in  Europe,  but  has  in  every  instance  been  conveyed  thither. 
Those  who  regard  its  reappearance  after  long  intervals  of  time  in  those 
countries  where  it  still  occasionally  prevails  as  spontaneous  are  compelled 
to  ignore  difficulties  in  reasoning  far  greater  than  the  supposition  of  an 
equally  prolonged  condition  of  quiescence  or  an  inexplicable  or  unsus- 
pected reintroductiou  of  the  cause. 

As  to  the  disputed  question  of  the  contagiousness  of  the  plague,  to  set 
forth  the  arguments  and  examples  adduced  in  favor  of  either  view  would 
far  exceed  the  limits  of  the  present  article.  All  the  facts  are  to  be 
.explained  upon  the  theory  that  the  exciting  cause  of  the  plague,  like 
that  of  cholera  and  enteric  fever,  consists  of  a  miasm  that  must  undergo 
certain  changes  outside  the  body  before  acquiring  its  virulent  properties, 
and  that  the  time  required  for  these  changes  is  exceedingly  brief.  But 
what  the  physical  properties  of  this  miasm  are,  or  how  it  finds  access  to 
the  body,  or  how  it  is  eliminated,  are  alike  utterly  unknown  to  us. 

It  is  certain,  however,  that  it  is  incapable  of  being  freely  transmitted 
to  great  distances  in  the  air.  Whether  or  not  it  is  conveyed  or  retained 
by  the  discharges  from  the  bowel  is  not  known.  The  history  of  recently 
observed  outbreaks,  from  which  alone  definite  and  trustworthy  facts  are 
to  be  obtained,  goes  to  show  that  the  exciting  cause  of  the  plague  clings 
closely  to  the  patients  and  their  immediate  belongings.  The  closer  the 
relation  between  those  sick  and  the  healthy,  the  greater  the  risk  that  the 
latter  will  contract  the  disease.  Those  in  the  house  with  the  patients  are 
more  liable  to  fall  sick  than  those  in  the  adjoining  houses — those  who  are 
constantly  in  .their  presence  than  those  who  occasionally  see  them.  Thus, 
nurses  much  more  frequently  contract  the  plague  than  doctors,  though  the 
latter  have  in  all  epidemics  been  largely  numbered  among  the  victims. 
Among  357  deaths  in  the  outbreak  in  Vetlanka,  already  referred  to, 
were  a  priest,  his  wife  and  mother,  three  doctors,  six  assistant  medical 
officers,  and  two  Sisters  of  Mercy.  Dr.  Cabiadis  remarks  that  the 
information  obtained  "shows  that  the  malady  propagated  itself,  in  the 
first  instance,  from  the  sick  to  their  relatives  and  to  those  who  lived  with 
them  or  who  assisted  them  during  their  illness.  If,  on  the  one  hand, 
these  facts  showed  its  contagious  character,  on  the  other  hand  evidence  is 


SYMPTOM  A  TOLOG  Y.  777 

still  wanting  to  prove  whether  this  transmission  of  the  malady  was 
caused  by  contact  with  the  sick  and  their  clothing,  or  by  breathing  an 
atmosphere  impregnated  with  the  deleterious  particles  emanating  from 
their  morbid  bodies." 

The  period  of  incubation  is  from  two  to  seven  days.  In  the  report  of 
the  commission  of  the  French  Academy  of  Medicine,  drawn  up  by  Prus 
in  1844,  the  statement  appears  that  the  plague  has  never  shown  itself 
among  compromised  persons  after  an  isolation  of  eight  days.  The  recent 
outbreaks  tend  to  confirm  this  conclusion.  L.  Arnaud  concluded  from 
observations  made  at  Benghazi  in  1874  that  the  mean  duration  of  this 
period  was  five  or  six  days,  and  that  the  maximum  did  not  exceed  eight 
days.  Cabiadis  sets  this  stage  down  as  three  days  as  the  rule,  but  as 
occasionally  not  exceeding  twenty-four  hours.  He  found  no  data,  how- 
ever, to  show  the  longest  period  to  which  it  could  extend.  Hirsch,  from 
information  collected  in  his  investigation  of  the  same  epidemic  (that  of 
Astrakhan),  concluded  that  the  minimum  period  of  incubation  observed 
was  from  two  to  three  days,  the  maximum  more  than  eight,  and  that  the 
average  was  five  days.  He  states  that  very  short  or  very  long  periods 
were  seldom  observed. 

SYMPTOMATOLOGY. — Individual  cases  of  the  plague,  as  of  other  epi- 
demic diseases,  differ  in  their  onset  and  progress  under  different  circum- 
stances and  at  different  periods  of  particular  outbreaks.  Besides  the 
ordinary  form,  to  which  as  a  type  the  greater  number  of  the  cases  more 
or  less  closely  conform,  there  are,  on  the  one  hand,  others  so  severe  that 
death  takes  place  before  the  characteristic  manifestations  have  time  to 
appear,  and,  on  the  other  hand,  cases  so  light  that  such  manifestations  are 
but  partly  developed,  and  the  nature  of  the  malady  is  only  to  be  recog- 
nized in  the  light  of  the  prevalent  epidemic  influence. 

Hence  among  the  cases  three  forms  are  recognized  :  (a)  The  grave  or 
ordinary  form ;  (6)  the  fulminant  form ;  and  (o)  the  larval  or  abortive 
form. 

(a)  Grave  or  Ordinary  Form. — The  plague  in  typical  cases  is  a  febrile 
malady  of  the  most  acute  kind,  with  localizations  in  the  form  of  buboes 
or  carbuncles. 

The  course  of  the  attack  may,  for  convenience  of  description,  be 
divided  into  four  stages  :  1,  the  stage  of  invasion ;  2,  the  stage  of  intense 
fever ;  3,  the  stage  of  fully-developed  localizations ;  and  4,  the  stage  of 
convalescence.1 

1.  The  stage  of  invasion  is  marked  by  a  feeling  of  lassitude,  by  pains 
in  the  loins  and  extremities.  There  is  extreme  bodily  and  mental  weak- 
ness, headache,  fulness  and  throbbing  of  the  head,  dizziness.  The 
patient's  expression  is  dull,  stupid;  he  replies  to  questions  slowly  or 
awkwardly,  his  face  is  pale,  his  eyes  languid,  his  gait  feeble  and  stagger- 
ing. The  appearance  in  this  stage  has  been  compared  by  several  observers 
to  that  of  a  drunken  man.  Shivering  occurs,  but  if  fever  be  present  it 
is  slight.  Nausea,  vomiting,  and  diarrhoea  are  symptoms  sometimes 

1  This  formal  division  of  the  description  is  suggested  in  some  of  the  older  accounts. 
(See  '•  Loimologia  ;  or,  An  Historical  Account  of  the  Plague  in  London  in  1665,  by  Nathan 
Hodges,  M.  D.,  and  Fellow  of  the  College  of  Physicians,  who  resided  in  the  City  all  that 
Time,  Lond.,  1721.") 

The  appearance  of  the  plague  in  France  in  1720  was  the  occasion  of  a  great  number 
of  curious  and  interesting  publications  on  this  subject. 


778  THE  PLAGUE. 

observed.     This  stage  begins  suddenly.     It  is  often  imperfectly  devel- 
oped, and  it  may  last  only  a  few  hours  or  a  day  or  two. 

2.  The  second  stage  is  characterized  by  fever  of  the  most  intense  kind. 
It  is  ushered  in  by  a  chill,  sometimes  slight,  commonly  severe.     The 
lassitude  continues,  the  headache  increases,  the  dulness  deepens  to  stupor 
or  gives  way  to  delirium.     The  temperature  rises  to  102°— 104°  F.,  or 
even  to  107.6°  F.     The  pulse  quickly  mounts  to  120  or  130.     The  skin 
is  hot  and  dry ;  the  patient  complains  of  burning  inward  heat  and  of 
great,  sometimes  unbearable,  thirst.     The  eyes  are  sunken  and  injected ; 
the  tongue  moist,  pale,  and  thickly  covered  with  a  chalk-white  or  grayish 
pasty  coating ;  the  vomiting  often  continues.     The  delirium  is  commonly 
active  or  noisy,  and  accompanied  by  great  restlessness ;  it  may,  however, 
be  mild,  tending  to  sopor  or  coma.     The  progress  of  the  disease  now 
rapidly  advances.     The  patient  falls  into  the  so-called  typhoid  state.     His 
tongue  becomes  dry,  hard,  and  fissured ;  sordes  collect  upon  the  teeth 
and  lips,  bloody  crusts  about  the  nostrils.     At  this  time  the  evidences  of 
failure  of  the  forces  of  the  circulation  become  conspicuous.     The  pulse 
grows  feeble,  small,  often  irregular — sometimes  it  can  scarcely  be  felt ; 
the  lips  become  bluish,  the  extremities  cold.     There  is  tendency  to  col- 
lapse.    During  the  course  of  this  stage  buboes  begin  to   make   their 
appearance.     Sometimes  the  enlargement  of  the  superficial  lymphatics  is 
preceded  by  tenderness  or  pain   of  more  or  less  intensity;    often  the 
glands  are  found  to  be  enlarged  only  upon  search. 

The  termination  of  this  stage  is  marked  by  a  sudden  fall  of  the  tem- 
perature to  subnormal  ranges  (93.2°  F.  has  been  observed);  at  the  same 
time  copious  strong-smelling  sweat  not  infrequently  occurs.  The  pulse 
grows  feebler,  and  falls  to  100  or  below  it,  and  the  mind  becomes  clearer. 

3.  These  changes  lead  up  to  the  stage  of  fully-developed  local  mani- 
festations.    The  enlarged  lymphatics  are  most  commonly  situated  in  the 
groins  or  on  the  upper  part  of  the  thighs  at  a  point  below  that  commonly 
the  seat  of  venereal  buboes ;  less  often  they  are  to  be  found  in  the  arm- 
pits or  the  region  of  the  angle  of  the  jaw;  as  a  rule,  they  occupy  only  one 
or  two  of  these  positions  in  the  same  patient.     They  vary  in  size  from  a 
little  mass  or  kernel,  only  to  be  discovered  after  careful  search,  to  the 
bulk  of  a  hen's  egg  or  a  mandarin  orange.     The  swelling  of  the  gland 
takes  place  at  times  with  great  rapidity.     Suppuration  is  followed  by  the 
discharge  of  an  ichorous  pus,  and  not  rarely  by  ulcerative  destruction  of 
the  surrounding  tissues.     Suppuration  occurs  more  frequently  than  reso- 
lution, but  is  comparatively  rare  in  fatal  cases.     Hence  it  has  come  to 
be  popularly  regarded  as  a  favorable  prognostic  sign,  whilst  the  early 
subsidence  of  the  swelling  has  been  looked  upon  as  an  omen  of  grave 
import. 

The  time  of  the  appearance  of  the  buboes  varies  greatly.  In  the 
greater  number  of  cases  they  have  shown  themselves  on  the  second,  third, 
or  fourth  day  of  the  attack,  occasionally  within  six  or  eight  hours  of  the 
beginning  of  the  attack,  and  occasionally  they  have  been  observed  to  pre- 
cede the  general  manifestation  of  the  disease;  rarely  they  have  appeared 
as  late  as  the  fifth  day.  In  many  cases  they  are  absent  altogether. 

Carbuncles  demand  attention  as  being  among  the  characteristic  local 
manifestations  of  this  stage.  They  are  less  common  than  buboes.  Their 
usual  position  is  upon  the  lower  extremities,  the  buttocks,  or  the  back  of 


SYMPTOMATOLOGY.  779 

the  neck.     In  favorable  cases  the  gangrene  after  a  few  days  becomes  lim- 
ited and  the  slough  separates.     Boils  also  occasionally  appear. 

PetechifB  occur  in  the  worst  cases,  and  often  at  an  early  period  in  the 
course  of  the  disease.  Their  appearance  usually  indicates  a  fatal  issue. 
They  occupy  at  times  extensive  areas  of  the  body  or  the  greater  part  of 
its  surface;  at  times  they  appear  only  in  the  neighborhood  of  the  buboes. 
They  vary  in  size  from  a  mere  speck  to  spots  several  lines  in  diameter. 
When  very  numerous  they  give  a  livid  hue  to  the  skin,  and  that  appear- 
ance to  the  cadaver  to  which,  together  with  the  high  mortality,  was  doubt- 
less due  the  term  black  death  by  which  severe  epidemics  were  known  in 
the  Middle  Ages. 

Vibices  and  extensive  ecchymoses  sometimes  appear  shortly  before 
death. 

4.  The  stage  of  convalescence  sets  in  between  the  sixth  and  tenth  days. 
It  is  often  protracted  by  prolonged  suppuration  of  the  bubonic  enlarge- 
ments. Both  relapses  and  distinct  second  attacks  have  been  noted  by 
recent  as  well  as  the  older  observers. 

In  addition  to  the  foregoing  sketch  of  the  course  of  the  disease  in  its 
ordinary  form  it  is  necessary  to  describe  certain  other  symptoms. 

The  attack  has  sometimes  begun  with  a  convulsive  tremor,  at  other 
times  with  a  prolonged  shaking,  which  has  lasted  from  six  hours  to  three 
days,  the  patient  remaining  free  from  fever  and  not  complaining  of  cold. 
This  condition  has  terminated  in  coma,  followed  speedily  by  death. 

Sometimes  the  attack  has  come  upon  the  patient  with  great  confusion 
of  mind,  so  that  he  appears  dazed,  or  else  a  curious  distraction  has  befallen 
him  in  the  midst  of  his  ordinary  avocations.  If  absent  from  home,  such 
patients  commonly  at  once  set  out  to  return,  either  trembling  and  stagger- 
ing as  though  tipsy,  or  else  rushing  wildly  through  the  streets  with  frantic 
gestures  and  outcries. 

The  vomited  matters  are  usually  at  first  gastric  mucus  with  bile,  after- 
ward dark  coifee-colored  fluid ;  in  certain  cases  blood  is  vomited.  Bleed- 
ing from  the  nose,  lungs,  bowels,  vagina,  and  urethra  have  also  been 
observed.  Cases  attended  by  hemorrhages  have  in  almost  all  instances 
terminated  fatally. 

Constipation  has  been,  as  a  rule,  present  during  the  acute  stages;  later 
in  the  attack  diarrhoea  has  occasionally  occurred.  It  has  been  looked 
upon  as  a  favorable  symptom. 

The  urine  has  been  diminished  and  suppressed  in  grave  cases.  Trust- 
worthy observations,  both  as  to  its  quantity  and  its  chemical  composition, 
are  wanting.  It  has  been  observed  to  contain  blood. 

As  has  been  already  pointed  out,  the  Mtlhamari  of  North-western  India 
has  been  especially  characterized  by  lung  symptoms.  Other  regions  also 
have  been  visited  by  epidemics  in  which  acute  pulmonary  lesions  formed 
a  prominent  part  of  the  morbid  complexus. 

(6)  The  Fulminant  Form. — Chiefly  in  the  early  days  or  weeks  of  epi- 
demics, but  to  some  extent  also  later,  cases  occur  in  which  the  intensity 
of  the  sickness  is  so  great  that  the  patient  dies  before  its  usual  manifesta- 
tions have  time  to  develop.  The  duration  of  the  whole  attack,  which 
ends  fatally,  is  often  not  more  than  a  few  hours;  its  symptoms,  which 
diifer  but  little  if  at  all  from  those  of  similar  cases  of  other  epidemic  dis- 
eases— such,  for  example,  as  epidemic  cerebro-spinal  fever  in  its  fulminant 


7SO  THE  PLAGUE. 

form — are  of  the  most  aggravated  character,  and  the  patient  perishes  over- 
whelmed by  the  infection  as  though  struck  by  a  thunderbolt.  Profound 
disturbance  of  the  nervous  centres,  convulsions,  coma,  the  rapid  forma- 
tion of  vibices  and  petechiae,  collapse,  are  the  speedy  forerunners  of  the 
fatal  issue. 

(c)  The  Larval  or  Abortive  Form. — Toward  the  close  of  an  epidemic 
the  character  of  the  disease  usually  undergoes  a  change.  It  becomes  less 
malignant.  The  cases  present  the  essential  symptoms,  but  in  diminished 
intensity.  Some  cases  terminate  in  an  early  defervescence  with  rapid  sub- 
sidence of  beginning  local  manifestations;  others  present  merely  the  evi- 
dences of  a  slight  disturbance  of  the  general  health,  without  any  charac- 
teristic symptoms  of  the  prevalent  disorder;  others,  again,  are  character- 
ized by  the  appearance  of  buboes  without  pain  or  fever.  These  swellings 
undergo  resolution  in  fourteen  days  or  thereabout.  Exceptionally  they 
suppurate. 

The  duration  of  the  plague  is  from  six  to  ten  days  in  typical  cases 
running  a  favorable  course;  those  of  fatal  cases  from  one  to  twenty  days. 
Clot  Bey l  found  the  duration  of  the  worst  cases  two  or  three  days,  of 
those  next  in  point  of  severity  five  or  six  days,  whilst  in  milder  cases 
death  did  not  occur  until  the  second  or  third  week.  Of  534  fatal  cases 
noted  by  W.  H.  Colvill,  126  occurred  one  day  after  the  attack,  80  two 
days  after  it,  105  three  days,  76  four  days,  60  five  days,  26  six  days  after 
the  attack.  After  six  days  the  number  of  deaths  rapidly  declined;  on  the 
nineteenth  day  1  death,  and  on  the  twentieth  day  after  the  attack  11  deaths, 
occurred.  It  is  said  that  death  after  the  seventh  day  is  commonly  not  in 
consequence  of  the  disease  itself,  but  of  sequels.  Of  16  fatal  cases  in  the 
village  Prischib  in  Astrakhan,  noted  in  the  report  of  Dr.  Cabiadis,  and 
of  whom  the  names,  as  well  as  the  day  of  their  exposure,  their  falling 
sick,  and  their  death  are  given,  1  died  in  one  day,  4  in  two  days,  6  in 
three  days,  3  in  four  days,  and  2  in  six  days. 

The  mortality  of  the  plague  is  greater  than  that  of  any  other  epidemic 
disease.  In  all  epidemics  a  large  majority  of  those  who  contract  the  dis- 
ease die.  This  is  especially  true  of  epidemics  at  their  beginning,  when  it 
has  often  happened  that  for  a  time  all  the  cases  have  perished.  Of  this, 
as  of  other  epidemic  diseases,  it  is  true  that  the  death-rate  has  varied  in 
different  outbreaks  and  at  different  periods  of  the  same  outbreak.  Colvill 
states  that  in  the  epidemic  of  1874  in  Mesopotamia  the  mortality  of  stricken 
villages  during  the  first  half  of  the  time  was  93  to  95  per  cent,  of  those 
attacked,  but  that  afterward  the  majority  of  those  attacked  recovered. 
The  same  authority  states  that  in  Bagdad  in  1876  the  mortality  was  55.7 
per  cent,  of  persons  attacked.  Arnauld  gives  the  mortality  at  Benghazi 
in  1874  as  39  per  cent,  of  attacks.  The  death-rate  at  Vetlanka  was  82 
per  cent,  of  those  attacked.  In  Tonlon  in  1721,  of  a  population  of  about 
26,000  human  beings,  about  20,000  were  attacked,  and  of  these  16,000 
died.  It  has  been  by  no  means  of  rare  occurrence  that  nearly  half  the 
population  of  towns  have  perished  in  an  epidemic,  or  that  small  villages 
have  been  completely  depopulated  by  this  scourge. 

COMPLICATIONS  AND  SEQUELS.— The  appalling  mortality  of  the  plague 
on  its  approach,  the  rapidity  of  its  spread,  the  popular  commotion  upon 
its  appearance,  its  brief  course,  and  the  fact  that  its  recent  outbreaks  have 
1  De  la  Peste  observee  en  £gypte,  Paris,  1840. 


MORBID  ANATOMY.  781 

taken  place  in  regions  where  trained  European  physicians  have  been, 
with  a  few  exceptions,  beyond  reach,  all  unite  in  maintaining  the  gloom 
that  has  since  the  Middle  Ages  enveloped  the  clinical  facts  of  this  dis- 
ease. 

Of  its  clinical  course,  beyond  the  brief  outline  already  given,  little  is 
accurately  known,  of  its  complications  still  less.  In  some  of  the  recent 
epidemics,  and  particularly  in  the  outbreaks  of  plague  in  India,  the  evi- 
dences of  pulmonary  lesions  have  been  so  conspicuous  that  they  deserve 
to  be  classed  among  the  essential  manifestations  of  the  disease  rather  than 
as  complications ;  in  others  pulmonary  congestion,  haemoptysis,  the  evi- 
dences of  crotipous  or  catarrhal  pneumonia,  have  occurred  in  a  small  pro- 
portion of  the  cases.  Aside  from  this,  there  is  nothing  to  be  said  as  to 
the  complications. 

Among  the  known  sequels  are  protracted  ulceration  of  the  enlarged 
lymphatics,  boils,  superficial  or  deep  abscesses,  catarrhal  pneumonia, 
pertussis,  mental  troubles,  and  the  like.  Extensive  and  deep  cicatrices  are 
not  infrequently  found  in  the  site  of  the  ulcerating  local  manifestations. 

MORBID  ANATOMY. — The  existing  knowledge  of  the  morbid  anatomy 
of  the  plague  is  but  scanty.  The  observers  of  the  'early  outbreaks  con- 
tributed nothing ;  the  recent  outbreaks  have  taken  place  under  circum- 
stances in  which  anatomical  investigations  were  impracticable.  The  know- 
ledge which  we  possess  is  almost  wholly  due  to  the  investigations  con- 
ducted by  the  French  in  Egypt  at  the  close  of  the  last  and  the  beginning 
of  the  present  century,  and  again  during  the  years  1833  to  1838. 

The  descriptions  of  Bulant,1  Clot  Bey,  and  others  point  to  gross 
lesions,  such  as  are  found  after  death  in  the  acute  stages  of  the  infectious 
diseases  in  general.  The  viscera  were  engorged  with  dark  fluid  blood ; 
ecchymoses  were  often  found  in  the  mucous  and  the  serous  membranes, 
in  the  substance  of  the  different  organs,  and  into  the  connective  tissue. 
The  spleen  was  in  almost  all  cases  enlarged,  softened,  and  of  a  dark  color. 
Not  rarely  the  kidneys  were  deeply  engorged,  and  extravasations  of  blood 
into  their  substance,  their  pelves,  and  into  the  surrounding  connective 
tissues  were  often  encountered. 

The  only  constant  and  characteristic  changes  relate  to  the  lymphatic 
system.  The  lymphatic  glands  were,  as  a  rule,  enlarged  and  deeply 
injected  with  blood.  Where  no  buboes  existed  the  glands  of  the  various 
cavities  of  the  body  showed  evidences  of  acute  inflammatory  processes.  In 
some  instances  the  affection  of  the  glands  appeared  to  be  general ;  less 
frequently  it  was  most  conspicuous  in,  or  apparently  limited  to,  one  or 
more  great  groups.  Thus,  the  bronchial,  the  mediastinal,  the  mesenteric, 
the  lumbar,  etc.  were  severally  the  seat  of  marked  changes  with  or  with- 
out enlargement  of  superficial  groups,  or  several  of  these  groups  were  at 
the  same  time  implicated. 

In  no  instance  were  symmetrical  enlargements  of  the  inguinal  regions, 
the  axillae,  or  the  throat  met  with. 

According  to  Runnel,2  in  2700  cases  there  were  inguinal  buboes  in 
1841,  axillary  in  569,  maxillary  in  231 ;  inguinal  buboes  occurred  175 
times  on  both  sides,  729  times  on  the  right  only,  589  times  on  the  left 
only ;  the  axillary  buboes  were  double  9  times,  right  only  185,  left  only 

1  De  la  peste  oriental  d'cpres  les  mater  naux  recuil  les  d  Alexandrie,  &  Smyrne,  etc.,  pendant  les 
Annees  1S33  d  1838,  Paris,  1839.  *A  Treatise  on  the  Plague,  London,  1791. 


782  THE  PLAGUE. 

163.     Buboes  of  the  ueck  only  occurred  130  times,  and  of  them  67  cases 
were  children. 

The  connective  tissue  surrounding  the  affected  glands  was  the  seat  of 
an  infiltration  sometimes  serous,  sometimes  cellular ;  it  also  very  commonly 
contained  more  or  less  extensive  extravasations  of  blood.  Even  where  no 
buboes  appeared  on  the  surface  of  the  body  the  glands  were  enlarged  to 
twice  their  usual  size  or  more.  The  substance  of  the  glands  in  the  larger 
swellings  was  at  times  uniformly  red  or  violet,  again  whitish  or  marbled 
or  pulpy  or  denser,  or  of  the  consistence  of  fat.  It  was  also  sometimes 
soft  like  jelly,  and  rarely  it  contained  minute  collections  of  pus.  Some 
observers  speak  of  dilatation  of  the  lymph-vessels  in  the  neighborhood 
of  the  enlarged  glands. 

DIAGNOSIS. — The  difficulties  attending  the  recognition  of  the  plague 
at  the  beginning  of  an  outbreak  speedily  subside.  The  rapid  spread  of 
the  disease,  its  frightful  mortality,  the  overwhelming  intensity  of  the 
symptoms,  the  prompt  occurrence  of  cases  characterized  by  buboes,  car- 
buncles, or  petechise,  are  collectively  considered  diagnostic  of  this,  and  of 
no  other  disease  whatever.  In  regions  subject  to  the  repeated  visitations 
of  this  pest  there  exists  a  universal  unwillingness  to  mention  even  the 
name  of  a  disease  whose  suspected  presence  alone  is  followed  by  conse- 
quences of  the  most  serious  nature  to  the  freedom  of  personal  and  com- 
mercial intercourse.  To  this  unwillingness,  rather  than  to  any  real  like- 
ness between  the  plague  and  other  diseases  with  which  it  has  been  com- 
pared, are  to  be  traced  most  of  the  difficulties  as  to  the  differential  diag- 
nosis that  have  been  raised,  especially  in  the  regions  bordering  on  the 
Mediterranean  Sea. 

It  is  not,  therefore,  necessary  in  this  place  to  discuss  the  diagnosis 
between  the  plague  and  malarial  and  other  pernicious  fevers,  malignant 
typhus,  epidemic  dysentery,  lymphadenitis,  syphilitic  buboes,  parotitis, 
and  so  forth. 

TREATMENT. — Preventive. — The  efficient  treatment  consists  in  pro- 
phylaxis. The  history  of  this  disease  indicates  with  singular  clearness 
the  measures  which,  properly  carried  out,  are  capable  of  controlling  the 
spread  of  the  epidemic  diseases.  These  measures  arrange  themselves  into 
two  groups,  of  which  the  first  has  to  do  with  the  removal  of  the  con- 
ditions familiar  to  the  development  of  the  disease,  the  predisposing 
influences ;  and  the  second  with  the  restriction  of  the  disease  to  the 
locality  in  which  it  shows  itself — isolation,  quarantine. 

The  conditions  favorable  to  the  development  of  the  plague  have 
already  been  set  forth  under  the  heading  Etiology.  They  relate  to 
poverty  and  ignorance,  and  their  attendant  evils,  in  communities.  They 
are  those  conditions  which  tend  to  disappear  under  the  influences  of 
civilization,  and  in  truth  it  may  be  said  that  at  the  present  time  the 
plague  occurs  only  in  half-civilized  countries. 

Preventive  medicine  has  achieved  no  other  work  comparing  in  magni- 
tude and  importance  with  the  extinction  of  the  plague  in  Europe.  This 
was,  to  use  the  words  of  Hirsch,  "  a  gradual  process,  and  kept  pace  in 
great  measure  with  the  development  and  perfection  of  the  quarantine 
system  with  reference  to  the  Orient  and  the  different  countries  of 
Europe."  This  author  continues :  "  I  cannot,  in  fact,  understand  how 
any  one  criticising  the  facts  without  prejudice,  and  having  regard  to  the 


TREATMENT.  783 

state  of  the  plague  in  the  East,  can  for  a  moment  hesitate  to  attribute  thp 
chief  cause  of  the  disappearance  of  the  plague  from  European  soil  to  a 
well-regulated  quarantine  system."  The  European  has  by  no  means  lost 
his  susceptibility  to  the  disease.  He  is  liable  to  attack  in  the  East.  His 
protection  at  home  lies  in  the  restriction  of  the  exciting  cause  of  the 
disease  to  its  present  haunts. 

Any  extended  notice  of  quarantine  and  quarantine  laws  is  beyond  the 
scope  of  this  article.  It  may  be  said,  however,  that  with  reference  to  the 
plague  measures  quite  unnecessary  under  ordinaiy  circumstances  assume 
the  greatest  importance  when  this  disease  makes  its  appearance  in  countries 
bordering  upon  Europe,  and  that  no  amount  of  hardship  to  individuals 
necessary  to  avert  so  great  a  calamity  as  a  plague  epidemic  could  be 
looked  upon  as  excessive.  Indeed,  we  can  with  difficulty  realize  the 
severity  with  which  measures  of  isolation  have  been  carried  into  effect  at 
times  when  the  devastation  produced  by  the  plague  was  still  vividly 
remembered.  Violation  of  the  orders  issued  during  an  epidemic  has 
been  punished  with  no  less  a  penalty  than  death.  It  is  related  that  upon 
the  appearance  of  the  plague  in  the  little  town  of  Noja  in  Lower  Italy  in 
1815,  troops  were  despatched  immediately  to  surround  the  place  with  a 
cordon.  The  town  was  encircled  by  two  deep  ditches,  and  opposite  the 
gates  three  ditches  were  spanned  by  drawbridges,  which  served  as  a 
means  for  the  introduction  of  provisions,  but  no  other  communication  was 
allowed.  Only  letters  were  allowed  to  leave  the  city,  and  these  were  first 
dipped  in  vinegar.  Cannons  were  posted  at  the  city  gates.  The  ditches 
were  occupied  by  sentinels,  who  were  ordered  to  shoot  down  any  one  who 
approached  and  failed  to  stand  still  the  moment  he  was  hailed.  A  plague 
patient  who  escaped  while  delirious  and  attempted  to  pass  the  lines  was, 
in  fact,  shot  dead.  Outside  this  cordon  two  others  were  established. 
Those  who  disobeyed  the  orders  were  treated  with  the  greatest  severity. 
An  inhabitant  of  Noja,  who  had  thrown  a  pack  of  cards  to  the  soldiers, 
together  with  the  soldier  who  picked  it  up,  was  tried  by  court-martial 
and  shot.1 

Lower  Italy,  possibly  Europe  also,  owed  its  escape  to  the  rigorous 
measures  carried  out  in  this  instance;  nor  can  it  be  doubted  that  the 
measures  of  isolation  practised  during  the  outbreak  on  the  Volga 
1878-79  restricted  the  disease  to  the  district  in  which  it  appeared  and 
brought  it  to  a  speedy  end.  On  this  occasion  three  efficient  cordons  were 
established  to  isolate  the  infected  places.  The  first  cordon  was  put 
around  every  place  where  plague  prevailed,  to  prevent  persons  from 
entering  or  quitting  that  locality  until  forty-two  days  had  elapsed  after 
the  last  attack  of  the  malady  there.  The  second  cordon  was  formed 
around  the  infected  area,  encircling  all  the  infected  localities.  Its  circum- 
ference extended  800  kilometres,  and  was  guarded  by  pickets  of  soldiers 
stationed  at  intervals  of  five  kilometres.  This  cordon  had  four  quaran- 
tine stations.  The  third  and  outermost  cordon  was  established  lound 
the  whole  province  of  Astrakhan.  It  served  to  control  the  functions  of 
the  inner  cordons,  inasmuch  as  all  persons  coming  from  within  its  area, 
who  could  not  prove  that  they  had  undergone  quarantine  at  the  stations 
of  the  middle  cordon,  were  stopped. 

1  Ueber  die  Pest  zu  Noja,  Niirnberg,  1818,  quoted  by  Liebermeister  in  Ziemssen's 
dopedia,  article  "  Plague." 


784  THE  PLAGUE. 

The  complete  disinfection  of  all  clothing  and  other  articles  used  in  the 
service  of  the  sick  is  to  be  included  among  measures  of  prophylaxis. 
It  is  no  uncommon  thing  to  destroy  by  fire  the  houses  in  which  cases 
have  occurred,  along  with  their  contents. 

Xo  efficient  means  of  protection  are  known  for  those  who  during  an 
outbreak  cannot  escape  from  the  infected  neighborhood.  It  would  be 
without  purpose  other  than  to  amuse  the  reader  to  reproduce  the  quaint 
fancies  of  the  older  physicians  in  this  matter,  or  to  dwell  upon  the  amu- 
lets and  incantations,  the  absurd  costumes,  the  protective  power  of 
tobacco,  according  to  Diemerhoeck,  or  the  disbelief  in  its  virtues  on  the 
part  of  Hodges,  who  preferred  "  canary,  of  the  best  sort,  of  which  he 
frequently  drank  while  he  attended  the  sick." 

Clinical. — "The  treatment  of  individual  cases  must  in  the  present 
state  of  knowledge  be  expectant  and  symptomatic.  Notwithstanding  our 
acquaintance  with  the  symptoms  that  characterize  plague,  we  are  utterly 
ignorant  of  the  treatment  best  suited  to  its  cases  "  (Cabiadis). 

Physicians  who  have  written  from  personal  observation  unite  in 
advising  a  treatment  of  the  simplest  kind.  Ventilation,  cleanliness,  a 
liquid  diet,  abundant  cool  drinks,  are  to  be  ordered.  The  initial  collapse 
and  the  evidences  of  failure  of  the  circulation  call  for  the  use  of  stimulants, 
and  especially  of  alcohol.  Cold  or  tepid  sponging,  in  accordance  with  the 
sensations  of  the  patient,  may  be  resorted  to.  If  there  be  high  fever  an 
energetic  antipyretic  treatment  might  be  carried  out.  Cold  effusion  is  said 
to  have  been  of  use  in  many  instances. 

Purging,  bloodletting,  mercurials,  blistering,  emetics,  have  proved 
either  positively  injurious  or  altogether  without  effect  upon  the  course 
of  the  disease. 

Of  drugs,  ammonium  chloride,  salicylic  acid,  carbolic  acid,  quinine, 
have  been  administered  without  positive  effect. 

It  is  stated  that  the  free  inunction  of  oil  from  the  very  beginning  of 
the  attack  was  affirmed  to  exert  a  favorable  influence.1 

In  early  times  the  buboes  were  often  incised,  or  even  excised,  as  soon 
as  they  began  to  swell.  More  recently  they  have  been  treated  with 
leeches  or  inunctions  of  mercurial  ointment.  The  treatment  by  poul- 
tices and  the  evacuation  of  pus  as  soon  as  it  can  be  detected  is  at  present 
regarded  with  greater  favor.  Carbuncles  are  likewise  to  be  treated  in 
accordance  with  accepted  surgical  procedures. 

1  See  Griesinger,  Virchow's  Handbuch  der  Specidlen  Patholor/ie  wid  Tlierapie,  ii.  2,  a.  316 


LEPROSY. 

br   JAMES    C.  WHITE,    M.  D. 


DEFINITION. — Leprosy  is  a  constitutional  disease  of  chronic  course 
and  fatal  termination,  characterized  by  peculiar  changes  in  the  tissues  of 
skin,  mucous  membrane,  nerves,  and  most  organs  of  the  body. 

SYNONYMS. — Elephantiasis  of  Greek  writers ;  Lepra  of  Arabian 
authors ;  Anssatz  (Germany) ;  Spedalskhed  (Norway).  The  local  names 
in  use  among  the  numerous  races  in  which  it  prevails  are  too  numerous 
to  be  given  here. 

HISTORY. — Although  great  confusion  has  existed  among  the  most 
ancient  as  well  as  later  medical  writers  with  regard  to  the  defini- 
tion of  this  disease,  it  having  been  confounded  with  several  other  affec- 
tions (elephantiasis  arabum,  syphilis,  psoriasis,  morphoea,  etc.),  leprosy 
has  prevailed  in  certain  parts  of  the  world  from  the  time  of  the  earliest 
records.  The  biblical  accounts  show  that  it  existed  among  the  Jews  in 
Egypt,  although  it  was  not  accurately  distinguished  from  other  diseases 
resembling  it  in  some  respects.  It  was  recognized  in  Greece  before  the 
Christian  era,  and  in  the  early  centuries  after  Christ  it  had  extended 
widely  over  Europe.  In  the  seventh  and  eighth  centuries  special  leper- 
houses  were  founded  in  Italy,  France,  and  Germany.  The  disease  reached 
its  height  in  Europe  in  the  twelfth  and  thirteenth  centuries,  when  19,000 
lazarettos  are  said  to  have  been  in  existence.  Its  spread  was  greatly 
increased  by  the  constant  intercourse  kept  up  between  Europe  and  the 
East  during  the  Crusades.  In  the  fifteenth  century  it  began  to  diminish, 
and  in  the  course  of  the  seventeenth  it  had  almost  wholly  disappeared 
from  the  most  civilized  states.  It  has  lingered,  however,  in  other  parts, 
and  exists  to-day  in  France  and  Spain  and  Portugal,  in  Norway  and 
Sweden,  and  in  Italy,  Greece,  and  Southern  Russia.  As  in  ancient  times, 
it  is  widely  spread  along  the  coasts  of  Africa  and  prevails  largely 
throughout  Asia.  It  is  found  in  many  of  the  islands  of  the  Indian  and 
Pacific  Oceans,  in  Japan,  New  Zealand,  Madeira,  the  West  Indies,  exten- 
sively in  some  of  the  states  of  Central  and  South  America  and  Mexico 
and  the  Hawaiian  Islands. 

It  may  be  interesting  to  trace  its  history  in  the  United  States  and 
adjacent  districts  more  minutely.  It  is  not  known  just  when  leprosy  was 
introduced  into  North  America.  According  to  the  Louisiana  historian, 
Gayarr6,  the  Spaniards  established  leper  hospitals  in  several  of  their 
colonies  on  the  Gulf  of  Mexico  during  the  last  century.  One  existed  in 
New  Orleans  as  late  as  1785.  In  1776  the  disease  was  reported  as  exist- 
ing among  the  blacks  in  Florida.  It  seems  to  have  died  out,  and  with 

VOL.  I.— 50  78S 


t786  LEPROSY. 

it  all  remembrance  of  its  former  existence  amongst  us,  until  within  the 
last  few  years,  when  its  occurrence  in  the  Southern  States  has  again 
attracted  attention.  In  Louisiana  the  first  case  was  discovered  in  1866 
in  an  old  woman  whose  father  came  from  the  south  of  France ;  she  died 
in  1870.  In  1871  it  appeared  in  one  of  her  sons,  in  1872  in  two  others, 
and  in  1876  in  a  nephew.  A  sixth  case  developed  in  a  young  woman 
who  was  in  constant  attendance  upon  the  first  case.  In  addition  to  this 
group,  other  cases  have  been  observed  in  several  parishes,  amounting  to 
twenty-one  in  all,  as  collected  by  Salomon  of  New  Orleans  in  1878.1 
Two  other  cases,  brother  and  sister,  in  Louisiana  are  known  to  the  writer, 
one  of  whom  has  recently  died  under  his  care.  In  South  Carolina  the 
disease  is  reported  by  J.  F.  M.  Geddings2  to  have  been  observed  in 
sixteen  cases  since  the  year  1846 ;  four  were  Jews,  four  negroes,  and 
eight  whites.  In  none  was  any  hereditary  taint  to  be  traced.  No  new 
cases  have  developed  since  that  report.3 

In  Minnesota  and  other  North-western  States  leprosy  has  been  known 
to  exist  for  a  considerable  time  among  the  Norwegian  immigrants  who 
have  settled  in  them  in  large  numbers.  Holmboe  in  1863  and  Prof. 
Boeck  later  made  visits  to  these  colonies  while  in  this  country,  and  pub- 
lished reports  concerning  them  after  their  return.4  The  latter  found 
eighteen  cases  among  his  countrymen,  most  of  which  were  leprous  before 
emigration ;  in  others  the  disease  developed  after  arrival  in  America.  It 
had  not  manifested  itself  in  any  person  born  in  this  country.  The  cha- 
racter and  progress  of  the  affection  seem  to  have  been  little  influenced  by 
residence  here.  Since  these  observations  other  cases  have  been  collected  by 
the  committee  on  statistics  of  the  American  Dermatological  Association,5 
showing  the  continuance  of  the  disease  in  these  States.  In  1879  there 
were  fifteen  cases  in  Minnesota.  Its  spread  in  this  portion  of  our  country 
is  slow. 

Since  1871,  52  cases  of  the  disease  have  been  inmates  of  the  hospital 
for  lepers  in  San  Francisco,  California.  Of  these,  all,  with  one  excep- 
tion, were  Chinese,  and  forty-five  of  them  had  been  sent  back  to  China. 
It  is  presumed  to  have  shown  itself  after  arrival  in  this  country,  as 
"unproductive  labor  would  not  be  imported  by  the  Six  Companies."6 
No  case  of  the  disease  known  to  have  been  acquired  in  this  country  has 
yet  been  reported  upon  the  Pacific  Coast.  One  case  IMS  developed  in 
San  Francisco  after  residence  in  the  Hawaiian  Islands. 

In  Oregon,  too,  the  disease  has  appeared  among  the  Chinese  immi- 
grants, steps  having  been  recently  taken  to  re-ship  five  lepers  from  the 
poor-farm  at  Portland  to  China. 

Since  1815,  possibly  earlier,  leprosy  has  prevailed  among  the  poor 
French  settlements  along  the  Miramichi  River,  near  the  Bay  of  Chaleurs, 
New  Brunswick.  It  was  first  noticed  in  a  woman  whose  mother  came 
from  Normandy,  and  has  continued  mainly  in  her  descendants  since. 
No  measures  were  taken  to  control  the  disease  until  1844,  when  a  hospi- 
tal was  erected  on  Sheldrake  Island.  In  1849  the  present  lazrr*etto  at 

1  New  Orleans  Med.  and  Sura.  Journal,  March,  1878. 

2  Trans.  Intern.  Med.  Congress,  Philadelphia,  1876. 

3  See  article  on  "  Contagiousness  of  Leprosy  "  by  writer,  in  Amer.  Journ.  of  Mei,  S& 
ences,  Oct.,  1882. 

4  British  and  For.  Med.-Chir.  Review,  Jan.,  1870,  and  Nord.  Medic.  Ark.,  Bd.  iii. 
5Seo  Transactions.  •  Trans.  Am.  Derm.  Assoc.,  1887 


ETIOLOGY.  787 

Tracadie  was  established.  During  the  first  five  years  (1844-49)  there 
were  admitted  32  patients;  from  1849  to  1863,  67  additional  patients 
were  received ;  and  from  the  latter  date  to  1879,  30  more,  making  a  total 
number  of  129  up  to  the  last  report.  The  greatest  number  present  at 
any  one  time  was  37.  In  1878  there  were  16  patients  in  the  lazaretto 
— 6  men  and  10  women.  The  total  number  of  deaths  in  the  hospital 
has  been,  up  to  1878,  123.  A.  C.  Smith,  who  resides  near  Tracadie, 
states  that  at  the  -latter  date  but  three  cases  were  known  to  exist  outside 
the  lazaretto.  Residence  is  not  compulsory,  and  no  sufficient  measures 
are  taken  to  remove  patients  from  their  homes  before  they  may  have 
inoculated  other  members  of  the  family.  The  disease  is  more  restricted 
in  locality  than  formerly. 

Within  the  last  two  years  two  or  three  small  groups  of  the  disease 
have  been  discovered  in  the  island  of  Cape  Breton,  which  are  described 
in  the  Canadian  Journal  of  Med.  Science,  Sept.,  1881. 

These  are  all  the  places  north  of  Mexico  where  the  disease  exists  in 
an  endemic  form.  A  considerable  number  of  cases  have  been  reported 
within  the  past  few  years  from  other  parts  of  the  United  States,  where  it 
has  manifested  itself  in  persons  who  have  formerly  resided  in  leprous 
countries  or  in  those  who  have  wandered  from  the  above  infected  districts. 
A  very  few  instances  have  been  recorded  in  which  it  has  appeared  in  those 
who  have  never  visited  any  infected  locality  or  have  been  in  apparent 
contact  with  lepers.  Such  cases,  if  authentic,  establish  the  possibility  of 
a  sporadic  origin  of  the  affection.  The  fact  of  so  many  foci  already 
established,  and  the  penetration  of  a  race  so  prone  to  the  disease  as  the 
Chinese  into  all  parts  of  the  country,  give  the  study  of  leprosy  in  Amer- 
ica a  special  importance. 

ETIOLOGY. — The  study  of  the  etiology  of  leprosy  is  intimately  con- 
nected with  that  of  its  history  and  geographical  distribution.  From  the 
earliest  times  it  was  regarded  in  all  parts  of  the  world  as  a  contagious 
affection,  and  efforts  were  made  by  the  sternest  laws  of  Church  and  State 
to  control  its  spread  by  segregation,  by  interdiction  of  marriage,  etc.  No 
disease  has  ever  been  regarded  with  an  equal  degree  of  abhorrence  by 
mankind ;  none  has  received  greater  attention  from  physicians  of  every 
age.  Within  the  present  century  it  has  come  to  be  regarded,  almost 
without  exception,  by  the  profession  as  non-contagious.  Peculiarities  of 
climate,  soil,  and  modes  of  life  have  been  looked  upon  as  predisposing, 
exciting,  or  even  essential  influences  in  its  causation ;  but  the  widespread 
distribution  of  the  disease,  with  the  consequent  diversity  of  diet  and 
customs  of  living,  its  prevalence  upon  the  coast  and  in  interior  regions, 
in  high  altitudes  as  well  as  at  the  sea-level,  in  Iceland  as  in  the  tropics, 
show  that  these  conditions,  however  they  may  affect  the  course  of  the 
affection,  have  no  direct  relation  to  its  causation.  The  theory  of  heredity, 
as  the  most  plausible  explanation,  has  received  its  strongest  support  in 
the  investigations  of  Boeck  and  Danielssen  in  Norway,  where  the  disease 
can  be  traced  for  several  generations  in  families.  The  same  conclusions 
readily  present  themselves  where  the  disease  is  studied  in  restricted  local- 
ities, as  in  Louisiana  and  New  Brunswick  at  the  present  time,  where,  as 
we  have  seen,  it  manifests  itself  closely  in  families  in  different  generations. 
But  this  is  a  narrow  point  of  view  from  which  to  study  the  etiology  of 
leprosy.  It  often  fails  to  manifest  itself  in  the  descendants  of  lepers  in 


788  LEPROSY. 

such  communities,  and  affects  persons  in  whose  families  it  has  never 
previously  existed.  Moreover,  in  countries  where  it  does  not  prevail  it 
not  infrequently  attacks  individuals  who  have  at  some  time  visited  legions 
where  it  was  endemic,  and  in  the  latter  places  may  develop  in  immi- 
grants from  parts  of  the  world  where  it  has  never  existed. 

The  same  class  of  facts  which  seem  to  demonstrate  its  hereditary  nature 
may  be  used  in  support  of  its  infectious  character.  The  proper  field  for 
observation  in  this  regard  would  be  a  virgin  region  where  its  natural 
course  could  be  studied  independently  of  theories.  Fortunately  for 
science,  such  an  opportunity  is  afforded  in  the  history  of  the  disease  in 
the  Hawaiian  Islands.  The  exact  date  and  mode  of  its  introduction  there 
are  not  definitely  known.  The  islands  have  for  years  been  the  resort  of 
the  whaling-fleets  manned  by  sailors  coming  from  leprous  regions.  The 
natives  also  shipped  as  sailors,  and  after  visiting  such  ports  returned 
home.  The  absence  of  any  restraint  in  the  intercourse  of  crews  and 
native  women  is  well  known.  Isolated  cases  may  have  occurred  as  far 
back  as  1830,  but  the  disease  made  slow  headway  until  about  1860,  when 
it  increased  so  rapidly  that  the  government  took  stringent  measures  to 
control  it,  all  cases  discovered  being  sent  to  the  leper  segregation  upon 
an  island  from  which  there  is  no  escape.  Since  1866,  2000  cases  have 
been  received  there,  and  at  last  report  the  asylum  contained  750  inmates. 
This  by  no  means  represents  the  extent  of  its  prevalence  in  the  islands, 
however.  As  the  native  population  by  recent  census  was  only  44,000,  it 
will  be  seen  that  the  proportion  affected  is  very  large.  This  unwonted 
rapidity  of  spread  cannot  be  accounted  for  on  the  ground  of  heredity. 
Transference  from  individual  to  individual  by  inoculation  seems  to  be 
the  only  possible  explanation,  and  all  resident  physicians  believe  that  the 
disease  is  contagious  in  this  sense.  It  affects  almost  exclusively  those  of 
native  descent,  and  their  habits  of  life  are  such  as  would  greatly  facilitate 
its  wide  dissemination  in  this  way — viz.  their  great  licentiousness  and  absence 
of  all  fear  of  the  disease,  which  affords  no  bar  to  ordinary  association  or 
cohabitation ;  the  crowding  of  large  families  in  small  huts  and  sharing 
the  same  mats  and  blankets ;  the  eating  of  poi  with  the  fingers  from  the 
same  dish ;  passing  a  common  drinking- vessel  or  pipe  from  mouth  to 
mouth,  ete.1  Promiscuous  and  compulsory  vaccination  with  impure 
virus,  too,  has  been  generally  practised  during  recent  epidemics  of  small- 
pox. It  is  evident  that  abundant  opportunity  has  in  many  ways  been 
presented  for  the  inoculation  of  pus  or  blood  into  the  circulation  from 
infected  to  healthy  persons.  Where  immunity  from  contraction  has 
followed  marriage  with  a  leper,  it  may  be  assumed  that  the  conditions  of 
au  abraded  surface  and  the  contact  with  pus  or  blood  have  not  been  ful- 
filled. The  wide  spread  of  syphilis  among  the  natives,  and  a  consequent 
cachexia,  have  no  doubt  contributed  to  these  conditions  and  established  a 
national  lack  of  resistance  to  the  ravages  of  the  disease.  Nor  can  we 
overlook  the  proclivity  of  all  endemic  diseases  to  extraordinary  manifest- 
ations of  virulence  in  insular  nations  not  previously  protected  by  gradual 
inoculation.  Many  reliable  cases  are  cited  by  resident  physicians  where 
the  evidence  of  direct  communication  of  the  disease  seems  to  be  reliable. 
Facts  of  the  same  nature  may  be  collected  in  the  study  of  the  history  of 

1  Dr.  G.  ~\V.  Woods,  U.  S.  X.,  in  Hygienic  and  Med.  Reports  of  Navy  Department,  vol. 
iv-  1879. 


SYMPTOMATOLOGY.— TUBERCULAR  LEPROSY.  789 

the  disease  in  New  Brunswick  and  in  Louisiana,  where,  as  above  stated, 
much  better  fields  for  investigating  this  question  exist  than  in  the  Old- 
World  regions  where  the  affection  has  been  rife  for  centuries. 

If  we  admit  the  fact  of  transference  by  inoculation  in  a  single  instance, 
there  is  no  reason  why  we  should  not  regard  this  as  the  principal  if  not 
the  only  means  of  extension  of  the  disease,  whether  we  accept  or  not  the 
theory  of  its  parasitic  nature.  It  is  not  inconsistent  with  our  knowledge 
of  its  laws  and  history  to  believe  that  leprosy  is  an  affection  communi- 
cated with  difficulty,  and  after  a  prolonged  period  of  incubation,  from 
one  person  to  another  by  contact  with  certain  products  of  the  diseased 
tissue;  that  it  has  in  past  and  present  time  in  this  way  spread  from  nation 
to  nation ;  and  that  its  progress  as  an  endemic  affection  has  been  checked 
only  by  laws  based  upon  this  theory.  All  the  negative  facts  so  frequently 
urged  against  this  doctrine  of  contagion  apply  as  strongly  to  that  of 
heredity,  and  may  be  interpreted  in  support  of  the  former.  The  latest 
investigations  into  its  pathology  afford  tangible  evidence  in  its  favor.  It 
may  at  least  be  claimed  that  the  question  of  contagion  through  inocula- 
tion must  be  reopened.1 

Leprosy  affects  both  sexes  in  about  equal  degree,  and  may  first  show 
itself  in  early  childhood.  It  is  apt  to  produce  sterility,  so  that  marriages 
between  lepers  are  rarely  fruitful.  This  result  seems  to  limit  the  exten- 
sion of  the  disease  under  the  law  of  heredity  if  we  admit  its  action. 
There  can  be  no  doubt  that  cohabitation  may  take  place  for  years  without 
communication  of  the  disease  where  one  party  alone  is  leprous ;  and  such 
immunity  may  be  explained  by  the  failure  of  favorable  conditions  for 
sexual  inoculation,  just  as  in  syphilis.  The  disease  would  naturally  be 
most  dangerous  in  its  ulcerative  tubercular  form. 

SYMPTOMATOLOGY. — There  are  two  well-marked  forms  of  leprosy — 
viz.  the  tubercular  and  the  anaesthetic — which  are  characterized  by  certain 
easily  recognized  external  manifestations,  and  which  are  accompanied  by 
symptoms  indicative  of  disturbances  of  the  general  economy  as  well  as  of 
special  organs.  These  forms  are  not  always  sharply  defined,  and  often 
occur  simultaneously  or  in  succession  in  individual  cases.  Both  are  gen- 
erally preceded  by  premonitory  symptoms,  consisting  of  unaccountable 
languor  of  mind  and  body,  tingling  sensations  in  the  skin,  rise  of  tem- 
perature in  the  evening,  and  various  disturbances  of  digestion,  or  by  the 
occasional  outbreak  of  single  or  several  blebs.  This  prodromal  stage 
affords  no  indication  of  the  type  of  disease  to  follow,  and  may  last  for 
days,  months,  or  even  years,  with  greater  or  less  intervals  and  intensity. 

TUBERCULAR  LEPROSY. — This  form  may  declare  itself  at  once  by  the 
characteristic  tubercles,  but  frequently  an  earlier  manifestation  is  the 
appearance  of  macules  or  dull  red  spots,  varying  in  size  from  a  pea  to  two 
or  three  inches  in  diameter.  They  have  an  indistinct  margin,  a  glazed 
and  smooth  surface,  and  become  paler  on  pressure.  The  patches,  although 
not  at  all  or  but  slightly  elevated  above  the  general  surface,  are  firmer, 
and  penetrate  more  or  less  deeply  into  the  cutaneous  tissues.  They  may 
increase  in  size  peripherally  and  undergo  involution  in  the  older  central 
portions  simultaneously.  During  the  latter  process  the  color  changes 
from  a  more  or  less  dull  red  to  a  brown,  yellow,  or  grayish  tint,  and 

1  See  article  on  the  question  of  contagion  in  leprosy  in  the  American  Journal  of  Med, 
Sciences,  Oct.,  1882,  by  the  writer. 


790  LEPROSY. 

finally  may  become  quite  white.  The  spots  also  become  thinner  or  even 
slightly  depressed.  Their  seat  is  principally  the  trunk,  but  also  the 
limbs,  and  less  frequently  the  face.  This  condition  of  the  skin  may  pre- 
cede any  other  changes  in  its  tissues  for  months  or  years,  the  patches 
appearing  and  disappearing  or  remaining  as  permanent  stains.  At  last 
well-defined  tubercular  elevations  show  themselves,  varying  in  size  from 
a  small  shot  to  a  filbert,  flattened  or  semi-globular  in  form,  generally 
smooth  and  firm  to  the  touch,  and  of  a  dull  red  or  brown  color.  They 
occur  upon  any  part  of  the  surface,  but  are  especially  abundant  upon  the 
face,  where  they  may  cause  great  deformity  of  the  features.  The  fore- 
head and  eyebrows  may  become  very  greatly  thickened  by  general  infil- 
tration, or  thrown  out  into  very  prominent  folds  and  protuberances  by 
the  massing  of  individual  tubercles.  The  lips  thicken,  the  nose  broadens, 
and  the  ears  stand  out  conspicuously  with  their  increased  bulk.  All  these 
changes  In  form,  with  the  great  darkening  in  tint  which  is  often  present, 
give  at  times  a  most  repulsive  expression  to  the  face.  The  tubercles  are 
sometimes  to  be  felt  imbedded  in  the  skin,  or  considerable  areas  are  found 
to  be  uniformly  thickened  and  scarcely  at  all  prominent.  All  forms  are 
capable  of  involution  after  an  existence  of  months,  and  may  leave  dark- 
colored  atrophic  patches  to  mark  their  seat.  They  are  rarely  painful,  and 
occasionally  slightly  sensitive.  They  may  be  transformed  into  ulcers, 
especially  upon  prominent  positions,  as  the  knuckles,  elbows,  knees,  as  the 
result  of  pressure  or  injury,  which  are  extremely  indolent,  although  shal- 
low, and  may  heal  and  break  down  repeatedly.  Occasionally  they  give 
rise  to  serious  complications — inflammation  of  the  lymph-vessels-,  suppu- 
ration of  the  joints  with  loss  of  the  attendant  members,  as  the  fingers 
and  toes.  Tubercles  appear  also  upon  the  mucous  membrane  of  the  nasal 
cavities,  the  mouth,  and  larynx,  often  in  great  abundance,  causing  a  very 
characteristic  hoarseness  or  loss  of  voice.  With  these  changes  in  the 
cutaneous  tissues,  which  may  be  accompanied  in  their  periods  of  greatest 
activity  by  febrile  disturbances,  there  are  developed  after  months  or  years, 
with  gradual  failure  of  strength,  manifestations  of  changes  in  the  internal 
organs,  the  lungs,  intestines,  and  brain,  which  may  prove  fatal  at  any 
time,  or  the  patient  may  die  of  slowly  progressive  marasmus.  The  course 
of  the  tubercular  form  is  on  the  average  between  eight  and  ten  years.  At 
any  period  there  may  supervene  manifestations  of  the  anaesthetic  type, 
which  makes  the  so-called  mixed  variety,  in  which  either  form  may  pre- 
dominate. 

ANESTHETIC  LEPROSY. — This  variety  is  characterized  by  the  loss  of 
sensation  in  the  skin  over  areas  of  varying  extent,  which  occupy  no  defi- 
nite positions  in  relation  to  nerve-distribution.  The  anaesthetic  patches 
may  appear  upon  the  seat  of  old  maculae  or  former  tubercles  or  of  a  pre- 
ceding bullous  efflorescence,  or  upon  parts  not  previously  affected  in  any 
way.  They  may  follow  a  reddened  and  hyperaesthetic  condition  of  the 
cutaneous  tissues,  or  they  may  be  surrounded  by  a  serpiginous  border  of 
this  character.  The  degree  of  anaesthesia  in  the  affected  parts  is  some- 
times so  complete  that  the  skin  and  underlying  tissues  may  be  deeply 
pricked  or  cut  or  burned  without  the  patient  being  aware  of  the  injury. 
Such  patches  may  possibly  regain  their  sensibility.  Their  surface  appears 
in  later  stages  dry,  wrinkled,  shrunken,  and  of  a  brownish  color,  and 
atrophy,  not  only  of  the  skin  but  of  the  muscles,  is  gradually  developed, 


PATHOLOGICAL  ANATOMY.  791 

in  consequence  of  which  the  expression  of  the  face  undergoes  a  marked 
change.  The  eyelids  and  lips  droop,  the  hair  falls,  the  hands  contract, 
and  the  joints  of  the  fingers  and  toes  are  laid  bare,  so  that  the  phalanges, 
or  even  the  whole  hands  and  feet,  drop  off.  Ulceration  or  gangrene  of 
the  parts  may  develop,  and  whole  extremities  may  shrivel  up.  With 
these  manifestations  of  local  derangements  of  nerve-action  the  functions 
of  the  brain  fail,  the  patient  becoming  stupid  and  incapable  of  action  or 
motion,  the  temperature  and  pulse  are  lowered,  and  death  comes  slowly 
by  marasmus  or  the  most  various  complications — tetanus,  disease  of  the 
lungs,  pyaemia,  etc.  The  average  duration  of  this  form  is  from  eighteen 
to  twenty  years. 

PATHOLOGICAL  ANATOMY. — The  structural  changes  which  take  place 
in  the  tissues  of  parts  which  are  the  seat  of  the  appearances  above 
described  have  received  the  special  study  of  many  excellent  observers 1  in 
recent  times,  and  are  now  well  understood.  A  section  through  the  thick- 
ened skin  or  a  tubercle  shows  the  corium  and  underlying  connective  tissue 
infiltrated  with  round  cells,  as  in  lupus  and  syphilis  ;  in  other  words,  con- 
verted into  "  granulation  tissue."  This  change  first  takes  place  along  the 
course  of  the  cutaneous  vessels  and  glands,  penetrating  more  deeply  and 
forming  a  firmer  cell  new-growth  in  proportion  to  duration,  the  cells 
being  enclosed  in  a  coarse  meshwork  of  fibrous  tissue,  and  encroaching 
upon  the  various  structures  of  the  skin,  so  as  to  produce  atrophy  and 
finally  destruction  of  all  its  characteristic  tissues.  This  cell-infiltration 
may  of  itself  undergo  later  changes,  as  fatty  degeneration  and  softening 
(ulceration).  The  lymph-glands  and  corpuscles  assume  a  special  fatty 
metamorphosis.  An  examination  of  the  tubercles  upon  the  mucous  mem- 
brane reveals  the  same  small-celled  new-growth.  In  the  nerve-tissues  also 
marked  structural  changes  are  found,  both  in  the  central  and  peripheral 
systems,  in  the  anaesthetic  form  of  the  disease.  In  many  cases  the  pos- 
terior segments  of  the  gray  cornua  and  the  fibres  of  the  commissure,  as  well 
as  the  nerves  of  the  extremities,  have  been  found  altered  by  inflammation, 
which  will  account  for  the  disordered  sensibility  and  the  subsequent  dis- 
turbances of  nutrition,  muscular  atrophy,  etc.  The  nerve-trunks  are  often 
to  be  felt  beneath  the  skin,  thickened  and  sensitive  on  pressure.  The 
chronic  cell-infiltration  affects  the  fibrous  structure  of  the  outer  sheath, 
the  neurilemma,  and  the  septa  between  the  nerve-bundles,  producing  fatty 
metamorphosis  and  atrophy  of  the  nerve-bundles.  Similar  cell-infiltra- 
tions are  found  also  in  the  connective  tissue  of  all  the  internal  organs  of 
the  body,  which  lead  to  destructive  processes  in  their  respective  struc- 
tures. 

Within  the  last  two  years  repeated  observations  have  been  made  which 
confirm  the  statement  published  by  Hansen  in  1873,  that  a  peculiar  bac- 
terium occurs  in  leprous  tissues,  which,  it  is  claimed,  establishes  the 
parasitic  nature  of  the  affection.  These  examinations  have  been  carried 
on  with  leprous  material  derived  from  many  parts  of  the  world,  and  the 
results  have  been  uniform.  Within  the  round  cells  which  characterize 
the  cutaneous  neoplasms,  both  in  the  distinct  tubercles  and  the  diffused 

1  Boeck  and  Danielssen,  Traite  de  la  Spedalskhed,  Paris,  1848;  Virchow,  Die  Krank- 
haften  Oeschwillste ;  Kaposi  in  Hebra's  Lehrbuch  der  Hantkrankheiten ;  Monasterski,  Vier- 
teljahressch.  filr  Derm.  u.  Syph.,  1879,  p.  203 ;  Hansen,  Virchou/s  Archiv,  Band  79,  1880 ; 
Neisser,  Virchoufs  Archiv,  Band  84,  1881 ;  Cornil  et  Souchard,  Annales  de  Derm,  et  de 
Syph.,  1881,  No.  4. 


792  LEPROSY. 

infiltrations,  small  agglomerations  of  minute  rod-  or  staff-like  bodies 
(bacilli)  are  found,  arranged  in  parallel  rows  or  placed  end  to  end.  Their 
length  is  one-half  or  three-fourths  the  diameter  of  a  red  blood-globule, 
and  their  breadth  is  one-fourth  their  length.  With  them  minute  granular 
particles  are  seen  in  the  cells.  They  occur  in  greatest  numbers  in  the 
cells  of  the  upper  layers  of  the  true  skin,  which  are  considerably  swollen 
by  their  presence.  They  never  penetrate  the  epithelial  layer,  nor  are  they 
found  in  epithelial  cells  in  any  position.  When  the  protoplasm  of  the  cell 
is  interfered  with  by  the  later  tissue-changes  of  the  disease,  the  bacillus 
perishes.  They  are  found  not  only  in  the  leprous  cells,  but  also  in  those 
of  the  connective  tissue  running  between  the  agglomerated  masses  of  the 
former.  Between  the  leprous  cells  and  the  filaments  of  connective  tissue 
but  few  free  bacilli  are  seen.  The  neoplasms  of  the  mucous  membrane 
and  of  many  organs  of  the  body  have  been  found  to  contain  them  also. 
In  the  blood  they  have  been  detected  by  some  observers.  Their  presence 
in  the  nerve-tissues  is  of  importance  as  throwing  light  upon  the  question 
of  the  specific  or  inflammatory  nature  of  the  morbid  processes  above  de- 
scribed as  affecting  them.  If  we  regard  the  bacteria  as  pathognomonic  of 
leprous  tissue-changes,  their  occurrence,  recognized  in  the  cells  penetrat- 
ing; between  the  fibres  of  the  peripheral  nerves,  would  seem  to  make  all 
primary  structural  changes  identical,  and  the  anaesthetic  as  much  as  the 
tubercular  form  the  direct  result  of  their  presence.  Neisser  draws  the 
following  conclusions  from  his  investigations  :  "  Leprosy  is  a  real  bacterial 
disease,  caused  by  a  special  kind  of  bacterium.  The  bacilli  appear  in  the 
tissues  as  such,  or  more  probably  as  spores,  and  remain  for  a  longer  or 
shorter  time  in  a  state  of  incubation,  according  to  circumstances,  in 
depots,  perhaps  in  the  lymph-glands.  This  period,  much  longer  than  in 
other  infective  diseases,  is  in  proportion  to  the  physiological  resistance  of 
the  human  organism  compared  with  the  feeble  developing  power  of  the 
bacilli.  It,  as  well  as  the  course  of  the  disease,  is  more  rapid  in  tropical 
countries  than  in  Europe.  From  these  depots  the  disease  extends  through- 
out the  body  in  those  portions  of  the  skin  most  exposed,  the  face,  hands, 
elbows,  knees,  and  into  the  peripheral  nerves.  The  other  organs  are  less 
freely  invaded.  The  bacilli  excite  inflammation,  and  by  a  specific  action 
transform  the  migrating  cell  into  the  leprous  cell.  Leprosy  is  probably 
an  infectious  disease,  and  its  specific  products  are  contagious — viz.  the 
leprous  cells  of  the  tubercles,  the  tissue-fluids,  and  the  pus  containing 
bacilli  or  viable  spores.  On  the  other  hand,  the  pus  may  not  always  be 
infectious,  as  the  fluid  contained  in  the  bullse  is  not." 

It  must  be  said  that  the  bacterial  nature  of  leprosy,  if  established 
in  accordance  with  the  above  observations,  furnishes  a  satisfactory  basis 
of  explanation  of  all  facts,  historical,  clinical,  and  pathological,  which 
have  so  long  been  awaiting  solution.  The  inability  of  the  parasite  to 
penetrate  the  epithelial  layer  of  the  skin  and  mucous  membrane  explains 
why  contagion  is  so  difficult,  and  why  the  ulcerative  tubercular  form 
would  be  more  favorable  to  such  transference  than  the  anesthetic  variety. 

DIAGNOSIS. — Leprosy  in  some  of  its  early  appearances  may  be  readily 
confounded  with  vitiligo,  morphoea,  pemphigus,  lupus,  and  syphilis.  In 
some  cases  its  prodromal  manifestations  cannot  be  positively  diagnosti- 
cated until  other  symptoms  have  developed,  which  by  concurrence  estab- 
lish their  true  significance.  Such  are  the  pemphigus-like  bullao,  the 


*    PROGNOSIS.— TREATMENT.  793- 

pigment-changes,  and  the  smaller  tubercular  efflorescences.  In  regions 
where  the  disease  occurs  only  by  importation,  and  in  the  so-called  spor- 
radic  cases,  it  is  not  at  all  strange  that  it  should  fail  of  recognition,  even 
in  well-advanced  forms,  unless  the  observer  is  acquainted  with  its  whole 
symptomatology.  On  the  other  hand,  there  is  no  disease  which  presents 
more  strikingly  characteristic  features  in  its  advanced  stages. 

PROGNOSIS. — Leprosy  is  almost  uniformly  a  fatal  affection,  and  its 
course  toward  this  termination  varies  but  slightly  under  the  most  diverse 
conditions  of  life.  Its  development  and  progress  are  naturally  more 
rapid  under  circumstances  of  least  individual  resistance,  where  food  is 
poor  and  scanty,  where  extremes  of  climate  are  most  felt,  where  the  con- 
stitution of  the  individual  or  nation  is  debilitated  by  previous  disease,  as 
that  of  the  Hawaiians  by  syphilis,  or  where  no  proper  professional  care  is 
employed.  It  has  been  believed  that  a  change  of  residence  from  infected 
to  non-leprous  regions  would  retard  its  advance  or  avert  its  appearance 
in  those  supposed  to  be  hereditarily  disposed ;  but  the  former  effect  fol- 
lows probably  only  so  far  as  the  general  condition  of  the  patient  is  affected 
by  the  change,  as  in  other  constitutional  disorders,  and  the  latter  is  neces- 
sarily a  matter  wholly  of  conjecture.  No  case  of  leprosy  in  the  Norwe- 
gian colony  in  our  North-western  States  has  ceased  to  progress  after 
arrival  toward  its  fatal  ending,  even  if  this  has  been  somewhat  delayed 
in  individual  cases  under  more  generous  ways  of  living.  If  it  could  be 
known  that  a  child  born  in  Norway  had  escaped  leprosy  by  removal  to 
America,  we  should  not,  if  we  accept  the  bacterial  origin  of  the  disease, 
consider  that  climate  or  other  mysterious  'influences  had  overcome  its 
inherited  tendencies,  but  that  it  had  been  taken  away  from  the  chance 
of  direct  inoculation.  It  is  stated  that  very  rarely  cases  cease  to  progress 
beyond  certain  stages  even  in  countries  where  the  disease  is  endemic. 
The  course,  as  has  been  stated,  varies  according  to  the  clinical  form,  the 
duration  of  the  tubercular  variety  being  on  an  average  but  one-half  that 
of  the  purely  anaesthetic  type.  Leprosy  may  be  called  the  slow  disease, 
its  period  of  incubation,  so  far  as  this  can  be  determined,  extending  from 
one  to  several  years,  its  prodromal  stage  lasting  often  several  more  years, 
and  its  well-developed  forms  requiring  at  times  more  than  twenty  years 
to  destroy  the  patient.  Cases  sometimes  prove  fatal,  however,  in  a  single 
year. 

TREATMENT. — In  a  disease  which  affects  so  many  of  the  races  and 
such  great  numbers  of  mankind,  which  has  been  for  centuries  the  object 
of  special  attention  on  the  part  of  physicians,  and  of  late  years  of  govern- 
ment commissions  and  of  eminent  pathologists,  it  is  evident  that  every 
remedy  which  the  materia  medica  includes,  as  well  as  those  of  merely 
popular  reputation  in  the  widely-diverse  geographical  regions  in  which  it 
prevails,  must  have  been  employed  in  its  treatment.  None  of  them  exert 
any  specific  action  upon  it ;  it  remains  incurable.  Every  year  some  new 
article  is  employed  with  the  usual  claims  of  success  which  accompany  the 
introduction  of  new  remedies,  but  they  merely  swell  the  long  list  of  fail- 
ures in  the  therapeutics  of  the  affection.  Still,  leprosy  is  influenced 
somewhat  by  medical  care;  life  may  be  prolonged  and  made  more 
comfortable.  To  this  end  we  may  employ  remedies  which  are  capable 
of  improving  and  maintaining  the  constitutional  powers  of  resistance  to 
the  disease,  such  as  are  found  of  service  in  other  chronic  wasting  affections. 


794  LEPROSY. 

The  patient  is  to  be  put  in  as  healthy  ways  of  living  as  possible,  removed 
from  debilitating  localities,  and  given  generous  diet  and  tonics,  as  iron 
and  quinia.  Several  new  drugs  which  seem  to  stimulate  the  nutrition 
and  produce  temporary  improvement  in  the  local  and  general  symptoms 
have  lately  been  widely  employed,  as  Gurjun  balsam  and  chaulmoogra 
oil,  but  they  have  wrought  no  cure.  Digestion  is  to  be  aided,  diarrhoea 
to  be  checked,  and  disturbances  of  respiration  to  be  alleviated.  Local 
treatment  is  also  of  service.  The  tubercles  may  sometimes  be  made  to 
disappear — partly,  at  least — by  stimulating  applications,  and  ulcers  made 
to  heal  by  cauterization  and  other  well-known  methods  of  dressing. 
These  ulcers  and  their  secretions  should  be  regarded  as  possible  sources 
of  infection  by  attendants  and  members  of  the  patient's  household.  For 
the  anaesthetic  alterations  in  the  tissues  but  little  can  be  done  locally. 
If  the  bacterial  origin  and  causation  of  the  disease  be  eventually  estab- 
lished, its  future  extinction  must  be  based  upon  studies  directed  to  the 
nature  and  mode  of  protection  against  this  organism.  Collectively,  the 
disease  should  be  treated  by  every  nation  by  thorough  segregation,  and 
importation  should  be  prevented  by  the  most  rigid  quarantine  laws. 


EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

BY  ALFRED  STILLE,  M.  D.,  LL.D. 


DEFINITION. — A  febrile,  and  often  malignant,  but  non-contagious  dis- 
ease of  unknown  origin ;  usually  occurring  as  a  local  epidemic ;  confined 
hitherto  to  the  North  American  and  European  continents,  and  to  the  vicin- 
ity of  the  latter ;  characterized  by  its  rapid  and  irregular  course,  and  usu- 
ally by  a  tetanic  rigidity  or  retraction  of  the  neck,  a  tendency  to  disor- 
ganization of  the  blood,  and  the  formation  of  inflammatory  exudates 
beneath  the  membranes  of  the  brain  and  spinal  cord. 

SYNONYMS. — Spotted  fever ;  petechial  fever ;  malignant  purpuric  fever ; 
malignant  purpura ;  pestilential  purpura;  black  death;  typhus  petechialis ; 
typhus  syncopalis;  febris  nigra;  febbre  soporoso-convulsivo ;  tifo  apo- 
plettico  tetanico ;  fievre  c6rebro-spinale ;  typhus  cerebro-spinale ;  phreni- 
tis  typhodes;  epidemic  meningitis;  epidemic  cerebro-spinal  meningitis; 
malignant  meningitis ;  typhoid  meningitis ;  m6ningite  cer6bro-spinale  epi- 
demique ;  m^ningite  c6rebro-rachidienne ;  Genickkrampf ;  Genickstarre. 

The  names  which  have  been  given  to  this  disease  convey  more  or  less 
distinctly  one  or  the  other  of  two  ideas:  1st,  that  the  disease  is  essen- 
tially a  blood-disorder ;  and  2d,  that  it  is  an  inflammation  of  the  cerebro- 
spinal  meniuges.  Under  the  first  head  belong  the  following  names : 
Malignant  purpuric  fever;  malignant  purpura;  pestilential  purpura; 
petechial  fever ;  spotted  fever ;  febris  nigra ;  black  death,  etc.  Under 
the  second  head  belong  epidemic  cerebro-spinal  meningitis ;  epidemic 
meningitis ;  malignant  meningitis  ;  typhoid  meningitis,  etc.  As  partak- 
ing of  the  qualities  of  both  categories  may  be  cited  the  names  cerebro- 
spinal  fever  and  fever  with  cerebro-spinal  meningitis.  In  regard  to  all 
those  of  the  first  class  it  is  sufficient  to  repeat  the  criticism  made  by  the 
early  American  writers  who  described  this  disease  after  having  largely 
studied  it.  One  only  of  them  need  be  cited,  because  he  expresses  the 
opinion  of  all.  Miner,  writing  in  1822,  said  :  "  It  is  quite  unfortunate 
that  a  single  symptom  (petechise),  and  one,  too,  that  is  wanting  in  a  great 
majority  of  cases,  should  have  been  seized  upon  to  give  it  the  odious  and 
deceptive  name  of  spotted  fever,  as  that  name  has  been  applied  by  Euro- 
pean writers  to  a.  very  different  kind  of  fever."  Among  the  names  given 
to  the  disease,  cerebro-spinal  fever  is  perhaps  the  least  suitable  and  the 
least  in  harmony  with  the  principles  of  scientific  nomenclature.  It  is  one 
of  those  terms  which  may  be  pardoned  when  used  by  the  laity,  but  which 
educated  physicians  ought  not  tolerate.  Parallel  examples  may  be  found 
in  such  compounds  as  brain-fever,  lung-fever,  gastric-fever,  and,  most 
unfortunate  of  all,  enteric  fever.  The  first  three  of  these  are  inflamma- 

795 


796  EPIDEMIC  CEREBEO-SPINAL  MENINGITIS. 

tions,  pure  and  simple,  of  the  brain,  lung,  and  stomach ;  and,  after  their 
example,  cerebro^spinal  meningitis  would  be,  what  it  is  not,  merely  an 
inflammation  of  the  membranes  of  the  brain  and  spinal  marrow.  The 
name  of  the  remaining  disease  has  only  to  be  turned  into  English  and 
called  intestinal  fever  to  demonstrate  its  defects.  It  is  evident  that  other 
diseases — and  dysentery  in  particular — are  equally  entitled  to  be  called 
enteric  fever.  Moreover,  there  are  cases  of  enteric  fever  in  which  death 
takes  place  so  early  that  the  intestinal  lesion  is  undeveloped,  and  the  fatal 
issue  must  be  attributed  to  the  fever-poison  in  the  blood  or  else  to  the 
changes  it  has  wrought  in  that  fluid.  Analogous  illustrations  abound  in 
the  history  of  the  eruptive  fevers.  The  disease  we  are  studying  presents 
another  affection  in  which  the  septic  element  sometimes  so  far  overrides 
the  inflammatory  as  to  destroy  life  before  the  latter  has  developed  charac- 
teristic tissue-changes.  There  may  be  no  valid  objection  against  classing 
it  among  the  fevers,  but  there  can  be  no  excuse  for  denominating  it  cerebro- 
spinal  fever.  The  very  reasons  that  militate  against  its  being  regarded  as 
a  meningitis  forbid  its  being  considered  as  a  meningeal  fever.  But  if  it 
is  a  meningitis,  inchoate  or  complete,  then  the  prefix  epidemic  denotes  its 
constitutional  nature  and  its  probable  blood  origin,  and  a  term  is  employed 
which  is  descriptive  and  accurate,  and  not  misleading.  Moreover,  the 
term  epidemic  indicates,  or  at  least  implies,  the  characteristic  type  of  the 
disease,  which  is  asthenic  and  sometimes  more  or  less  typhoidal,  just  as 
'  other  inflammatory  diseases  become  so  in  their  epidemic  form — e.  g.  pneu- 
monia, bronchitis  (influenza)^  dysentery,  etc. 

There  ought  to  be  no  doubt  whether  epidemic  meningitis  should  be 
classed  with  general  diseases  or  with  inflammations.  It  is  excluded  from 
the  latter  class  by  the  total  absence  of  any  tangible  external  cause  from  its 
causation,  as  well  as  by  its  frequent  fatal  termination  before  the  charac- 
teristic signs  of  inflammation  have  had  time  to  form,  or  because  the  pecu- 
liar type  of  the  disease  prevents  their  development.  It  belongs  to  the 
former  class  because  it  is  epidemic  in  the  largest  sense,  its  outbreaks  occur- 
ring simultaneously  in  remote  parts  of  the  earth  and  independently  of  all 
cognizable  celestial  or  terrestrial  influences.  In  this  as  in  other  elements 
of  its  pathology  the  disease  stands  absolutely  alone.  While  the  acute 
affections  of  the  pulmonary  and  digestive  organs,  which  were  just  now 
alluded  to,  affect  large  districts,  and  even  sweep  over  a  whole  continent 
epidemic  meningitis  breaks  out  in  limited  localities,  and  may  for  years 
prevail  in  a  populous  city  within  a  hundred  miles  of  another  still  more 
populous  which  during  that  time  may  altogether  escape  its  ravages.  Of 
this  curious  fact  the  cities  of  Philadelphia  and  New  York  present  a  strik- 
ing illustration.  Since,  then,  we  are  ignorant  of  the  circumstances  under 
which  the  disease  arises,  and  since,  as  will  more  distinctly  appear  later  on, 
its  several  forms  really  include  quite  various  morbid  conditions,  we  are 
compelled  to  consider  it  as  occupying  a  peculiar  and  exceptional  nosologi- 
cal  position. 

HISTORY. — Previous  to  the  present  century  the  existence  of  this  dis- 
ease can  hardly  be  demonstrated.  And  yet  Dr.  B.  W.  Richardson 
believed  that  some  faint  traces  of  it  could  be  discovered,  as  in  the  follow- 
ing statement:1  "The  great  plague  which  visited  Constantinople  in  543, 
and  which  Procopius  and  Enagrius  described,  the  plague  of  hallucina- 
1  Diseases  of  Modern  Life,  p.  16. 


HISTORY.  797 

tion,  drowsiness,  slumbering,  distraction,  and  ardent  fever,  with  eruption 
on  the  skin  of  _  black  pimples  the  size  of  a  lentil, — this  plague,  which 
usually  killed  in  five  days,  and  left  many  who  recovered  with  withered 
limbs,  wasted  tongues,  stammering  speech  or  such  utterance  of  sound 
that  their  words  could  not  be  distinguished, — this  plague,  which  had 
passed  into  mythical  learning  under  the  name  of  cerebro-spinal  menin- 
gitis, has  also  in  our  time  reappeared."  The  concluding  statement  in 
regard  to  the  name  of  the  plague  is  quite  erroneous,  and  there  is  nothing 
in  the  description  which  distinctively  applies  to  the  disease  we  are  exam- 
ining. On  the  other  hand,  we  know  that  Procopius  wrote  a  history  of 
the  Oriental  plague,  which  invaded  Europe  for  the  first  time  at  the  very 
date  above  given.  It  had  as  a  distinctive  symptom  the  well-known 
inguinal  bubo,  and  there  is  no  mention  whatever,  in  the  descriptions  of  it 
that  have  survived,  of  the  tetanoid  symptoms  belonging  to  epidemic  men- 
ingitis. In  1802  an  epidemic  occurred  at  Koetlingen  in  Franconia  which 
had  a  certain  resemblance  to  the  subject  of  this  article,  for  it  was  charac- 
terized by  lacerating  pains  in  the  back  of  the  neck.  According  to  Hecker, 
this  was  the  sweating  sickness  which  had  ravaged  various  parts  of  Europe 
during  the  Middle  Ages,  and  of  which  limited  outbreaks  still  recur.  In 
1 880  such  a  one  took  place  at  File  d'Oleron  in  France,  and  many  of  the 
patients  were  affected  with  tonic  or  clonic  spasms,  both  general  and  local, 
but  not,  apparently,  opisthotonic.1 

If  epidemic  meningitis  occurred  before  the  nineteenth  century,  it  must 
have  been  confounded  with  other  affections,  but  when  we  consider  its  cha- 
racteristic symptoms  such  an  error  seems  improbable.  The  comparatively 
rare  resort  at  that  time  to  post-mortem  examinations,  particularly  of  the 
cranial  and  spinal  cavities,  may  in  part  account  for  such  a  confusion  of 
ideas ;  and  even  when  dissections  were  made,  the  skill  to  interpret  the 
discovered  lesions  was  possessed  by  few.  It  has  been  thought  that  in  the 
latter  part  of  the  last  century  some  cases  of  this  disease  were  seen  and 
described,  although  their  nosological  value  was  unrecognized.  Thus, 
Stoll 2  speaks  of  a  young  soldier  who  was  seized  with  a  pain  in  the  back 
of  the  head  and  neck,  and  who  was  affected  with  opisthotonos  before  he 
died.  On  examination  pus  was  found  between  the  arachnoid  and  the 
pia  mater.  The  first  clear  and  unquestionable  description  of  epidemic 
meningitis  was  published  in  1805,  first  by  Vieusseux  and  directly  after- 
ward by  Mathey.3  The  disease  appeared  at  Geneva  in  the  spring  of  the 
year,  in  a  family  composed  of  a  woman  and  three  children,  of  whom  two 
of  the  latter  died  within  twenty-four  hours.  A  fortnight  later  four 
children  in  a  neighboring  family  died  of  it  after  fourteen  or  fifteen  hours' 
illness,  and  a  young  man  in  an  adjoining  house,  being  attacked,  died  the 
same  night,  with  his  whole  body  of  a  violet  color.  The  disease  ceased 
during  the  spring,  after  having  destroyed  thirty-three  lives.  Its  dis- 
tinctive features  were  an  abrupt  attack  during  the  night,  bilious  vomit- 
ing, excruciating  headache,  rigidity  of  the  spine,  difficult  deglutition,  con- 
vulsions, nocturnal  paroxysms,  petechise,  and  death  in  from  twelve  hours 
to  five  days.  Vieusseux  calls  it  "a  malignant  non-contagious  fever," 
.and  Mathey  gives  as  the  lesions  revealed  by  dissection  a  gelatinous  exu- 

1Pineau,  Archives  gen.  de  med,  torn,  i.,  1882,  pp.  25,  169. 

2  Quoted  by  Boudin,  Hist,  du  typhus  cerebro-spinal,  p.  5. 

8  Journ.  de  Med.,  Chirurg.  et  Pharm.,  etc.,  an.  xiv.,  torn.  xi.  pp.  163,  243 


798  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

dation  covering  the  convex  surface  of  the  brain,  and  a  yellow  puriform 
matter  upon  its  posterior  aspect,  upon  the  optic  commissure,  the  inferior 
surface  of  the  cerebellum,  and  the  medulla  oblongata. 

After  its  first  appearance  at  Geneva  the  disease  does  not  seem  to  have 
extended  in  any  direction  from  that  place  as  a  centre,  but  we  next  hear  of 
it  at  two  points  remote  from  it  and  from  one  another — Germany  and  the 
United  States.  From  the  former  it  extended  to  the  conterminous 
countries,  Bavaria,  Holland,  and  the  east  of  France,  where,  however,  it 
prevailed  neither  extensively  nor  fatally,  and  soon  died  out;  while  in 
America  it  first  appeared  at  Medfield,  Mass.,  in  1806.  The  European 
epidemic  was  faintly  felt  in  England  the  following  year,  and  between  that 
time  and  1816  it  prevailed  at  several  places  in  the  east  of  France,  and 
slightly  at  Paris,  while  during  the  corresponding  period  it  had  extended 
through  New  England  into  Canada,  New  York,  Pennsylvania,  and 
several  Western  and  South-western  States.  It  is  a  noteworthy  fact  that 
on  both  sides  of  the  Atlantic  it  ceased  in  the  same  year  (1816).  During 
the  six  following  years  we  can  discover  no  trace  of  its  existence,  but  in 
1822-23  it  reappeared  at  Vesoul  in  France,  and  at  Middletowu,  Con- 
necticut, and  does  not  seem  to  have  extended  beyond  those  places.  Again, 
after  an  interval  of  five  years,  in  1828  it  was  heard  of  in  Trumbull  co., 
Ohio,  two  years  later  at  Sunderland  in  England,  and  three  years  after- 
ward (in  1833)  at  Naples. 

After  four  years  of  quiescence  the  disease  entered  upon  a  wider  and 
more  destructive  career  than  ever  before,  which  was  almost  uninter- 
rupted from  1837  to  1850.  During  the  first  two  years  of  its  recurrence 
in  Europe  it  was  confined  almost  wholly  to  France.  It  began  in  the 
southern  departments,  with  Bayonne  as  a  centre,  and  extended  gradually 
westward  and  northward,  in  some  places  attacking  only  military  garrisons 
and  in  others  only  civilians.  Elsewhere  the  predilection  was  reversed, 
or,  again,  civilians  and  soldiers  were  equally  affected.  As  Boudin  has 
pointed  out,  "  it  located  itself  in  certain  districts ;  in  garrison-towns  it 
seemed  to  affect  certain  barracks  only,  and  in  them  only  certain  rooms. 
In  one  place  it  broke  out  in  a  prison  and  spared  the  soldiers ;  in  another  its 
victims  were  among  the  soldiers  and  the  citizens,  while  the  prisoners  were 
untouched."  Thus  the  disease  spread  over  the  whole  of  France,  and  was 
more  fatal  almost  everywhere  else  than  in  Paris  itself.  Almost  at  the  gates 
of  the  capital,  at  Versailles,  and  among  the  garrison,  it  was  very  destruc- 
tive in  1839,  causing  a  mortality  among  those  attacked  of  from  50  to  75 
per  cent.  About  the  same  time  it  occasioned  a  great  mortality  at  other 
military  posts,  especially  at  Rochefort  and  Metz,  and  in  1840-41  at 
Strasbourg.  In  1843  the  disease  had  almost  ceased  to  prevail  in  France, 
out  in  1846  it  reappeared  at  Lyons,  and  in  the  following  years,  and  until 
1849,  affected  the  garrisons  of  Orleans,  Cambrai,  Saint-£tienne,  Metz 
again,  Luue'ville,  Dijon,  Bourges,  and  Toulon.  In  some  of  these  places 
the  military  experienced  five,  and  even  seven,  successive  epidemics. 
Meanwhile,  the  disease  spread  to  Algeria  (1839-47),  and  to  Italy  in  the 
former  year — not,  however,  on  the  confines  of  France,  but  at  Naples  and 
in  the  Romagna,  whence  it  extended  to  Sicily  and  Gibraltar,  and  did  not 
cease  there  until  1845.  In  1839  it  first  showed  itself  in  Denmark,  and 
remained  for  about  three  years,  while  in  1846  it  "appeared  in  the 


HISTORY.  799 

majority  of  the  workhouses  of  Ireland/'  and  in  the  spring  of  the  same 
year  it  occurred  in  England,  at  Liverpool  and  Eochester. 

While  the  disease  was  thus  spreading  throughout  Europe,  it  again,  in 
1842,  appeared  in  the  United  States,  but  at  places  as  remote  as  possible 
from  Transatlantic  communication  and  hundreds  of  miles  distant  from 
one  another — e.  g.  in  Louisville,  Kentucky,  in  Eutherford  co.,  Tennessee, 
and  in  Montgomery,  Alabama.  In  the  following  year  it  prevailed  in 
Arkansas,  Mississippi,  and  Illinois.  In  1848  it  occurred  again  at  Mont- 
gomery, Ala.,  and  simultaneously,  in  Beaver  co.,  Pa. ;  in  1849  it  existed 
in  Massachusetts  and  in  Cayuga  co.,  N.  Y.,  and  in  1850  at  New  Or- 
leans. 

Between  1850  and  1854  epidemic  meningitis  ceased  to  be  heard  of,  but 
in  the  spring  of  the  latter  year  it  began  to  appear  in  the  southern  prov- 
inces of  Sweden,  whence  it  rapidly  spread  over  the  greater  part  of  the 
kingdom,  reaching  an  extreme  degree  of  fatality  in  1858,  and  not  finally 
disappearing  until  1861.  It  is  said  to  have  caused  more  than  four 
thousand  deaths.  It  was  not  until  the  height  of  the  Swedish  epidemic  in 
1858  that  it  invaded  Norway,  where  it  seems  to  have  been  even  more 
malignant  and  extensive.  Between  1850  and  1860  local  outbreaks  of 
the  disease  took  place  in  Ireland,  and  isolated  cases  were  observed  in 
various  parts  of  England,  but  in  that  country  it  has  never  prevailed  as  a 
general  epidemic.  This  fact  alone  is  sufficient  to  defeat  all  the  attempts 
that  have  been  made  to  trace  the  origin  of  th§  disease  to  any  of  the  con- 
ditions associated  with  a  crowded  population.  In  Scotland,  where  such 
conditions  exist  in  their  greatest  intensity  and  fulness  of  development,  it 
has  never  occurred  as  an  epidemic.  During  the  decade  under  considera- 
tion (in  1856  and  1857)  epidemic  meningitis  again  appeared  in  the  United 
States,  and,  as  before,  at  points  very  remote  from  one  another.  In  the 
former  year  it  occurred  for  the  first  time  in  North  Carolina,  and  in  the 
latter  year  in  the  central  portions  of  New  York  and  Massachusetts. 

Hardly  had  the  disease  subsided  in  the  Scandinavian  peninsula  and  in 
the  United  Kingdom  when  it  reappeared  in  Holland  during  the  winter  of 
1860—61.  In  the  following  year  and  at  the  same  season  it  occupied  a 
large  extent  of  Portuguese  territory,  including  the  cities  of  Oporto  and 
Lisbon,  and  now  for  the  first  time  it  spread  over  Germany.  Beginning 
slightly  during  the  summer  of  1863  in  Prussia,  it  acquired  new  vigor 
during  the  succeeding  winter,  and  in  the  two  following  years  it  devas- 
tated almost  every  part  of  Northern  Germany,  and  in  1864—65  extended 
throughout  Bavaria  except  in  its  southern  and  western  provinces.  Strange 
to  relate,  the  disease  appears  to  have  passed  almost  wholly  by  Austria 
proper,  and  to  have  prevailed,  although  not  extensively  nor  fatally,  in 
Hungary,  and  in  the  latter  part  of  the  decade  in  Istria,  Greece,  Turkey, 
and  Asia  Minor. 

The  American  counterpart  of  this  epidemic  first  appeared  in  Living- 
ston co.,  Missouri,  in  the  winter  of  1861—62,  and  during  the  same  season 
it  invaded  Indiana  and  Kentucky  in  the  West  and  Connecticut  in  the 
East.  From  about  the  same  date,  and  until  1864,  it  prevailed  in  Ohio, 
and  during  the  last-named  year  in  Illinois.  Cases  occurred  at  Newport, 
Ehode  Island,  in  1863,  and  in  Vermont  in  1864.  In  the  winter  and 
spring  of  the  latter  year  it  broke  out  at  Carbondale,  Pa.,  and  in  a  popu- 
ulatlon  of  6000  caused  the  death  of  400,  principally  among  children  and 


800  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

very  young  persons.1  In  the  winters  of  1863-64  and  of  1864-65  it  pre- 
vailed in  the  U.  S.  ariny,  and  in  the  early  part  of  this  period  in  the  Con- 
federate army  which  at  the  time  was  stationed  near  Fredericksburg,  Va. 
In  North  Carolina  also,  from  1862  to  1864,  the  disease  assumed  a  very 
malignant  type,  and  affected  citizens  and  soldiers  equally,  and  the  latter 
in  the  Union  and  Confederate  armies  alike.  During  the  winter  of  1 864- 
£5  a  limited  but  very  fatal  epidemic  of  the  disease  prevailed  at  Little 
Rock,  Arkansas.  About  the  same  time  it  existed  as  an  epidemic  in  Mary- 
land, Alabama,  and  other  Southern  States,  and  throughout  the  Civil  War 
affected  both  whites  and  negroes,  but  showed,  as  in  France,  an  excep- 
tional gravity  among  the  military. 

The  first  appearance  of  the  disease  in  Philadelphia  took  place  in  1863, 
and  from  that  date  until  the  present  (1884)  it  has  never  failed  to  appear 
among  the  causes  of  death  in  the  reports  of  the  Health  Office.  A  table 
compiled  by  Dr.  C.  F.  Clark,  and  printed  in  a  paper  on  the  subject  by 
Dr.  James  C.  Wilson,2  exhibits  the  difficulties  of  obtaining  accurate  sta- 
tistics, even  from  official  reports,  on  this  subject.  The  medical  profession 
of  the  city,  having  had  but  little  knowledge  of  the  disease  either  by 
reading  or  observation,  reported  deaths  from  it  which  occurred  in  their 
practice  under  various  denominations.  At'  first  it  was  spotted  fever, 
which  continued  to  be  used  by  many  for  a  year  or  two,  when  it  was 
superseded  almost  entirely  by  cerebro-spinal  meningitis.  There  can  be 
no  doubt  that  both  of  these  terms  were  used  to  designate  the  same  dis- 
ease, and  therefore  no  error  will  be  committed  in  merging  the  deaths 
charged  to  each  of  them,  and  in  estimating  by  their  annual  totals  at  least 
the  relative  mortality  of  the  disease  in  the  successive  years  of  the  period. 
But  in  the  Health  Office  reports  there  are  at  least  three  other  rubrics 
that  suggest  doubt.  One  is  typhus  fever,  which  seems  to  have  presented 
a  sudden  and  remarkable  increase  of  mortality  during  the  first  years,  and 
the  most  fatal,  of  the  existence  of  cerebro-spinal  meningitis.  It  should 
also  be  observed  that  typhus  fever  is  applied  by  many  German  physicians 
in  this  country,  as  in  their  native  land,  to  typhoid  fever.  A  second  is 
malignant  fever,  and  a  third  is  congestive  fever,  neither  of  which  has 
claimed  many  victims  in  the  health  reports  of  Philadelphia  except  while 
meningitis  was  epidemic.  It  seems  probable,  therefore,  that  nearly  all 
of  the  deaths  charged  under  these  heads  belong  to  the  disease  under 
consideration. 

Deatlis  in  Philadelphia  from  Cerebro-Spinal  Meningitis  from  1863-82. 

Brought  over 1136 


1863 49 

1864 384 

1865 192 

1866 92 

1867 109 

1868 55 

1869 37 

1870 36 

1871 49 

1872 133 


1873 246 

1874 82 

1875 83 

1876 85 

1877 56 

1878 90 

1879 62 

1880 78 

1881 90 

1882 41_to  Sept.  23d. 


1136  Total 2049 


If  to  these  deaths  are  added  those  charged  to  malignant  fever,  111,  and  to 
1  Burr,  Trans.  Med.  Soc.  State  of  N.  York,  1865,  p.  40.        2  Phila.  Med.  Times,  xiii.  88. 


ETIOLOGY.  801 

congestive  fever,  279,  we  obtain  a  total  of  2439  deaths,  nearly  all  of 
which  may  be  set  to  the  account  of  epidemic  meningitis.  It  may  also  be 
remarked  that  up  to  the  date  at  which  this  computation  was  made  (May, 
1883)  hardly  a  week  passed  in  which  the  Health  Office  did  not  register 
several  deaths  from  this  cause.  Hence  it  would  appear  that  the  disease 
continues  to  linger  in  this  locality  longer  than  has  been  reported  of  any 
other  place  from  which  information  has  been  obtained. 

In  the  city  of  New  York  it  appears  to  have  been  much  more  limited 
both  in  extent  and  duration.  The  first  recorded  death  from  it  was  in 
1861  ;  in  1866  the  deaths  were  18;  in  1867  the  deaths  were  32;  in  1868 
they  were  34 ;  in  1869,  42 ;  in  1870,  32 ;  in  1871,  48.  In  1872  the 
disease  became  epidemic,  and  "  from  January  6  to  May  31,  inclusive, 
632  cases  were  reported  to  the  City  Sanitary  Inspector,  and  469  deaths 
to  the  Bureau  of  Records  of  Vital  Statistics"  (Clymer).  After  this 
period  the  disease  seems  to  have  declined  very  rapidly,  and  not  to  have 
reappeared,  since  no  notice  is  taken  of  its  recurrence  by  the  medical 
journals  of  New  York. 

It  Avas  mentioned  above  that  about  1870  some  traces  of  the  disease 
were  observed  in  Asia  Minor,  and  in  1872  several  cases  are  said  to  have 
occurred  at  Jerusalem,1  but  beyond  that  time  and  place  it  does  not  appear 
to  have  extended  as  an  epidemic.  In  1879,  Cheevers  said:  "I  am  not 
aware  of  the  existence  of  any  report  of  an  outbreak  of  the  disease  in 
India."  He  refers,  however,  to  several  cases  occurring  in  Calcutta  as 
possibly  representing  this  affection.2 

In  1867—68  sporadic  cases  occurred  at  Little  Rock,  Ark.,  and  in  the 
former  year  in  Madison  co.,  N.  Y.,  thirty-three  cases  were  reported.3  In 
Chicago,  between  February  and  April,  1872,  Dr.  Davis  reported  forty 
cases  observed  in  his  own  practice  in  seventy-two  days.  In  the  same 
year  the  disease  occurred  at  Elizabethtown,  Ky.,4  and  at  Louisville,  Ky., 
in  December  of  the  same  year.  It  existed  in  Michigan  between  1868 
and  1874,  but  only  in  the  latter  year  epidemically,  and  not  to  a  very 
great  extent. 

Of  later  occurrences  of  the  disease  the  following  may  be  mentioned : 
Several  cases  were  reported  in  London  in  1867,  1871,  1876,  and  1878.5 
In  1870  four  cases  were  observed  in  Providence,  R.  I.6  In  1882  cases  were 
met  with  in  Boston,  New  York,  Philadelphia,  Pittsburg,  Western  Ohio, 
Indianapolis,  Detroit,  Louisville,  Memphis,  New  Orleans,  Richmond, 
Milwaukee,  St.  Louis,  Salt  Lake  City,  San  Francisco,  etc.,  but  in  none  of 
these  places  did  the  disease  become  epidemic. 

ETIOLOGY. — Epidemic  meningitis  has  occurred  in  Europe  and  America 
in  every  portion  of  the  temperate  zone,  but  its  greatest  prevalence  and  mor- 
tality have  undoubtedly  been  in  the  northern  rather  than  in  the  southern 
portions  of  that  region.  One  of  its  most  interesting  features  consists  in 
its  appearing  simultaneously  at  points  very  remote  from  one  another  and 
having  no  connection  with  each  other  save  through  the  atmosphere.  Of 
this  statement  several  illustrations  have  already  been  presented.  Another 

1  Berlin  Min.  Wochensch.,  May,  1872.  2  Times  and  Gazette,  Aug.,  1879,  p.  121. 

3  Trans.  Med.  Soc.  State  of  N.  Y.,  18G8,  p.  251. 

4  Richmond  and  Louisville  Journ.,  Nov.,  1872,  p.  555. 

5  Times  and  Gazette,  July,  1867,  pp.  58,  59  ;    Nov.,  1867,  p.  511 ;    Guy's  Hospital  Rep., 
3d  Ser.,  xvii.  440;  St.  Bart's  Report*,  xii.  2f>7  ;   Times  and  Gaz.,  Aug.,  1878,  p.  167. 

6  Boston  M.  and  S.  Jour.,  Oct.,  1870,  p.  261. 

VOL.  I.— 51 


802  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

peculiarity  of  the  disease  consists  in  its  occurring  with  hardly  any  relation 
to  external  natural  conditions  or  to  those  of  its  victims.  It  affects  locali- 
ties as  diverse  as  possible  in  their  geological,  meteorological,  and  sanitary 
states,  the  rich  and  the  poor,  the  old  and  the  young,  and  both  sexes,  and 
(as  it  is  certainly  not  in  a  strict  sense  contagious)  its  rise  and  spread  must 
necessarily  be  attributed  to  some  occult  cause  pervading  the  atmosphere. 

It  is  evident  that  the  prevalence  of  the  disease  has  some  relation  to 
meteorological  agencies,  for  not  only  is  it  greater,  on  the  whole,  in  cold 
than  in  warm  climates,  but  it  is  also  greater  in  cold  than  in  warm  seasons. 
Thus,  if  we  examine  the  epidemics  in  Europe  and  America  we  shall  find 
that  they  almost  invariably  were  most  severe  in  the  winter  and  spring. 
Yet  the  rule  presents  several  exceptions  on  both  continents.  In  France, 
out  of  216  local  epidemics,  more  than  one-fourth  took  place  during  the 
warm  mouths  of  the  year,  and  in  Sweden  the  proportion  was  about  the 
same.  It  is  evident,  therefore,  that  cold  is  not  an  essential  cause  of  the 
disease.  Among  the  problems  that  remain  unsolved  in  regard  to  this  dis- 
ease none  is  more  obscure  than  the  apparent  immunity  of  Russia  from  its 
ravages,  although  the  climate  seems  adapted  to  favor  it,  and  the  domestic 
habits  of  no  people  are  fitter  to  intensify  it  if  individual  conditions  entered 
into  the  etiology  of  the  disease ;  but,  in  truth,  no  such  causes  are  related 
to  epidemic  meningitis.  Localities  of  every  sort,  high  and  low,  dry  and 
moist,  those  saturated  with  marsh  miasmata  and  those  fanned  by  pure 
mountain-breezes,  have  been  alike  visited  by  this  disease.  It  has  passed 
by  large  cities  reeking  with  all  the  corruptions  of  a  soil  saturated  with 
ordure  and  populations  begrimed  with  filth,  as  Vienna,  Berlin,  Paris, 
London,  and  New  York,  to  devastate  clean  and  salubrious  villages  and 
the  families  of  substantial  farmers  inhabiting  isolated  spots. 

By  far  the  greatest  number  of  the  subjects  of  epidemic  meningitis  are 
young  persons.  In  Sweden,  according  to  Hirsch,  of  1267  fatal  cases  of 
the  disease,  889  occurred  in  persons  under  fifteen  years  of  age,  328 
between  sixteen  and  forty  years,  and  50  in  persons  of  forty  years  and 
upward.  In  1866,  in  the  Krouach  district  (Germany),  of  115  cases,  75 
occurred  under  the  seventh  year,  22  between  the  seventh  and  twelfth  years, 
and  10  between  the  thirteenth  and  twentieth  years  (Schweitzer).  Dur- 
ing 1865  a  local  outbreak  of  the  disease  in  Bavaria  affected  53  persons, 
of  whom  22  were  children  under  ten  years  of  age,  18  between  ten  and 
twenty  years,  and  11  between  twenty  and  thirty  years.  Under  the  fifth 
year  few  were  attacked  (Orth).  Dr.  J.  L.  Smith l  found  that,  according 
to  the  reports  of  the  Board  of  Health  of  the  city  of  New  York,  out  of 
975  cases,  771  occurred  in  persons  under  fifteen  years  of  age,  the  greatest 
number  for  any  quiquennial  period  being  336  in  children  under  five  years. 
Of  the  469  deaths  occurring  in  this  epidemic,  216  were  of  children  under 
five  years  of  age,  and  the  next  largest  number  for  an  equal  period  was  99, 
which  represented  the  deaths  between  the  ages  of  five  and  ten  years.  Of 
adults  or  persons  beyond  the  age  of  twenty,  the  whole  number  was  but  39. 
The  peculiar  liability  to  the  disease  of  the  young  recruits  in  the  French 
army  has  already  been  alluded  to.  The  proportion  of  male  victims  to 
this  affection  is  rather  larger  than  that  of  females  in  the  civil  population, 
but  in  France  especially  the  excess  was  greatly  on  the  side  of  males, 
owing  to  the  prevalence  of  the  disease  in  the  army.  In  other  places,  as 
1  Amer.  Jour,  of  Med.  ScL,  Oct.,  1873,  p.  320. 


ETIOLOGY.  803 

in  Sweden  and  Germany,  the  number  of  deaths  among  females  equalled, 
or  even  exceeded,  that  of  males,  and  in  Leipsic  the  garrison  remained 
exempt  while  the  disease  prevailed  among  the  citizens.  In  1847  a  fatal 
epidemic  of  it  affected  the  second  regiment  of  the  Mississippi  Rifles,  and  was 
entirely  confined  to  that  corps  (Love).  During  the  Civil  War  of  the 
United  States  the  disease  affected  particular  corps  or  regiments  in  the 
South  or  in  the  North,  yet  it  never  became  epidemic  in  the  army,  even 
when  the  disease  prevailed  among  the  adjacent  civil  population. 

Various  depressing  or  debilitating  causes,  such  as  lowness  of  spirits, 
home-sickness,  mental  or  bodily  strain,  over-eating,  drinking  alcohol,  the 
action  of  excessive  cold  or  heat,  checking  perspiration,  etc.,  have  been 
enumerated  as  causes  of  this  disease.  It  is  unnecessary  to  dwell  upon 
such  gratuitous  assumptions.  All  of  these  influences  are  constant,  but 
epidemic  meningitis  is  the  rarest  of  epidemic  diseases,  and  the  agencies 
referred  to  have  no  further  operation  than  to  lessen  the  resistance  of  the 
body  to  morbid  influences  of  every  description.  If  there  be  one  pecu- 
liarity about  this  disease  which  is  more  surprising  and  inexplicable  than 
another,  it  is  that  its  peculiar  victims  are  not  the  feeble  and  delicate, 
but  the  vigorous  and  active — not  the  old  and  decaying,  but  the  young 
and  stalwart. 

No  one  of  authority  has  claimed  that  this  disease  can  be  propagated  by 
contagion.  All  of  its  early  American  historians  are  of  the  same  opinion 
upon  this  question,  and  nearly  all  European  authorities  are  in  perfect 
accord  with  them.  The  apparent  exceptions  to  this  all  but  universal 
judgment  are  so  insignificant  in  number  and  weight  as  not  in  the  least  to 
diminish  its  validity.  A  case  has  been  published  in  which  a  pregnant 
woman  at  full  term  died  of  the  disease  after  giving  birth  to  an  appar- 
ently healthy  child.  "  Two  hours  later  the  infant  presented  symptoms 
of  meningitis,  followed  rapidly  by  death."  ]  Supposing  the  concluding 
statement  to  be  accurate,  the  case  only  shows  that  the  cause  of  the  disease 
which  destroyed  the  mother's  life  infected  the  system  of  the  child  also. 
If  there  is  one  point  in  the  history  of  the  disease  established  by  the  con- 
curring testimony  of  American  and  European  writers,  it  is  the  extreme 
rarity  of  its  attacking  either  the  physicians  and  nurses  in  attendance 
upon  patients  affected  with  it,  or  those  laboring  under  other  diseases  and 
occupying  beds  adjacent  to  persons  ill  with  epidemic  meningitis.  ^  That, 
nevertheless,  there  is  a  material  morbific  principle  which  inheres  in  cer- 
tain localities,  so  that  those  who  occupy  them  successively  are  liable  to 
suffer  from  this  disease,  and  that  also  this  principle  may  be  carried  from 
place  to  place  so  as  to  render  certain  houses  (barracks)  infectious,  seems 
to  be  demonstrated  by  the  history  of  the  disease  in  the  French  army. 
Between  1837  and  1850,  when  the  disease  prevailed  in  various  parts  of 
France,  it  did  so  not  indiscriminately,  but  it  usually  followed  the  ordinary 
routes  of  communication,  and  especially  the  movements  of  the  military 
in  their  transfers  from  one  post  to  another,  and  the  course  of  navigable 
streams.  Strangely,  also,  it  attacked  soldiers  much  oftener  than  civilians. 
The  most  curious  fact  of  all  is  one  already  referred  to— viz.  that  although 
the  disease  prevailed  in  almost  every  part  of  the  provinces,  and  although 
then  as  ever  an  incessant  stream  from  them  was  flowing  into  the  capital, 
neither  its  civil  nor  its  military  population  was  generally  affected,  nor, 

1  Med.  Record,  xxii.  547. 


804  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

indeed,  at  all  so,  until  near  the  close  of  the  period  mentioned.  Mean- 
while, however,  the  disease  extended  to  several  countries  conterminous 
with  France  or  in  close  and  frequent  intercourse  with  it — to  Italy  (1839- 
45),  Algeria  (1839-47),  England,  Ireland,  and  Denmark  (1845-48). 
These  events  seem  to  point  to  a  certain  transmissibility  of  the  disease 
until  we  examine  the  negative  facts  that  bear  upon  the  question.  They 
are  such  as  these :  The  epidemic  did  not  spread  at  all  from  France  into 
two  of  the  adjacent  countries,  Belgium  and  Switzerland,  with  which  the 
first-named  country  maintained  an  incessant  intercourse  by  travel  and 
traffic,  but,  on  the  other  hand,  it  broke  out  at  an  early  date  within  the 
period  mentioned  at  places  very  remote  and  absolutely  independent  of  all 
influence  emanating  from  France  or  any  other  European  source — in  the 
south-western  portions  of  the  United  States.  It  is  by  numerous  facts  of 
this  description  that  we  are  compelled  to  remove  the  disease  from  the 
category  of  endemic  and  even  epidemic  diseases,  and  relegate  it,  along 
with  influenza,  to  that  of  pandemic  affections. 

There  seems  to  be  some  reason  for  thinking  that  the  epidemic  cause  of 
this  disease  may  affect  the  lower  animals  as  well  as  man.  It  was  stated 
by  Gallup  in  1811  that  during  the  epidemic  of  meningitis  in  Vermont 
"  even  the  foxes  seemed  to  be  affected,  so  that  they  were  killed  in  numbers 
near  the  dwellings  of  the  inhabitants;"  and  of  the  epidemic  in  1871  in 
New  York,  Dr.  Smith  relates  that  "  it  was  common  and  fatal  in  the  large 
stables  of  the  city  car  and  stage  lines,  while  among  the  people  the  epi- 
demic did  not  properly  commence  until  January,  1872."  It  would  be 
desirable  to  learn  more  precisely  the  characters  of  these  vulpine  and 
equine  epidemics  before  associating  them  with  the  disease  we  are  study- 
ing, the  more  so  that  we  have  been  unable  to  discover  a  similar  relation 
between  any  epizootic  and  other  epidemics  of  meningitis.  In  this  con- 
nection may  be  recalled  the  statement  of  Dr.  Law  of  Dublin,  that  while 
he  was  attending  a  lady  suffering  from  cerebro-spinal  meningitis  "  nine 
rabbits,  out  of  eleven  which  her  son  had,  died,  all  in  the  same  way  :  their 
limbs  seemed  to  fail  them,  they  fell  on  their  side,  and  then  worked  in 
convulsions,  and  died."  On  examination  of  the  bodies  of  several  of 
them  congestion  of  the  vessels  of  the  base  of  the  brain  was  found,  and 
also  "vascularity  of  the  membranes  of  the  spinal  marrow,  indicating 
inflammation." 1 

TYPES. — No  disease  presents  a  greater  variety — and,  indeed,  dissimi- 
larity— of  symptoms  than  epidemic  meningitis.  Some  of  its  epidemics 
are  sthenic  and  even  inflammatory  in  their  type,  while  others  have  the 
malignant  aspect  of  rapid  blood-poisoning.  These  contrasts  have  been 
exhibited  on  a  large  scale,  for  while  upon  the  continent  of  Europe  the 
disease  for  the  most  part  has  presented  sthenic  phenomena,  it  has  been 
more  generally  astheuic  and  adynamic  in  Ireland.  One  might  be  inclined 
to  attribute  the  latter  peculiarity  to  the  permanent  prevalence  of  typhus 
fever  in  the  latter  country,  or  rather  to  the  special  causes  producing 
typhus,  were  it  not  that  in  the  United  States  both  types  of  the  disease 
have  been  observed  at  different  times  and  in  different  places.  Such  con- 
trasts of  type  are,  however,  not  unusual  in  other  diseases  that  occur  as 
epidemics,  including  not  only  the  eruptive  fevers,  but  inflammations,  or 
affections  involving  inflammation,  such  as  pneumonia,  dysentery,  diph- 
1  Dublin  Quarterly  Journ.,  May,  1866,  p.  298. 


TYPES.  805 

theria,  etc.  Hence  it  is  evident  that  certain  epidemics,  and  certain  cases 
in  each  epidemic,  may  exhibit  on  the  one  hand  a  predominance  of  inflam- 
matory, or  on  the  other  of  adynamic  or  ataxic,  symptoms,  and  each  of 
them  in  every  conceivable  degree  and  combination.  It  is  this  variation 
of  type  that  has  led  to  such  different  conceptions  of  the  nature  of  epi- 
demic meningitis,  many  physicians  regarding  it  as  a  fever,  and  many 
others  as  an  inflammation,  while,  as  we  believe,  it  is  both  the  one  and 
the  other,  and  acquires  from  either  element,  according  to  its  ascendency, 
the  typical  character  of  the  particular  epidemic  under  observation. 

As  illustrative  of  these  statements  we  may  mention  in  this  place  the 
several  forms  of  the  disease  as  they  have  been  seen  and  interpreted  by 
different  observers.  Forget  classified  them  as  follows:  (A)  CEREBRO- 
SPIXAL  ;  1,  Explosive  (foiidroyante)  ;  2,  Comatose-convulsive;  3,  Inflam- 
matory ;  4,  Typhoid;  5,  Neuralgic;  6,  Hectic;  7,  Paralytic.  (£) 
CEREBRAL:  1,  Ceplialalgic ;  2,  Cephalalgic-delirious ;  3,  Delirious;  4, 
Comatose.  In  the  first  of  these  divisions  three-sevenths  belong  to  the 
first  and  fourth  varieties.  But  "  there  were  slight  and  severe  cases ;  vio- 
lent and  hectic  forms ;  cerebral  symptoms  predominant  in  some  and  spinal 
in  others,  etc." 

In  his  excellent  paper  on  the  epidemic  of  1848  in  New  Orleans,  Ames 
arranged  his  cases  in  two  categories — the  Congestive  and  the  Inflammatory, 
subdividing  the  former  into  the  Malignant  and  the  Mild.  Malignant 
congestive  cases  were  distinguished  by  prostration,  coma  or  delirium,  or 
both;  opisthotonos;  and  a  pulse  varying  extremely  in  its  degree  of  fre- 
quency. In  mild  congestive  cases  a  good  degree  of  strength  was  preserved ; 
the  pulse  was  below  90 ;  there  were  marked  pain  in  the  head  and  tender- 
ness of  the  spine,  but  no  coma,  delirium,  or  stiffness  of  any  muscles 
besides  those  of  the  neck.  The  purely  inflammatory  cases  were,  in  general, 
distinguished  by  a  temperature  of  the  skin  above  that  of  health  and  a  full, 
firm  pulse,  but  the  malignant  inflammatory  were  marked  by  the  early 
occurrence  of  delirium  or  coma,  great  irregularity  of  pulse,  opisthotonos, 
convulsive  spasm,  strabismus,  and  occasional  amaurosis,  with  vomiting 
and  a  rapid  and  fatal  course ;  the  grave,  by  a  slighter  development  of  the 
same  symptoms,  except  coma  and  delirium  ;  and  the  mild,  by  a  lower 
grade  of  febrile  excitement,  the  preservation  of  a  good  degree  of  strength, 
a  tendency  to  become  chronic,  and  by  the  absence  of  coma,  drowsiness, 
delirium,  and  a  cold  stage. 

Wunderlich  adopted  the  simple  plan  of  arranging  the  cases  in  three 
categories  :  1,  the  gravest  and  most  rapidly  fatal  cases  ;  2,  the  less  grave  ; 
and  3,  the  lightest.  The  arrangement  of  Hirsch  had  more  significance, 
as  well  as  a  clinical  foundation — -viz.  1,  the  abortive;  2,  the  explosive  (rn. 
siderans,  the  same  as  m.  foudroyante  of  Tourdes)  ;  3,  the  intermittent;  4, 
the  typhoid. 

Dr.  Bedford  Brown,1  who  observed  the  epidemics  in  North  Carolina 
from  1862  to  1864,  arranged  the  cases  under  the  following  heads  :  1,  the 
inflammatory  form,  in  which  the  fever  is' high,  the  pain  very  acute,  and 
the  delirium  furious,  but  which  is  exceedingly  rare  ;  2,  the  neuralgic 
form,  which  is  stated  to  be  the  most  frequent  and  protracted,  with 
moderate  fever  and  a  pulse  but  slightly  accelerated,  and  giving  a  favor- 
able prognosis ;  3,  the  ataxic  form,  in  which  great  nervous  depression  is 
1  Richmond  Med.  Jour.,  ii.  1. 


806  EPIDEMIC  CEREBEO-SPINAL  MENINGITIS. 

associated  with  a  low  and  busy  delirium,  and  the  temperature  "  is  gener- 
ally much  reduced  below  the  natural  standard This  is  always  a 

dangerous  form ;"  4,  the  paralytic  form,  in  which  stupor  and  insensibility 
are  early  and  prominent  features,  with  a  very  slow  and  feeble  pulse, 
blanched  skin,  and  death  by  syncope. 

Dr.  Purcell  of  Cork  *  furnished  a  classification  which  is  one  of  the 
best  for  practical  and  clinical  purposes — viz.  1,  the  rapid  variety,  attended 
with  purple  blotches,  embarrassed  respiration  and  circulation,  followed 
by  sopor,  insensibility,  and  coma ;  2,  the  cerebro-spinal  form,  with  retrac- 
tion of  the  head,  pain  and  cramps  of  the  muscles,  hypcreesthesia  of  the 
skin,  delirium,  etc.,  accompanied  by  fever,  herpetic  eruptions,  etc.  These 
two  forms  are  apt  to  be  more  or  less  associated  in  the  same  case. 

Of  the  various  forms  admitted  by  different  authors,  and  of  which  we 
have  seen  examples,  we  would  class  together — (a.)  The  abortive,  in 
which  the  characteristic  phenomena  are  often  faintly  defined,  and  yet  to 
the  practised  eye  distinctive.  (6.)  The  malignant,  in  which  the  symp- 
toms, of  whatever  kind,  are  exaggerated,  the  attack  sudden,  the  course 
short,  and  the  issue  fatal,  (c.)  The  nervous,  including  1,  the  Ataxic — 
viz. — 1,  the  delirious;  2,  the  cephalalgic  ;  3,  the  neuralgic  ;  4,  the  con- 
vulsive; 5,  the  paralytic;  and  6,  the  adynamic  (comatose  and  typhoid). 
(J.)  The  inflammatory,  (e.)  The  intermittent.  Of  these  the  abortive 
and  intermittent  call  for  a  brief  explanation.  Abortive  meningitis  is 
observed  only  during  the  prevalence  of  the  disease  in  a  more  character- 
istic form.  Thus,  the  mother  of  a  boy  who  had  died  of  the  fully-devel- 
oped disease  "  complained  of  the  head  and  back  and  limbs,  and  of  chilli- 
ness, and  presented  a  petechial  eruption.  After  active  purgative  and 
counter-irritant  treatment  she  was  about  her  work  on  the  second  day.2 
The  late  Dr.  Burns  of  Fraukford,  Philadelphia,  while  attending  patients 
affected  with  the  disease  suffered  from  headache,  severe  pains  along  the 
spine  and  in  every  joint  of  the  body,  and  a  general  languid  feeling.3 
Kempf  during  the  decline  of  an  epidemic  observed  "  a  great  number  of 
individuals,  especially  adults,  who  complained  of  headache,  malaise, 
neuralgic  pains  in  various  parts  of  the  body,  and  pain  in  the  nape  of  the 
neck  or  other  parts  of  the  spine."  4  In  a  case  observed  by  the  writer 
(June,  1867)  most  of  the  characteristic  symptoms  were  present  in  a 
mitigated  form,  and  the  pulse  was  at  60.  Within  five  days  restoration 
was  complete.5  The  intermittent  and  remittent  types  are  apt  to  be  quotidian 
or  tertian,  and  in  fatal  cases  the  former  has  been  taken  for  malignant 
intermittent  fever,  which  it  resembles  by  a  periodical  febrile  movement, 
with  pains,  cramps,  delirium,  etc.  This  type  sometimes  first  manifests 
itself  during  the  decline  of  an  attack. 

SUMMARY  OP  THE  SYMPTOMS. — Like  other  fatal  epidemic  diseases, 
meningitis  is  sometimes  sudden  and  sometimes  gradual  in  its  develop- 
ment. In  the  former  case  the  patient,  who  has  gone  to  bed  apparently  in 
perfect  health,  awakes  suddenly  from  a  sound  sleep  about  the  small  hours 
of  the  night  to  find  himself  in  a  severe  chill.  In  the  case  of  young 
children  a  convulsion  attends  the  awakening.  Or  the  patient,  while  pur- 

1  Dublin  Quarterly  Jour.,  Aug.,  1870,  p.  243. 

2  Sargent,  Amer.  Jwr.  c,f  Med.  Sci.,  July,  1849,  p.  35. 
s  Amer.  Jour,  of  Med.  Sci.,  April,  1865,  p.  339. 

4 Ibid.,  July,  1866,  p.  55.  6  Epidemic  Meningitis,  p.  42. 


SUMMARY  OF  THE  SYMPTOMS.  807 

suing  his  ordinary  avocations,  may  be  seized  with  a  chill,  prostration, 
vomiting,  and  headache,  of  which  symptoms  the  last  is  often  intensely 
distressing.  In  this,  as  in  other  epidemic  diseases,  such  violent  seizures 
are  most  common  during  the  earlier  periods  of  its  prevalence,  but  later  in 
its  course  premonitory  symptoms  are  more  frequently  observed.  They 
may  last  for  an  hour  or  two,  or  may  extend  to  several  days ;  and,  in 
general,  it  may  be  stated  that  the  longer  their  duration  the  milder  will  be 
the  subsequent  attack.  But  the  symptoms  in  either  case  are  essentially 
the  same — prostration,  chilliness,  feverishness,  and  sometimes  vomiting 
and  sharp  pains  in  the  head,  back,  and  limbs.  The  character  of  the  vomit* 
ing,  as  well  as  the  absence  of  all  gastric  lesions  in  fatal  cases,  proves  that 
it  is  occasioned  by  an  irritation  of  the  central  nervous  system. 

In  the  cases  which  are  regularly  developed  these,  phenomena  more  or 
less  gradually  assume  a  graver  aspect  or  usher  in  a  heavy  chill,  which  in 
its  turn  is  followed  by  alarming  symptoms,  and  especially  by  an  excru- 
ciating pain  in  the  head,  a  livid  or  pale  and  sunken  countenance,  and 
extreme  restlessness.  The  pulse  is  as  often  slow  as  frequent,  and  the 
skin  is  rarely  hot,  and,  indeed,  is  generally  but  little,  if  at  all,  warmer 
than  natural.  The  vague  pains  that  began  with  the  attack  are  now  con- 
centrated, and  seem  to  dart  in  every  direction  from  the  spine,  which  is 
also,  at  its  upper  part,  the  seat  of  severe  aching;  and  in  some  cases  hyper- 
sesthesia  of  the  skin  is  very  marked.  In  a  large  proportion  of  cases  the 
spinal  muscles  become  more  or  less  rigidly  contracted,  so  that  the  head  is 
drawn  backward  or  the  whole  trunk  is  arched  as  in  tetanus.  Trismus  is 
not  uncommon,  and  clonic  spasms  frequently  affect  the  limbs.  Even 
general  convulsions  are  occasionally  observed.  As  these  phenomena  grow 
more  decided  delirium  of  various  degrees  is  often  manifested,  from  mere 
wanderings  and  hallucinations  during  the  sleepless  watches  of  the  night 
to  violent  maniacal  ravings  or  incoherent  mutterings,  or  the  stertor  of 
coma.  Frey  and  others  have  noted  a  remission  of  the  symptoms  occur- 
ring on  or  about  the  third  day  in  cases  of  a  regular  type.  The  rigidity 
of  the  cervical  muscles  becomes  relaxed,  the  headache  subsides,  and  the 
mental  condition  improves.  But  this  amelioration  lasts  but  a  short  time, 
and  then  the  normal  course  of  the  symptoms  is  resumed. 

As  the  attack  advances  the  pulse  gradually  or  rapidly  rises  above  the 
normal  rate,  and  sometimes  becomes  very  frequent,  and  the  skin,  although 
it  grows  warmer,  does  not  often  acquire  the  temperature  observed  in 
idiopathic  fevers  or  sustain  it  as  they  do.  In  many  cases  eruptions 
appear  upon  the  skin.  During  some  epidemics  the  only  one  observed 
is  herpes  labialis ;  in  others  the  eruption  resembles  roseola,  measles,  or 
the  mulberry  rash  of  typhus,  or  from  the  first  it  consists  of  petechiae, 
vibices,  or  extensive  ecchymoses.  The  tongue  presents  the  characters 
which  belong  generally  to  the  typhoid  state.  At  first  moist  and  coated 
with  a  whitish  fur  or  a  mucous  secretion,  it  afterward,  if  life  is  pro- 
longed, grows  red  and  shining  or  brown  and  fuliginous.  There  is  usu- 
ally a  complete  loss  of  appetite,  and  the  thirst  is  not  commonly  urgent. 
One  or  two  liquid  stools  at  the  commencement  are  generally  followed  by 
constipation,  which  continues  throughout  the  attack,  although  in  very 
grave  and  protracted  cases  diarrhoea  may  persist,  and  even  become  colli- 
quative.  When  the  attack  tends  to  a  fatal  issue  the  patient  generally, 
but  by  no  means  always,  sinks  into  a  soporose  condition,  in  which  mus- 


808  EPIDEMIC  CEREBEO-SPINAL  MENINGITIS. 

cular  relaxation,  debility,  and  tremulousness,  such  as  are  common  in  the 
typhoid  state  of  fevers,  are  associated  with  paralysis  of  the  sphincters 
and  of  other  muscles.  But  we  have  seen  rigid  opisthotonos  continue 
until  within  a  few  hours  of  death  in  a  case  of  more  than  the  average 
duration. 

In  cases  that  tend  toward  recovery  the  typhoid  condition  is  rarely  so 
grave,  but  patients  have  often  survived  very  severe  nervous  symptoms. 
It  is  true  that  the  return  to  health  may  be  tedious  and  uncertain,  and  not 
unusually  a  perfect  restoration  of  all  the  functions  is  very  long  delayed, 
or,  it  may  be,  is  never  attained. 

INDIVIDUAL  SYMPTOMS. — Pain  in  the  head  is  one  of  the  most  charac- 
teristic symptoms  of  epidemic  meningitis.  It  is  always  present,  except 
in  those  malignant  cases  in  which  the  morbid  poison  seems  to  spend  its 
fatal  power  upon  the  blood.  In  some,  however,  of  a  less  rapid  but  still 
malignant  type,  in  which  after  death  no  exudation  is  found,  but  only 
an  extreme  venous  congestion  of  the  membranes,  or  it  may  be  an  effu- 
sion of  blood  beneath  them,  this  symptom  may  be  more  or  less  marked. 
It  is  generally  an  excruciating  pain,  sometimes  darting  apparently  through 
the  head  from  the  nucha?  to  the  forehead,  extorting  cries  and  groans,  and 
is  variously  described  by  the  sufferers  as  throbbing,  boring,  lancinating, 
sharp,  or  crushing,  "  as  if  the  head  were  in  a  vice  or  nails  or  screws  were 
being  forced  into  the  brain."  Its  paroxysms  arouse  the  patient  from  his 
apathetic  stupor  or  his  coma,  and  cause  him  to  become  restless  or  violent 
or  to  shriek  with  agony.  Even  when  this  evidence  of  anguish  is  want- 
ing the  patient  often  attests  his  suffering  by  contortions  or  cries,  or  by 
frequently  carrying  his  hands  to  his  head.  That  it  depends  upon 
mechanical  pressure  upon  the  sensitive  ganglia  within  the  cranium  and 
upper  part  of  the  spine  is  shown  by  the  relief  which  revulsive  and  coun- 
ter-irritant measures  afford  when  applied  to  the  occipital  region  and  the 
back  of  the  neck.  Identical  in  cause  and  quality  with  this  pain  is  the 
spinal  pain  proper.  No  better  description  of  it  has  been  given  than  that 
of  Fiske  in  1810.  It  is  in  these  words:  "Its  bold  and  prominent 
features  defy  comparison In  some  a  pain  resembling  the  sensa- 
tion felt  from  the  stinging  of  a  bee  seizes  the  extremity  of  a  finger  or 
toe ;  from  thence  it  darts  to  the  foot  or  hand  or  some  other  part  of  the 
limbs,  sometimes  in  the  joints  and  sometimes  in  the  muscles,  carrying  a 
numbness  or  prickling  sensation  in  its  progress.  After  traversing  the 
extremities,  generally  of  one  side  only,  it  seizes  the  head,  and  flics  with 
the  rapidity  and  sensation  of  electricity  over  the  whole  body,  occasioning 
blindness,  faintings,  sickness  at  the  stomach,  with  indescribable  distress 
about  the  prsecordia — a  numbness  or  partial  loss  of  motion  in  one  or 
both  limbs  on  one  side,  with  great  prostration  of  strength.  The  horrible 
seasation  of  this  process  no  language  can  describe." l  These  spinal  pains 
are  always  aggravated  by  pressure  made  on  either  side  of  the  spinous 
processes  of  the  vertebrae,  and,  like  the  cephalic  pains,  are  more  or  less 
mitigated  by  revulsive  applications.  Accompanying  the  pains  is  a  hyper- 
sesthesia  or  morbid  sensibility  of  the  skin,  rendering  it  painfully  sensitive 
to  the  slightest  touch ;  in  the  advanced  stages  of  the  disease,  when  the 
spinal  phenomena  predominate,  the  irritation  of  the  nerves  by  the  press- 
ure of  .the  exudation  on  their  roots  is  exchanged  for  numbness  or  abso- 
1  North,  on  Spotted  Fever,  p.  176. 


INDIVIDUAL  SYMPTOMS.  809 

lute  insensibility,  due  to  the  increase  and  continuance  of  that  pressure. 
Moving  the  limbs  or  separating  the  closed  eyelids  will  sometimes  provoke 
resistance,  and  even  extort  cries ;  and  especially  is  this  true  of  attempts 
to  straighten  the  rigidly  bent  spine  or  the  flexed  extremities.  Lewis 
states  that  such  outcries  were  so  often  excited  by  slowly  introducing  the 
thermometer  into  the  rectum  that  he  was  forced  to  believe  that  the  anal 
and  perhaps  the  rectal  surface  was  hypersensitive. 

The  physical  causes  that  give  rise  to  the  pains  which  have  just  been 
described  likewise  occasion  the  spasmodic  and  tetanoid  phenomena  that 
are  so  peculiar  to  this  disease.  In  general  terms,  they  are  most  marked 
in  cases  attended  with  inflammatory  exudation,  and  least  so  when,  instead 
of  this  lesion,  there  is  only  vascular  congestion  of  the  meninges  of  the 
spinal  cord.  But  the  rule  is,  of  course,  not  absolute,  for  individuals  are 
so  differently  constituted  that  one  will  remain  impassive  under  an  irri- 
tation that  will  throw  another  into  convulsions.  There  is  no  doubt  that 
spinal  rigidity  may  be  produced  by  mere  congestion  of  the  cord,  and,  on 
the  other  hand,  that  it  may  be  absent  even  when  plastic  exudation  is 
abundant.  This  symptom  is,  however,  more  than  any  other  one,  charac- 
teristic of  the  disease.  It  existed  in  the  original  epidemic  at  Geneva, 
attracted  the  attention  of  the  earliest  American  observers  of  the  disease, 
and  elsewhere  has  marked  a  greater  or  a  smaller  proportion  of  the  cases 
in  every  epidemic.  It  was  described  by  such  terms  as  these  :  "  a  draw- 
ing-back of  the  head ;"  "a  corpse-like  rigidity  of  the  limbs;"  "the  form 
of  tetanus  called  opisthotonos ;"  "  spastic  rigidity  of  the  muscles  of  the 
lower  jaw  and  the  posterior  muscles  of  the  neck ;"  "  rigidity  of  the  pos- 
terior cervical  muscles,  retracting  the  head  considerably  backward."  The 
historians  of  the  disease  in  Europe  are,  if  possible,  still  more  emphatic  in 
their  elaborate  descriptions  of  this  phenomenon,  and,  on  the  Continent  at 
least,  it  seems  to  have  been  more  uniformly  present  than  it  was  in  Ireland 
or  in  this  country.  Tourdes,  in  describing  the  epidemic  of  1842  at 
Strasburg,  said  :  "  The  decubitus  of  the  sick  was  distinguished  by  a 
backward  flexion  of  the  head  and  spine ;  most  frequently  the  neck  alone 
was  affected,  but  sometimes  the  whole  trunk  was  arched."  And  again  : 
"The  contraction  often  involved  all  of  the  extensor  muscles  of  the  spine, 
and  the  trunk  formed  an  arch  opening  backward  and  resting  upon  the 
occiput  and  sacrum."  In  Ireland,  Gordon  says  of  a  patient,  "  Her  spine 
presented  a  most  wonderful  uniform  curve  concave  backward ;  her  head 
was  also  curved  backward  on  the  spine  of  the  neck."  During  an  epi- 
demic at  Birmingham  in  1875  in  one  case  "  the  retraction  was  so  marked 
that  a  slough  formed  from  the  occiput  pressing  between  the  scapulae." l 
In  some  cases  rigid  flexion  of  the  body  forward  or  laterally  has  been 
noticed.  The  rigidity  persists,  as  a  rule,  until  death,  but  sometimes 
ceases  a  short  time  before  that  event.  If  recovery  takes  place,  this 
symptom  gradually  subsides,  and  disappears  within  a  few  days ;  but,  on 
the  other  hand,  more  or  less  stiffness  of  the  spine  may  last  for  several 
weeks.  In  one  case  it  continued  for  more  than  two  months,  and  in 
another  until  death  on  the  forty-ninth  day. 

The  same  physical  cause  that  occasions  rigidity,  when  acting  less  in- 
tensely or  when  a  special  susceptibility  of  the  nervous  system  exists,  also 
excites  clonic  convulsions.  They  are  oftenest  observed  in  patients  of  the 
1  Hart,  St.  Barfs  Rep.,  iv.  141. 


810  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

age  especially  liable  to  spasmodic  affections — iii  children  before  the  com- 
pletion of  the  first  dentition.  They  vary  in  degree  from  twitching  or 
subsultus  affecting  particular  muscles,  as  of  the  eyes,  the  face,  a  limb,  etc., 
to  general  epileptiform  convulsions  with  loss  of  consciousness.  They  may 
be  associated  with  paralysis,  as  where  the  two  halves  of  the  body  are,  the 
one  convulsed  and  the  other  paralyzed.  A  case  occurred  in  Dublin  which 
"presented  the  very  striking  phenomenon  of  continued  and  violent  con- 
vulsions during  the  whole  of  the  brief  course  of  the  illness." l  These  con- 
vulsions, like  others  occurring  at  the  commencement  of  acute  diseases,  are 
by  no  means  always  fatal,  even  when  they  are  general.  In  the  case  of 
a  robust  adult  convulsions  occurred  repeatedly  during  the  first  two  days, 
and  less  frequently  during  the  two  following  days,  but  the  patient  ulti- 
mately recovered.2 

Paralysis,  it  may  be  inferred  from  the  statements  already  made,  is  an 
incident  of  this  disease,  for  an  excess  of  the  action  causing  tonic  or  clonic 
spasm  must  induce  paralysis.  Paralysis  of  an  arm  or  leg  or  of  the  mus- 
cles of  deglutition  was  long  ago  noticed  among  even  the  initial  symp- 
toms of  the  attack.  In  Dublin  (1865)  it  was  said  of  a  patient,  "All  his 
members  seemed  to  be  paralyzed ;  he  could  move  neither  arms  nor  legs." 
Wunderlich  describes  the  case  of  a  man  who  "  on  the  second  day  of  the 
disease  lost  both  sensibility  and  motility  in  the  lower  limbs  and  over  the 
greater  part  of  the  trunk,  while  his  left  arm  also  was  partially  paralyzed." 
In  another  case  complete  paralysis  of  the  right  side  occurred  on  the  third 
day,  the  left  side  being  rigid.3  Baxa  relates  the  case  of  a  soldier  in  whom 
paralysis  of  the  left  side  persisted  after  recovery  from  the  disease,4  and 
that  of  a  woman  in  whom  paralysis  of  the  left  lower  limb  continued  along 
with  right  ciliary  paralysis.  Ptosis,  strabismus,  paralysis  of  the  bladder 
and  rectum,  of  the  muscles  of  deglutition,  and  even  general  paralysis, 
have  been  observed.  Aphasia  also  has  been  recorded  by  Hirsch  and  b} 
Hayden.5 

The  condition  of  the  eyes  and  of  vision  in  this  disease  is  directly  due 
to  pressure  of  the  exudation  at  the  base  of  the  brain  upon  the  nerves  and 
blood-vessels  that  supply  these  organs.  One  of  the  most  striking  peculi- 
arities of  the  countenance  of  a  patient  at  the  beginning  of  an  attack  is  the 
diffused  and  uniform  redness  of  the  conjuuctivee.  In  children  it  has  a 
light  tint,  but  a  darker  one  in  adults,  and  in  some  cases  the  eye  becomes 
suffused  with  an  extravasation  of  blood.  The  conditions  of  the  pupil 
are  also  very  peculiar.  Very  long  ago  it  was  observed  to  undergo  sudden 
changes  from  contraction  to  dilatation,  or  the  reverse.  Dilatation  is,  how- 
ever, its  ordinary  condition,  especially  in  the  fully-formed  attack.  Very 
often  the  pupils  of  the  two  eyes  are  in  opposite  states.  In  cases  of  long 
duration,  with  great  exhaustion,  they  are  almost  invariably  dilated.  Photo- 
phobia is  not  uncommon,  and  oscillation  of  the  pupils  and  spasmodic 
movements  of  the  eyeball  have  frequently  been  observed.  Strabismus  is 
a  symptom  of  very  ordinary  occurrence,  particularly  when  other  paralytic 
or  spasmodic  phenomena  exist.  It  may  be  convergent  or  divergent,  but 
most  commonly  is  the  former,  and  may  be  either  a  transient  or  a  perma- 

1  Dublin  Quart.  Jour.,  xlvi.  187. 

1  Boston  Med.  and  Surg.  Jour.,  Feb.,  1884,  p.  121. 

8  Dublin  Quart.  Jour.,  1867,  p.  431. 

*  Wiener  med.  Presse,  No.  29,  p.  715.  5  Dublin  Quart.  Jour.,  xlvi.  187. 


INDIVIDUAL  SYMPTOMS.  811 

nent  symptom.  Like  other  individual  symptoms,  it  may  be  present  rarely 
or  frequently  in  a  particular  epidemic. 

Blindness  has  been  repeatedly  observed.  At  first  it  seemed  to  be 
noticed  as  a  transient  symptom  only.  Fish  (1809)  states  that  it  was 
sometimes  the  first  deviation  from  health,  and  then  was  followed  by  para- 
lytic spinal  symptoms.  He  also  observed  that  sight  was  sometimes 
restored  in  a  few  hours,  and  in  no  case  did  he  know  it  to  be  permanently 
lost.  American  as  well  as  European  physicians,  however,  have  met  with 
many  cases  in  which  the  sight  was  seriously  and  permanently  impaired  or 
altogether  destroyed.  In  1873  the  changes  affecting  the  eye  were  more 
fully  and  accurately  described,  especially  those  which  tend  to  the  structural 
injury  of  the  organ.  'The  abnormal  appearances  included  cloudiness  of 
the  media,  discoloration  of  the  iris,  irregularity  of  the  pupils,  and  their 
obstruction  with  exudatc.  In  exceptional  cases  the  cornea  ulcerated,  and 
the  globe  collapsed  after  losing  its  contents.  Ordinarily,  however,  says 
Lewis,  "no  ulceration  occurs,  and  as  the  patient  convalesces  the  oedema 
of  the  lids,  the  hyperamia  of  the  conjunctiva,  the  cloudiness  of  the  cornea 
and  of  the  humors  gradually  abate,  and  the  exudation  in  the  pupils  is 
absorbed.  The  iris  bulges  forward,  and  the  deep  tissues  of  the  eye,  viewed 
through  the  vitreous  humor,  which  had  a  dusky  color  from  hypersemia, 
now  present  a  dull  white  color.  The  lens  itself,  at  first  transparent,  after 
a  while  becomes  cataractous,  and  sight  is  lost  totally  and  for  ever." 

Impairment  or  loss  of  hearing  has  been  occasionally  observed  during 
the  successive  epidemics  of  tjiis  disease,  even  from  the  beginning  of  its 
history,  and  it  was  early  noticed  that  the  symptom  was  often  quite  inde- 
pendent of  any  cognizable  lesion  of  the  ear  itself.  It  was  also  observed 
that  the  sense  of  smell  sometimes  became  impaired  or  was  lost  at  the  same 
time  with  that  of  hearing.  More  recently,  Collins  reported  a  case  in 
which  the  patient  lost  the  sight  of  one  eye  and  became  permanently  deaf 
in  both  cars.  Knapp  states  that  in  all  of  thirty-one  cases  examined  by 
him  the  deafness  was  bilateral,  and,  with  two  exceptions  of  faint  percep- 
tion of  sound,  complete.  Among  twenty-nine  cases  of  total  deafness  only  one 
seemed  to  give  some  evidence  of  hearing  afterward.1  This  surgeon  holds 
that  the  deafness  results  from  a  purulent  inflammation  of  the  labyrinth, 
and  his  judgment  has  been  confirmed  by  Keller  and  Lucas.  When  the 
impairment  of  hearing  occurs  simultaneously,  or  nearly  so,  in  both  ears, 
it  is  probable  that  the  chief  cause  of  the  deafness  is  the  pressure  of  the 
plastic  exudation  in  which  the  auditory  nerve  is  imbedded.  Such  deaf- 
ness is  rarely  permanent.  When  the  loss  of  hearing,  whether  complete 
or  partial,  does  not  improve,  there  is  reason  to  believe  that  the  internal 
ear  has  suffered  great  and  incurable  changes  of  structure.  Sometimes 
this  follows  a  distinct  attack  of  suppurative  inflammation  of  the  middle 
ear ;  but  as  complete  and  permanent  deafness  sometimes  occurs  without 
being  preceded  by  any  such  affection,  it  must  be  inferred  that  atrophic 
changes  have  taken  place  in  some  portion  of  the  nervous  apparatus  of 
hearing.  It  is  stated  by  Moos  that  of  sixty-four  cases  of  recovery  from 
cerebro-spinal  meningitis,  which  showed  disturbance  of  hearing  as  a  sequel, 
one-half  manifested  in  addition  a  more  less  disordered  equilibrium.  Of 
these  twenty-nine  were  totally  deaf  on  both  sides,  two  totally  deaf  on 
one  and  hard  of  hearing  on  the  other  side,  and  one  case  had  merely 

'Smith,  loe.  cit. 


812  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

impaired  hearing  iu  both  ears.  The  disturbance  of  locomotion  had  existed 
for  periods  varying  from  three  weeks  to  five  years  from  the  inception  of 
the  disease,  and  was  chiefly  characterized  by  a  staggering  or  waddling 
gait.1  In  the  deaf-mute  institutions  at  Bamberg  and  Niirnberg  it  is 
said  that  out  of  91  pupils,  80  owed  their  infirmity  to  this  disease 
(Ziemssen).  Salamo  states  that  some  awake  out  of  sleep  totally  deaf,  and 
remain  so  for  a  long  time,  or,  it  may  be,  permanently  (Moos). 

The  expression  of  countenance  in  this  disease  is  peculiar.  When  the 
pain  in  the  head  is  severe  and  paroxysmal  the  features  are  apt  to  be 
violently  distorted ;  when  it  is  more  persistent  the  face  assumes  a  fixed  or 
rigid  expression,  or  is  at  the  same  time  dull,  particularly  after  a  long 
continuance  of  the  pain.  In  the  apoplectic  form  the  expression  may  be 
set  and  stupid,  but  the  features  have  neither  the  dark,  dull,  swollen,  and 
duskily-flushed-aspect  of  typhus,  nor  the  languid,  sleepy  expression,  and 
circumscribed  flush  on  the  cheek  which  are  so  characteristic  of  typhoid 
fever.  Except  during  absolute  insensibility  in  rapidly  fatal  cases  there 
is  a  look  of  greater  intelligence  than  belongs  to  either  of  the  diseases 
mentioned.  Indeed^  in  the  beginning  of  the  attack  iu  regular  casos  the 
distinctive  facies  presents  pale  and  sunken  features,  with  paleness  of  the 
skin  over  the  whole  body. 

Delirium  in  this  disease  exhibits  a  great  many  degrees  and  varieties. 
It  nuiy  occur  among  the  earliest  symptoms  in  certain  rapid  cases  not  of 
the  congestive  type,  but  is  more  apt  to  arise  on  the  second  or  third  day 
ID  those  more  typically  developed.  It  may  be  mild,  reasoning,  hysterical, 
or  maniacal,  or  it  may  change  from  one  to  another  of  these  forms  during 
the  same  attack.  Fish  states  that  it  is  apt  to  be  violent  if  it  comes  on  at 
the  commencement  of  the  illness,  but  that  when  it  begins  at  a  later 
period  it  is  milder,  and  sometimes  playful,  the  patient  being  sociable  and 
humorous.  All  good  observers  have  furnished  similar  descriptions  of 
this  symptom ;  some  have  added  that  the  mental  condition  is  often 
desponding  and  apprehensive,  and  others  that  certain  patients  remain 
sombre  and  silent ;  and  it  sometimes  happens  that  the  delirium  comes  on 
abruptly,  as  when  a  patient  "  woke  suddenly  in  the  middle  of  the  night 
and  began  to  hum  tunes,  to  fancy  that  people  were  conversing  with  him," 
etc.  (Gordon). 

Coma  is  met  with  sooner  or  later  in  nearly  all  fatal  cases,  but  rarely 
in  a  marked  degree  until  the  approach  of  death.  If  anything  is  sur- 
prising in  epidemic  meningitis,  it  is  the  absence  of  that  deep  and  pro- 
longed stupor  that  characterizes  the  typhoid  state,  notwitlistandiug  the 
pressure  of  the  exudation  upon  the  brain  in  most  cases,  and  in  others 
such  a  profound  alteration  of  the  blood  that  it  exudes  through  the  tissues 
as  water  passes  through  a  porous  body.  Another  striking  phenomenon 
of  the  disease  is  that  the  patient  after  recovery  has  generally  a  complete 
oblivion  of  all  that  happened  to  him  between  the  beginning  of  the  attack 
and  convalescence.  This  is  true  even  of  cases  in  which  the  brain  symp- 
toms are  far  from  being  conspicuous. 

Another  symptom  closely  related  to  the  local  lesion  and  the  blood- 
change  in  this  disease  is  vertigo.  As  originally  described  by  Miner  in 
1823,  it  occurred  from  the  very  commencement  of  the  attack,  and  was 
even  then  regarded  as  denoting  a  deficient  supply  of  the  blood  to  the 

1  Mening.  Cerebro- spinal  epid.,  p.  1 1. 


INDIVIDUAL  SYMPTOMS.  813 

brain,  so  that  when  the  patient  rose  to  an  erect  posture  it  was  felt  along 
with  uneasiness  in  the  stomach,  acceleration  of  the  pulse,  dimness  of 
sight,  nausea,  and  fainting.  Tourdes,  speaking  of  it  as  it  occurred  in 
the  Strasburg  epidemic,  says  that  it  confused  the  mind  and  rendered 
walking  impossible.  In  two  cases  patients  were  seized  with  a  giddiness 
which  compelled  them  to  whirl  around,  when  they  fell  and  did  not  rise 
again.  According  to  Moos  (1881)  unilateral  affections  of  the  labyrinth 
give  rise  to  vertigo,  and  bilateral  lesions  to  a  staggering  gait.  Bilateral 
hemorrhage  or  acnte  suppuration  of  the  ampullar  terminations  of  the 
auditory  nerve  occasions  paralysis  and  staggering.  Children,  and  those 
who  at  the  same  time  have  the  sight  impaired,  are  apt  to  remain  affected 
for  a  long  time.  Otherwise,  prolonged  and  systematic  muscular  exercise 
may  remove  the  tottering  walk. 

To  the  same  causes  must  doubtless  be  attributed  the  debility  which  is 
so  early  and  so  conspicuous  a  symptom  in  this  disease,  and  which  gave  it 
one  of  the  names,  typhus  syncopalis,  by  which  it  was  first  known  in  this 
country.  It  was  manifested  by  the  vertigo  already  noticed,  by  a  sense 
of  sinking  in  the  epigastrium,  by  a  quick,  frequent,  freble,  and  irregular 
pulse,  and  by  a  sudden  and  extreme  loss  of  muscular  power,  so  that  the 
patient  found  himself  unable  to  raise  his  hand  before  he  was  sensible  of 
being  ill.  This  state  of  asthenia  is  conspicuous  throughout  the  whole  of 
the  disease,  and  is  the  immediate  cause  of  the  slow  and  irregular  conva- 
lescence which  is  characteristic  of  it. 

Of  the  symptoms  peculiar  to  the  digestive  apparatus  hardly  any. 
belong  to  it  directly.  They  are  nearly  all  the  effect  of  reflex  influences. 
The  condition  of  the  tongue  is  for  the  most  part  quite  unlike  that  which 
belongs  to  the  typhoid  state.  The  fuliginous  condition  of  the  tongue, 
gums,  cheeks,  and  lips  which  characterizes  that  state  is  seldom  met  with 
in  epidemic  meningitis.  The  older  writers  agreed  that  even  when  the 
tongue  does  grow  dry  and  brown  the  condition  is  not  of  long  continuance, 
and  later  observers  have  confirmed  their  statements.  Thus,  J.  L.  Smith 
(1872)  says,  "Occasionally,  in  cases  attended  with  great  prostration,  the 
mr  of  the  tongue  is  dry  and  brown,  but  only  for  a  few  days,  when  the 
moist  whitish  fur  succeeds."  We  have  generally  found  it  moist,  whitish 
in  the  centre  and  at  the  tip  and  edges. 

Nausea  and  vomiting  are  very  constant  among  the  initial  symptoms 
of  the  disease,  and,  as  already  pointed  out,  are  due  to  irritation  of  the 
cerebro-spinal  ganglia.  Very  often  the  vomiting  is  not  preceded  by  nau- 
sea, and  is  brought  on  by  the  patient's  raising  himself,  etc.  The  stomach 
itself  undergoes  no  change.  Both  symptoms  are  usually  accompanied  by 
faintness  or  giddiness,  and  are  more  decided  in  the  initial  than  in  the 
later  stages  of  the  attack.  The  matters  vomited,  varying  with  the  con- 
tents of  the  stomach  and  the  urgency  and  duration  of  the  symptom, 
consist  of  ingesta,  mucus,  serum,  or  bile,  and  in  some  grave  cases  of  a 
dark  grumous  matter  taken  to  be  altered  blood.  In  some  epidemics, 
apparently,  more  than  in  others,  this  symptom  is  very  distressing,  as  it  was 
at  Birmingham  in  1875.1  The  inability  of  the  stomach  to  retain  food 
necessarily  leads  to  a  rapid  wasting  of  the  flesh,  which  is .  aggravated  by 
the  patient's  suffering,  restlessness,  and  want  of  sleep.  Nevertheless,  no 
sooner  is  the  vomiting  appeased  than  a  desire  for  food  is  felt,  and  when 
1  Hart,  St.  Bart's  Rep.,  xii.  112. 


814  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

it  is  retained  it  generally  undergoes  digestion.  Indeed,  in  no  other  disease 
is  the  return  of  a  good  appetite  and  digestion  so  prompt  and  complete. 
It  is  true  that  the  recovery  of  flesh  and  strength  is  not  always  in  propor- 
tion to  the  appetite.  As  might  be  expected  in  a  disease  in  which  fever 
plays  so  subordinate  a  part,  there  is  seldom  urgent  thirst.  But  epidemics 
differ  in  this  as  in  so  many  other  respects.  In  that  which  we  witnessed 
in  the  Philadelphia  Hospital  in  1866-G7  the  patients  were  clamorous  for 
liquids.  Constipation  is  the  rule  among  patients  with  this  disease,  as, 
indeed,  might  naturally  be  expected,  for  no  lesion  affects  the  bowels  and 
little  or  no  food  is  retained  by  the  stomach.  Yet  in  a  few  cases  diarrhoea 
accompanies  persistent  vomiting. 

The  fauces  appear  to  have  been  more  or  less  inflamed  in  some  epi- 
demics ;  swelling  of  the  parotid  glands  is  an  occasional  occurrence,  and 
sometimes  they  undergo  suppuration.  Aphthn  have  also  been  met 
with. 

The  secretion  of  urine  is  not  affected  in  any  uniform  manner.  Some- 
times it  is  diminished  and  sometimes  increased  in  quantity.  The  latter 
symptom  has  occasionally  long  survived  the  disease.  It  retains  its 
normal  acidity.  In  rare  cases  either  albumen  or  sugar  has  been 
detected ;  the  former  may  have  been  due  to  the  action  of  blisters  of 
cantharides  used  in  the  treatment  of  the  disease. 

One  of  the  most  curious  and  unintelligible  phenomena  occasionally 
met  with  in  this  disease  is  a  peculiar  affection  of  the  joints,  which  first 
was  observed  in  this  country.  Jackson  (1810  and  1813)  wrote:  "In 
some  cases  swellings  have  occurred  in  the  joints  and  limbs.  They  have 
been  very  sore  to  the  touch,  and  their  appearance  has  been  compared  to 
that  of  the  gout.  The  parts  so  affected  feel  as  if  they  had  been  bruised. 
These  swellings  arise  on  the  smaller  as  well  as  on  the  larger  joints,  and 
are  often  of  a  purple  color."  So  Collins1  reports:  "The  joints  some- 
times become  swollen,  red,  and  tender ;  at  other  times  red  and  painful 
without  any  swelling ;  while,  again,  intense  pain  and  rapid  enlargement 
from  effusion  have  occurred  unattended  with  redness.  The  joints  most 
usually  attacked  are  the  knee,  elbow,  wrist,  and  the  smaller  articulations 
of  the  fingers  and  toes."  In  an  epidemic  which  occurred  in  Greece  in 
1869  articular  swellings  similar  to  those  of  inflammatory  rheumatism 
were  observed.2  These  descriptions,  which  apply  to  some  cases  in  most 
epidemics,  are  of  more  than  casual  interest,  for  they  demonstrate  conclu- 
sively, as  we  think,  the  truth  which  the  whole  history  of  the  disease  con- 
firms— viz.  that  it  is  a  systemic  and  not  a  local  affection,  and  is  depend- 
ent for  its  existence  upon  a  specific  poison  which  is  absolutely  unlike 
every  other  morbid  poison  known  to  pathology. 

The  act  of  respiration  is  variously  modified  in  this  disease,  as  might, 
indeed,  be  expected  from  the  seat  and  nature  of  the  cerebro-spinal  lesions. 
It  is  sighing,  labored,  and  interrupted.  Burdon-Sanderson  describes 
its  differences  from  the  so-called  Chevne-Stokes  respiration ;  it  is,  he 
says,  "  marked  by  a  slow,  labored  inspiration,  followed  by  a  quick  expi- 
ration and  a  long  pause."  When  opisthotonos  is  very  great  and  per- 
sistent, it  necessarily  interferes  with  the  dilatation  of  the  lungs,  and  leads 
to  oedema  of  those  organs,  and  even  to  sanguine'ous  effusions  into  them. 

1  Dublin  Quart.  Jour.,  Aug.,  1868,  p.  170. 

1  Archives  generates  de  med.,  Mai,  1883,  p.  622. 


INDIVIDUAL  SYMPTOMS.  815 

Pneumonia  is  not  an  unusual  complication  of  the  disease  when  it  prevails 
in  cold  weather. 

The  distinguishing  characters  of  the  pulse  are  diminished  force  and 
volume,  and  a  tone  so  much  impaired  that  slight  causes  produce  extreme 
variations  in  its  rate  and  rhythm.  If  the  disease  be  a  fever,  as  is  by 
some  maintained,  then  it  is  the  only  fever  in  which  the  pulse-rate  is  often 
far  below  the  normal,  and  at  the  same  time  neither  full  nor  tense,  unless 
transiently  and  in  altogether  exceptional  cases.  In  no  other  disease  attended 
with  inflammation  do  the  rate  and  quality  of  the  pulse  vary  so  greatly  within 
short  intervals.  It  may  be  said,  in  general  terms,  to  be  variable  in  rate 
and  strength  even  in  the  most  stheuic  cases  of  the  disease,  and  in  those 
which  tend  to  a  fatal  issue  to  be  small,  thready,  weak,  intermittent,  or 
imperceptible  for  a  longer  or  shorter  time  before  death.  It  is  no  uncom- 
mon thing  for  the  pulse-rate  at  the  beginning  of  an  attack  to  fall  as  low 
as  40,  or  even  27,  and  afterward  rise  to  120  or  even  more,  in  a  minute, 
without  necessarily  indicating  a  fatal  issue.  Muscular  exertion,  rising 
from  a  recumbent  posture,  etc.,  will  sometimes  double  its  frequency,  besides 
producing  irregularity.  Read,  describing  the  pulse  as  he  observed  it  in 
Boston  in  1873—74,  speaks  of  cases  in  which  "both  the  rhythm  and 
the  force  of  the  beats  are  entirely  destroyed ;  .  .  .  .  one  moment,  while 

beating  very  fast,  it  will  suddenly  drop  to  a  much  lower  rate 

These  conditions  also  may  outlast  apparent  convalescence."     Some  fatal 
cases  are  attended  by  distressing  palpitations  of  the  heart. 

Nothing  is  more  remarkable  in  the  early  histories  of  this  affection  than 
their  unanimous  statement  that  it  is  not  distinguished  by  a  febrile  tem- 
perature. It  is  true  that  the  observers  of  those  days  had  not  the  advan- 
tage of  using  clinical  thermometers,  but  they  were  too  nearly  agreed  in 
their  judgments  and  harmonious  in  their  descriptions  to  permit  any  serious 
doubt  of  the  substantial  accuracy  of  their  conclusions,  which  were 
expressed  in  such  terms  as  these :  "  A  diminution  of  heat  may  be  con- 
sidered as  among  this  most  striking  symptoms  of  this  disease"  (Strong); 
or,  "  the  temperature  never  exceeded  the  standard  of  health  in  more  than 
three  or  four  cases,  ....  and  a  great  majority  of  the  patients  had  no 
fever  at  all  "  (Miner) ;  or,  again,  "  A  high  febrile  movement  took  place 
only  in  a  limited  number  "  (Gilchrist) ;  or,  "  The  heat  of  the  surface  was 
less  in  all  cases  than  is  usually  observed  in  acute  diseases"  (Jeuks.)  It 
will  be  observed  that  these  statements,  and  very  many  others  which  agree 
with  them,  were  founded  upon  the  perception  of  the  patients'  temperature 
by  the  hand,  which  was  of  course  applied  to  the  most  accessible  parts 
of  the  body — the  face,  neck,  arms,  and  hands — but  they  have  more 
real  value  and  significance  than  the  more  recent  measurements  taken  in 
the  mouth,  axilla,  rectum,  or  vagina,  for  we  know  that,  however  valuable 
the  temperatures  of  these  parts  may  be  for  comparative  studies,  they  do 
not  really  indicate  the  condition  of  the  individual  who  presents  them. 
It  is  a  familiar  fact  that  the  difference  of  temperature  in  cholera  when 
taken  in  the  rectum  and  the  axilla  may  be  4°  F.,  or  even  more  than  this. 
Since  the  thermometer  has  been  used  in  the  study  of  epidemic  men- 
ingitis greater  accuracy  of  results  has  been  attained,  and  yet  the  general 
statements  of  the  earlier*observers  have  been  confirmed.  Thus,  Githens 
has  shown  that  the  temperature  of  the  body  in  this  disease  is  lower  than 
that  recorded  of  any  other  fever  or  inflammatory  affection ;  the  average, 


816  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

indeed,  of  his  cases  was  lower  by  four  or  five  degrees  than  that  of  typhus 
or  typhoid  fever,  pneumonia,  etc.  In  2  cases  only  did  the  thermometer 
in  the  axilla  reach  105°.  The  highest  temperature  in  15  cases  was 
between  104°  and  105°;  in  12,  between  103°  and  104°  ;  in  7,  between 
102°  and  103° ;  in  6,  between  101°  and  102°  ;  and  in  2  it  was  below 
1000.1  Tourdes,  Niemeyer,  and  others  have  noted  the  slight  rise  of 
temperature  during  the  first  and  second  days  of  the  attack,  and  Wunder- 
lich  found  fever  of  very  unequal  degrees  and  with  very  variable  maxima, 
but  the  highest  temperatures  were  observed  by  him  as  well  as  others  in 
fatal  cases  and  immediately  before  death.  In  one  instance  it  reached 
107.5°  F.  Burdou-Sauderson  and  others  have  found  that  an  increased 
temperature  always  attended  exacerbations  of  pain.  Von  Ziemsseu  gives 
the  average  temperature  as  varying  from  100.4°  to  103°  F.,  but  with 
variations  between  higher  and  lower  points,  and  particularly  notes  the 
persistence  of  a  normal  temperature  while  the  other  symptoms  are  under- 
going a  variety  of  changes,  as  well  as  the  fact  that,  unlike  other  febrile 
affections,  this  disease  has  no  representative  temperature  curve.  In  his 
clinical  observations  Hart  found  for  several  successive  days  as  much  as 
six  degrees  of  difference  between  the  morning  and  evening  temperatures. 
A.  morning  rise  for  several  days  was  noticed  in  four  cases,  and  usually 
there  was  no  relation  between  the  pulse  and  the  temperature,  nor  any 
uniformly  between  the  temperature  and  the  gravity  of  the  attack.2  But 
not  rarely  it  has  been  noticed  that  the  daily  exacerbations,  if  any,  did  not 
occur  in  the  afternoon,  but  with  great  irregularity,  so  that  the  maxima 
and  minima  might  occur  on  successive  days  and  at  the  same  hour  of  the 
day.  Dr.  J.  L.  Smith,  whose  thermometric  observations  in  this  disease 
seem  to  have  been  carefully  made,  used  the  thermometer  in  the  rectum, 
and  thus  obtained  temperatures  higher  that  the  average  of  other  obser- 
vations, such  as  105.£°  to  107.f°  in  several  cases.  Yet  he  found  the 
fluctuations  of  rectal  temperature  remarkable,  though  less  so  than  the  sur- 
face temperature,  of  which  he  states  that  sometimes  it  rose  above  or  fell 
below  the  normal  standard  several  times  in  the  course  of  the  same  day. 

Nothing  can  be  more  irregular,  uncertain,  or  various  than  the  eruptions 
and  other  cutaneous  symptoms  that  have  been  met  with  in  this  disease. 
When  it  first  appeared  in  New  England  a  large  proportion  of  the  cases, 
and  especially  of  the  grave  cases,  exhibited  petechial  eruptions  and  ecchy- 
motic  spots,  whence  the  disease  presently  received  the  name  of  spotted 
fever.  Yet  even  then,  North  and  the  other  historians  of  its  epidemics  were 
careful  to  state  that  spots  on  the  skin  were  by  no  means  characteristic  of 
the  disease,  and  very  often  were  not  present  at  all,  especially  in  cases  that 
terminated  favorably.  Woodward,  for  example,  wrote  (1808):  "An 
eruption  on  the  skin  so  seldom  appeared  that  it  could  no  longer  be  con- 
sidered a  characteristic  symptom  of  the  disease."  In  various  American 
local  epidemics  an  eruption  of  some  kind  seems  to  have  existed  in  about 
one-half  of  the  cases.  In  one  that  we  observed  in  the  Philadelphia  Hos- 
pital no  eruption  whatever  was  observed  in  thirty-seven  out  of  ninety- 
eight  cases.  In  the  epidemic  at  Chicago  in  1872,  N.  S.  Davis  says  :3 
"  About  one-third  of  the  cases  presented  some  red  erythematous  spots  " 
between  the  third  and  the  seventh  day.  In  mild  cases  they  were  few  and 

1  Amer.  Jour,  of  Med.  Sri.,  July,  1867,  p.  38.  *  St.  Barfs  Reports,  xii.  112. 

*  Louisville  Med.  Jour.,  June,  1872,  p.  705. 


INDIVIDUAL  SYMPTOMS.  817 

bright  red ;  in  grave  cases,  darker  and  larger,  with  some  swelling  of  the 
skin ;  and  in  the  worst  cases,  purple  spots  one  or  two  or  more  inches  in 
diameter.  In  that  of  Louisville,1  Larrabie  states  that  the  eruption  "  was 
generally  herpetic  in  its  character,  and  accompanied  by  sudamina ;  but  in  sev- 
eral instances  an  urticarious  eruption  suddenly  appeared  and  disappeared." 
Nothing  is  said  of  petechise  or  ecchymoses.  In  the  New  York  epidemic 
of  18732  the  skin  in  grave  cases  presented  dusky  mottlings,  especially 
when  the  animal  temperature  was  reduced  ;  also  a  punctated  red  eruption, 
bluish  spots  a  few  lines  in  diameter,  and  large  patches  of  the  same  color. 
Herpes  also  was  common.  It  is  chiefly  in  cases  of  a  malignant  type  and 
rapid  and  fatal  course  that  ecchymoses  have  been  observed.  Of  this  state- 
ment illustrations  will  be  given  in  the  paragraph  relating  to  the  duration 
of  the  disease. 

In  continental  European  epidemics  of  meningitis  the  proportion  of 
cases  in  which  a  general  eruption  existed  seems  to  have  been  smaller  than 
it  was  in  this  country.  In  the  Geneva  epidemic  of  1805  a  considerable 
number  of  cases  at  the  point  of  death  presented  purplish  spots,  some 
earlier  than  this,  and  some  after  death  only.  In  the  Neapolitan  epidemic 
of  1833,  and  in  that  which  occurred  in  Dublin  in  1867-68,  ecchymoses 
were  often  present,  and  in  a  very  marked  degree.  Stokes  and  Banks 
mention  that  in  some  rare  instances  the  spots  ran  together  and  coalesced 
over  some  portions  of  the  body,  so  as  to  cover  a  large  extent  of  the  skin 
and  render  it  completely  black,  as  though  it  were  wrapped  in  some  dark 
shroud.  The  entire  right  arm  and  half  of  the  right  side  of  the  chest  in 
one  case,  and  in  the  other  the  whole  of  the  lower  portion  of  one  leg  and 
foot,  were  thus  affected.3  In  Strasburg,  on  the  other  hand,  only  three 
cases  of  petechise  were  observed  by  Tourdes ;  at  Rochefort  and  Versailles, 
in  1839,  they  were  rarely  noticed ;  at  Gibraltar,  in  1844,  they  do  not  seem 
to  have  been  observed  ;  in  1848-49,  at  the  Val  de  Grace  Hospital  (Paris), 
they  appear  not  to  have  attracted  attention;  and  at  Petit  Bourg  they 
were  not  noticed,  although  the  state  of  the  skin  was  fully  described.  In 
Prussia,  in  1865,  neither  Burdon-Sanderson  nor  Wimderlich  mentions 
petechise  or  vibices  as  occurring  during  life;  and  Hirsch,  after  noting 
their  occasional  presence,  is  obliged  to  draw  upon  American  authors  for 
an  account  of  them. 

Of  the  eruptions  other  than  petechise  and  ecchymoses,  several  of  which 
have  already  been  mentioned,  it  is  necessary  to  take  some  notice  here. 
They  are,  chiefly,  and  in  general  terms,  exanthems,  including  erythema, 
roseola,  and  urticaria,  and  in  addition  herpes,  particularly  of  the  lips. 
The  last  has  no  special  relation  to  this  affection,  as  it  is  met  with  in  almost 
every  febrile  disease,  but  it  has  sometimes  extended  to  the  whole  face  in 
this  one.  The  former  may  be  connected  pathologically  either  with  the 
altered  condition  of  the  blood  or  with  the  irritation  produced  by  the  exu- 
dation in  the  spinal  nervous  centres.  They  have  frequently  been  com- 
pared to  measles  and  to  scarlatina,  but  sometimes  they  have  assumed  the 
form  of  bullse.  Thus,  in  the  case  of  a  child  four  years  old,  described  by 
Grimshaw,4'an  eruption  of  pemphigus  occurred  over  the  whole  body. 
Jackson  long  before  had  mentioned,  as  one  of  the  eruptions  belonging  to 
this  disease,  "large  bullse,  as  if  produced  by  cantharides."  Jenks 

1  Louisville  Med..  Jour.,  Dec.,  1872,  p.  782.       tAmer.  Jour,  of  Med.  Sci.,  Oct.,  1873,  p.  329. 
8 Dublin  Quart.  Jour.,  xlvi.  199.  *  Jour,  of  Cutaneous  Med.,  ii.  37. 

VOL.  I.— 52 


818  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

described  "  large  elevated  spots  of  a  very  dark  color,  presenting  outside 
of  the  dark  color  a  blistered  appearance."  In  some  cases  gangrene  of  the 
skin  has  been  observed  when  the  spots  have  been  exceptionally  dark,  and 
occasionally  has  been  produced  by  pressure. 

The  cause  of  death  in  many  of  the  more  rapid  cases  is  coma,  which  is 
often  preceded  by  convulsions,  especially  in  children  ;  but  in  many  others, 
even  when  attended  with  all  the  marks  of  dissolution  of  the  blood,  con- 
sciousness may  be  but  slightly  impaired  until  the  actual  imminence  of 
death.  In  many  other  cases,  which  are  fatal  in  the  midst  of  an  attack 
with  spinal  symptoms,  death  is  due  to  asphyxia,  partly  owing  to  pres- 
sure on  the  medulla  oblongata,  and  partly  to  the  interference  with  the 
respiratory  act  due  to  this  pressure,  and  occasioning  excessive  bronchial  se- 
cretion. Again,  death  may  occur  through  a  gradual  exhaustion  of  the  powers 
of  life,  without  marked  spasm,  blood-change,  or  complication.  In  these 
cases  also  the  intelligence  remains  unimpaired  almost  until  the  moment 
of  dissolution.  Death  is  not  very  rarely  due  to  pneumonia,  and  when 
the  disease  is  greatly  prolonged  or  the  convalescence  from  it  is  imperfect  a 
fatal  termination  by  dropsy  of  the  brain  is  still  among  its  dangers. 

Hirsch  once  declared  that  the  duration  of  epidemic  meningitis  "  is 
between  a  few  hours  and  several  months,"  and,  however  hyperbolical  the 
phrase  may  seem,  it  is  quite  accurate.  Such  inequalities  are  more  charac- 
teristic of  acute  blood  diseases  than  of  inflammations,  and  in  this  case  the 
coexistence  of  elements  of  both  kinds  doubtless  accounts  for  the  extreme 
irregularity  of  the  symptoms  and  duration  of  the  attack.  The  early 
American  writers  insisted  strongly  on  this  as  a  characteristic  feature  of 
the  disease.  They  record  an  unusually  large  proportion  of  cases  that 
were  fatal  within  the  first  day,  and  even  after  an  illness  of  five  hours, 
although  they  agree  that  the  most  usual  date  of  death  was  between  the 
fourth  and  seventh  days — a  result  that  has  been  confirmed  by  subsequent 
observation.  Dr.  N.  S.  Davis  gives  the  duration  of  the  disease,  as  seen  by 
him,  as  between  twenty  hours  and  twenty-eight  days.  Out  of  469  fatal 
cases  in  the  city  of  New  York  in  1872,  334  are  said  to  have  terminated 
within  eleven  days,  and  of  this  number  270  were  fatal  in  the  first  six  days 
of  the  attack,  including  52  who  died  on  the  first  day,  and  51  in  from  one  to 
two  days.  It  is  perhaps  worthy  of  note  that  while  from  the  eleventh  to 
the  fourteenth  day  only  1 1  deaths  occurred,  20  took  place  on  the  four- 
teenth and  fifteenth ;  and  while  from  the  fifteenth  to  the  twenty-first  day 
only  16  died,  yet  from  the  twenty-first  to  the  twenty-second  12  deaths 
were  reported.  This  would  seem  to  indicate  a  peculiar  danger  on  the 
days  represented  by  multiples  of  seven.  Of  cases  that  recover,  the 
duration  is  even  more  indefinite  than  that  of  fatal  cases,  owing  to  compli- 
cations that  occur  in  many,  and  especially  such  as  involve  the  cerebro- 
spinal  centres.  When  death  takes  place  within  a  few  hours  it  usually,  if 
not  always,  is  attended  with  symptoms  that  denote  a  disorganization  of  the 
blood.  In  1864  we  attended  a  young  man  previously  in  perfect  health,  but 
who  died  in  twenty-one  hours  after  the  first  seizure.  His  mind  was  un- 
clouded throughout  his  brief  but  fatal  illness.  Within  seven  hours  of  death 
a  purpurous  discoloration  of  the  skin  began,  and  about  an  hour  before  that 
event  the  surface  everywhere  assumed  a  dusky  hue.  The  forearms  and 
hands  were  almost  uniformly  purple  and  the  face  turgid ;  many  ecchy- 
motic  spots  on  the  trunk  and  lower  limbs  were  nearly  black  and  measured 


INDIVIDUAL  SYMPTOMS.  819 

one  or  two  inches  in  diameter.1  In  the  case  of  a  child  of  five  years  death 
in  convulsions  took  place  after  an  illness  of  ten  hours,  the  skin  presenting 
purpurous  spots,  some  of  them  very  large  and  of  a  deep  bluish  livid  hue! 
On  post-mortem  examination  there  was  not  the  slightest  appearance  of 
any  meningeal  lesion,  except  a  few  dark  spots  like  sanguineous  eifusion 
under  the  arachnoid.  The  heart  was  full  of  dark  blood  in  a  semi-coagu- 
lated state,  and  the  white  corpuscles  were  three  times  as  numerous  as  the 
red.2  A  case  is  reported  by  Gordon 3  in  which  the  entire  duration  of  the 
illness  until  death  was  five  hours.  This  is  probably  the  shortest  case  on 
record.  A  lady  aged  twenty-two  years  died  in  sixteen  hours,  the  skin 
covered  with  livid  ecchymoses,  some  of  them  measuring  an  inch  or  an 
inch  and  a  half  in  diameter.4 

The  character  of  the  convalescence  from  epidemic  meningitis  must  evi- 
dently be  affected  by  the  causes  that  determine  its  duration,  the  grade  of 
the  disease,  the  development  and  extent  of  the  lesions,  etc. ;  but  it  is  cer- 
tain that,  except  in  those  imperfect  and,  as  it  were,  shadowy  cases  which 
denote  a  very  slight  action  of  the  morbid  cause,  its  subjects  do  not  recover 
rapidly.  The  essential  lesion  of  the  fully-formed  disease  requires  time 
for  its  removal,  just  as  in  typhoid  fever  the  intestinal  ulcers  are  often 
slow  of  healing,  and  hence  become  a  cause  of  tardy  recovery  and  even 
of  unlooked-for  death.  The  convalescence,  then,  from  the  disease  we  are 
now  studying  is  slow  and  irregular,  is  attended  often  with  debility  and 
emaciation,  and  sometimes  with  persistent  headache,  neuralgia,  convul- 
sions, stiffness  of  the  neck  and  pain  in  moving  it,  hypersesthesia  of  por- 
tions of  the  skin,  palpitation  of  the  heart,  dyspepsia,  etc.  Relapses  are 
very  far  from  being  uncommon. 

Among  the  causes  of  tardy  convalescence  in  this  disease  are  those 
lesions  and  disorders  which  may  be  embraced  by  the  term  sequelae. 
Impaired  vision,  due  to  various  affections  of  the  eyes,  has  already  been 
considered  among  the  symptoms  proper  of  the  disease,  but  they  are  not 
infrequently  developed  after  the  acute  attack  has  subsided.  Thus,  in 
a  case  reported  by  Larrabie : 5  "  Just  as  convalescence  seemed  beginning 
the  left  eye  became  affected  in  all  its  parts,  with  entire  loss  of  vision  and 
also  complete  deafness.  After  a  short  remission  hydrencephaloid  symp- 
toms appeared,  followed  by  the  same  changes  in  the  hitherto  sound  eye, 
complete  blindness  and  deafness,  general  cachexia  and  marasmus,  rigid 
flexion  of  the  right  limbs,  and  death  by  exhaustion  at  the  end  of  sixteen 
weeks."  The  impairment  of  hearing,  which  also  was  described  as  a 
symptom  of  the  acute  attack,  is  apt  to  become  more  marked  after  the 
acute  stage  has  passed  by,  and,  as  before  stated,  is  very  often  perma- 
nent. Occurring  in  young  children,  it  then  involves  deaf-mutism.  *  It  is 
in  many  cases  associated  with  defective  vision,  weakness  or  loss  of  mem- 
ory, mania,  impairment  of  intelligence,  persistent  pains  in  the  head  or 
chronic  hydrocephalus.  Sometimes  to  one  or  more  of  these  symptoms  is 
added  more  or  less  general  paresis  or  complete  paralysis.  Southhall6 
mentions  the  case  of  a  chiid  two  years  old  whose  attack  was  followed  by 
incomplete  paralysis,  and  death  at  the  end  of  eight  months  with  softening 

1  Amer.  Jour  of  Med.  Sci.,  July,  1864,  p.  133.          2  Dublin  Quart.  Jour.,  1867,  ii.  441. 

3  Loc.  cit. 

*  Med.  Press  and  Circular,  May,  1866.     For  other  cases  see  ibid.,  pp.  296,  298-300. 

5  Richmond  Journal  of  Med.,  Dec.,  1872,  p.  779. 

8  Ibid.,  Aug.,  1872,  p.  141. 


820  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

of  the  brain.  Gordon  thus  describes  the  conclusion  of  a  case :  "  The 
man  has  gradually  passed  into  a  state  of  almost  organic  life ;  he  eats, 
drinks,  and  sleeps  well ;  he  passes  solid  feces  and  urine  without  giving 
any  notice,  yet,  evidently,  not  unconsciously ;  ....  he  seems  to  under- 
stand, but  cannot  answer ;  ....  he  can  draw  up  his  legs  and  arms,  but 
he  cannot  use  his  hands  at  all."  Hirsch  has  remarked  that  disor- 
ders of  speech  are  met  with,  due  apparently  to  an  inability  to  articulate 
certain  sounds.  Von  Ziemssen  regards  chronic  hydrocephalus  as  not  a 
rare  consequence  of  epidemic  meningitis,  and  as  one  not  absolutely  or 
immediately  fatal.  Its  symptoms  include  severe  paroxysmal  pain  in  the 
head  or  neck  or  extremities,  with  vomiting,  loss  of  consciousness,  convul- 
sions, and  involuntary  evacuation  of  excrements.  Between  the  parox- 
ysms, which  sometimes  occur  periodically,  the  patient  generally  suffers 
from  neuralgic  pains,  hyperaesthesia,  and  various  motor  and  even  mental 
disorders ;  but  in  other  cases  the  intervals  are  free,  or  nearly  so,  from  all 
morbid  manifestations.  Davis'  (1872)  and  many  others  speak  of  severe 
neuralgic  pains  following  this  disease ;  according  to  Dr.  D.,  they  are  most 
frequent  at  the  heads  of  the  gastrocnemii  muscles,  in  the  abdomen,  and 
the  head;  a  very  fretful  disposition,  variable  appetite,  and  disturbed 
sleep  are  often  observed.  Relapses  have  been  noticed  in  almost  all 
the  epidemics,  and  it  seems  probable  that  they  are  often  due  to  the 
influence  of  accidental  exciting  causes,  mental  or  physical,  in  renew- 
ing the  inflammation  around  the  cerebro-spinal  lesions.  Miner  (1825) 
remarked  that  they  were  most  apt  to  occur  within  the  first  week, 
but  that  when  the  disease  had  once  run  its  course  there  were  very  few 
relapses  during  convalescence.  But,  he  adds,  there  were  several  repeated 
attacks  after  the  most  perfect  recovery,  and  several  of  the  patients  had 
had  the  disease  the  preceding  year. 

Like  other  epidemic  diseases,  meningitis  presents  itself  with  every  pos- 
sible degree  of  gravity  between  that  of  a  slight  indisposition  and  that  of 
a  malignant  and  deadly  malady.  The  mortality  in  a  number  of  epidem- 
ics compared  by  Hirsch  varied  between  20  per  cent,  and  75  per  cent.  It 
changes  with  the  locality.  '  Thus,  nearly  at  the  same  time  that  the  death- 
rate  from  this  disease  in  Massachusetts  was  61  per  cent.,  it  was  but  33 
per  cent,  in  the  Philadelphia  Hospital.  In  1872  the  whole  number 
of  deaths  caused  by  it  in  Philadelphia  was  133,  while  at  St.  John's 
College,  Little  Rock,  Ark.,  21  cases  out  of  29  were  fatal  (Southhall).  It 
differs,  also,  at  different  periods ;  for  while  ten  epidemics  in  various 
places,  occurring  between  1838  and  1848,  presented  an  average  mortality 
of  70  per  cent.,  a  similar  number,  occurring  between  1855  and  1865,  gave 
an  average  mortality  of  only  30  per  cent.  It  must,  however,  be  con- 
fessed that  such  statistics  cannot  be  relied  upon  as  accurate,  for  in  pri- 
vate practice  many  cases  occur  that  are  never  reported  unless  they  end 
fatally. 

MORBID  ANATOMY. — The  lesions  found  after  death  from  epidemic  men- 
ingitis consist  essentially  of  congestion  or  inflammation  of  the  cerebro- 
spinal  meninges,  but  they  also  include  in  many  cases  hemorrhage,  serous 
effusion,  plastic  exudation,  and  tissue-changes  in  the  brain  and  spinal 
marrow,  and  in  many  other  cases  an  impaired  constitution  of  the  blood. 
As  the  signs  of  the  latter,  and  not  the  former,  alterations  are  met  with 
iri  the  more  malignant  cases,  it  is  evident  that,  looking  at  the  disease  as  a 


MORBID  ANATOMY.  821 

whole,  it  must  involve  a  toxic  element  of  whose  operation  the  various 
post-mortem  lesions  are  only  effects.  These  lesions,  on  the  whole,  vary 
with  the  type  of  the  disease,  and  also  with  its  duration,  but  some  are 
chiefly  met  with  in  cases  of  a  malignant  and  others  in  cases  of  an  inflam- 
matory type. 

The  exterior  of  the  body  after  death  in  the  early  stages  of  this  disease 
almost  always  presents  the  marks  of  transudation  of  the  contents  of  the 
blood-vessels.  The  dependent  parts  of  the  body  exhibit  large  livid 
patches  or  a  uniform  discoloration  of  the  same  hue.  In  acute  cases 
the  muscles  are  more  deeply  colored  than  natural,  and  when  the  attack  is 
prolonged  they  are  said  to  have  their  cohesion  impaired  by  fatty  degenera- 
tion. Congestion  of  the  brain  is  an  unfailing  accompaniment  of  the  first 
stage  of  the  disease ;  its  blood-vessels  are  all  distended  with  dark  blood  ; 
the  sinuses  of  the  dura  inater  are  usually  filled  with  coagula  of  the  same 
hue,  though  sometimes  very  dense.  Serum  abounds  in  the  arachnoid 
cavity  and  in  the  ventricles  of  the  brain ;  it  may  be  clear  or  milky,  and 
sometimes  it  is  quite  purulent.  It  is  alleged  by  one  reporter  that  no  less 
than  three  pints  of  turbid  serum  escaped  in  a  case  in  which,  however, 
death  did  not  occur  until  the  thirty-fifth  day.  Craig  found  eight  and 
twelve  ounces  of  a  limpid  fluid  in  two  cases  ;  and  Tourdes  found  pus  in 
more  than  one-half  of  his  cases,  either  unmixed  or  forming  a  milky 
liquid.  J.  L.  Smith  refers  to  the  case  of  an  infant  who  had  the  disease 
at  the  age  of  five  months,  and  two  months  subsequently  great  prominence 
of  the  anterior  fontanelle,  and  other  symptoms  which  indicated  the  presence 
of  a  considerable  amount  of  effusion  within  the  cranium.  In  a  case 
in  Dublin,1  there  was  no  meningeal  lesion  except  in  a  "  few  dark  spots 
like  sanguineous  effusion  under  the  arachnoid."  White 2  mentions  the 
case  of  an  adult  that  terminated  fatally  in  thirty-six  hours,  in  which  the 
vessels  of  the  pia  mater  were  very  much  congested,  and  sanguineous 
effusions  existed  above  and  below  the  cerebellum,  and  a  clot  of  blood 
three  inches  long  and  external  to  the  theca  extended  downward  from  the 
lowest  portion  of  the  medulla  oblongata.  In  all  of  these  instances,  then, 
congestion,  the  first  stage  of  inflammation,  existed.  That  such  was  its 
real  nature  is  proved  by  what  follows. 

The  most  characteristic  lesion  is  a  fibrinous  or  purulent  exudation  in 
the  meshes  of  the  pia  mater.  American  physicians  described  it  as  early 
as  1806  in  such  terms  as  these  :  "  The  dura  mater  and  pia  mater  in  several 
places  adhered  together  and  to  the  substance  of  the  brain  ;  .  .  .  .  between 
the  dura  mater  and  the  pia  mater  was  a  fluid  resembling  pus  "  (Daniel- 
son  and  Mann).  In  1810,  Bartlett  and  Wilson  found  "an  extravasa- 
tion of  lymph  on  the  surface  of  the  brain ;"  and  in  the  same  year  Jack- 
son and  his  colleagues,  after  describing  the  congestion  and  serous  effusion 
found  within  the  cranium  "  in  those  who  perished  within  twelve  hours 
of  the  first  invasion,"  state  that  the  arachnoid  and  pia  mater  present  an 
effusion  between  them  of  "  coagulated  lymph  or  semi-purulent  lymph  " 
both  on  the  convexity  and  at  the  base  of  the  brain.  These  descriptions 
correspond  in  all  respects  with  those  of  Mathey  relating  to  the  epidemic 
at  Geneva  in  1805,  for  he  says:  "The  meningeal  blood-vessels  were 
strongly  injected.  A  jelly-like  exudation  tinged  with^blood  covered  the 
surface  of  the  brain  ;  ....  on  its  lower  surface  and  in  the  ventricles  a 

1  Dublin  Jour.,  July,  1867,  p.  441.  *  Med.  Record,  iii.  198 


822  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

yellowish  puriform  matter  was  found."  Such  lesions  have  been  described 
by  a  long  line  of  observers — by  Wilson  in  1813,  Gamage  in  1818,  Ames 
and  Sargent  in  1 848 ;  by  Squire,  Upham,  and  a  host  of  others  since 
1860  in  the  United  States,  and  by  Tourdes,  Gilchrist,  Ferrus,  "VVilks, 
Gordon,  Banks,  Gaskoin,  Niemeyer,  Burdon-Sanderson,  and  many  more 
in  Europe. 

It  is  evident,  therefore,  that  in  a  certain  number  of  fatal  cases  only 
sanguineous  congestion  of  the  membranes  of  the  brain  and  spinal  cord 
are  found,  and  in  certain  others — constituting,  it  may  be  added,  nine- 
tenths  of  the  whole  number — evidences  exist  of  cerebro-spinal  menin- 
gitis. Hence  the  natural  conclusion  is  that  the  congestive  lesions  repre- 
sent the  first  stage  of  a  process  which  if  prolonged  and  perfected  occa- 
sions the  lesions  peculiar  to  inflammation.  For  the  development  of  the 
latter  two  factors  would  seem  to  be  essential — not  only  a  fibrinous  condi- 
tion of  the  blood,  but  also  sufficient  time  for  exudation  to  occur.  But 
when  we  come  to  study  the  actual  results  of  examinations  post-mortem, 
it  is  found  that  the  duration  of  the  attack  does  not  determine  absolutely 
the  nature  of  the  lesions.  On  the  one  hand,  in  a  case  which  terminated 
fatally  after  a  week's  illness  there  was  found  reddish  serum  between  the 
arachnoid  and  the  pia  mater  and  in  the  lateral  ventricles,  with  intense 
injection  of  the  pia  mater  of  the  base,  medulla  oblongata,  and  upper  part 
of  the  spinal  cord,  but  no  exudation  of  lymph.1  And,  on  the  other 
hand,  numerous  cases  have  been  published  in  which,  although  death 
occurred  within  twenty-four  hours  from  the  onset  of  the  attack,  coagu- 
lated lymph  and  also  pus  were  found  upon  the  brain  and  spinal  marrow. 
For  example,  during  the  winter  of  1861-62,  in  the  army,  that  then  lay 
near  "Washington,  D.  C.,  a  soldier  was  attacked  with  a  chill,  severe  fever, 
and  headache,  followed  by  opisthotonos  and  repeated  convulsions  before 
his  death,  which  occurred  in  about  twenty-four  hours.  No  eruption  or 
discoloration  of  the  skin  is  mentioned  in  the  history.  On  examination 
there  was  found  beneath  the  arachnoid  a  thin  layer  of  lymph  and  abun- 
dant exudation  over  the  posterior  lobes  of  the  cerebrum,  and  also  at  the 
base  of  the  brain  and  on  the  medulla  oblongata.2  In  a  case  reported  by 
Gordon 3  the  entire  duration  of  the  illness  was  under  five  hours,  and 
after  death  the  cerebral  arachnoid  was  more  or  less  opaque,  and  in  some 
spots  had  a  layer  of  very  thin  purulent  matter  beneath  it.  And,  again, 
not  only  may  the  symptoms  belonging  to  blood-dissolution  be  consistent 
with  a  certain  prolongation  of  life,  but  also  with  decidedly  inflammatory 
tissue-changes.  Thus,  in  another  case  of  Gordon's  the  duration  of  the 
illness  was  at  least  six  days,  and  the  patient  presented  all  the  character- 
istic symptoms  of  the  disease,  including  "a  most  wonderful  and  uniform 
curve  of  the  spine  and  head  backward,"  "  spots  black  as  ink,"  "  bullae 
which  rapidly  became  opaque  and  dusky,"  "  herpetic  eruption,  etc." 
After  death  the  body  had  a  very  frightful  appearance.  It  was  still  promi- 
nently arched  forward.  It  was  of  a  dusky  blue  color,  with  a  copious 
eruption  of  black  spots  of  various  sizes,  and  one  or  two  of  them  were 

gangrenous When  the  theca  vertebralis  was  opened  purulent  matter 

flowed  out,  and  a  purulent  effusion  was  found  in  patches  on  the  brain. 

1  Davis,  Richmond  Med.  Jour.,  June,  1872,  p.  709. 

2  Frothingham,  Amer.  Med.  Times,  Apr.,  1864,  p.  207. 
s  Dublin  Quart.  Jour.,  May,  1867,  p.  409. 


MORBID  ANATOMY.  823 

The  cerebral  arachnoid  was  all  opaque,  the  lateral  ventricles  were  filled 
with  serum,  and  the  blood  in  all  the  cavities  was  very  fluid  and  dark 
colored.  From  all  that  precedes,  therefore,  it  must  be  inferred  that  the 
nature  of  the  lesions  in  this  disease  depends  not  on  the  type  alone,  nor  on 
the  duration  merely,  of  the  attack — that  a  very  brief  course  is  compatible 
with  marked  inflammatory  lesions,  and  a  prolonged  one  with  profound 
alterations  in  the  condition  of  the  blood.  In  other  words,  it  seems  that 
there  must  be  something  besides  the  appreciable  lesions  that  influences,  if 
it  _does  not  determine,  the  issue  of  an  attack  of  this  affection.  While 
bringing  forward  prominently  this  proposition,  and  the  facts  on  which 
it  rests,  we  have  no  intention  of  under-estimating  the  relative  significance 
of  the  two  most  conspicuous  types  of  the  disease,  the  purely  inflamma- 
tory and  the  adynamic,  or  calling  in  question  the  fact  that  the  evolution 
of  the  former  is  most  usually  comparatively  slow  and  regular,  and  of  the 
latter  rapid  and  irregular.  In  the  one,  when  death  takes  place  early,  con- 
gestive changes  are  found,  and  when  later  these  have  merged  into  exuda- 
tive lesions ;  in  the  other  or  adynamic  cases  congestion  and  liquid 
transudation  prevail,  and  the  results  of  complete  inflammation  are  seldom 
seen.  When  the  disease  has  been  very  much  prolonged  the  exudation 
becomes  tough,  adherent,  and  shrivelled. 

The  brain-tissue  has  generally  been  found  softer  than  natural,  and, 
although  in  some  cases  this  diminished  consistence  might  be  attributed 
to  post-mortern  changes,  yet  on  the  whole  it  must  be  associated  with  the 
inflammatory  lesions  of  the  meninges.  As  a  rule,  it  is  greater  the  longer 
the  attack  has  lasted,  and  is  by  no  means  equally  diffused,  but  is  more 
marked  where  the  meningeal  alterations  are  greatest.  Ames  found  soften- 
ing in  nine  out  of  eleven  cases,  and  chiefly  in  the  cortical  substance,  but 
also  in  the  fornix  and  septum  lucidum ;  and  Chauffard  states  that  in  pro- 
tracted cases  "  the  interior  surface  of  the  ventricles,  the  fornix,  and  septum 
lucidum,  were  reduced  to  a  pultaceous  and  creamy  consistence."  But  it 
is  by  no  means  true  that  softening  is  met  with  in  all  cases  of  long  dura- 
tion. 

The  lesions  of  the  spinal  marrow  and  its  membranes  correspond  with 
those  of  the  brain.  The  dura  mater  is  often  very  dark,  its  blood-vessels 
engorged,  its  arachnoid  cavity  distended  with  serum  more  or  less  bloody, 
turbid,  or  purulent.  Two  ounces  of  pus  have  been  removed  from  it 
through  a  puncture.  Fibrinous  and  purulent  exudation  fills  the  meshes 
of  the  pia  mater,  and  is  usually  most  abundant  in  the  cervical  and  dorsal 
portions,  and  generally  upon  the  posterior  rather  than  upon  the  anterior 
surface  of  the  organ  ;  but  sometimes  large  accumulations  of  lymph  and 
pus  are  found  at  the  lower  end  of  the  cord.  Gordon1  relates  of  a  case 
that  "  when  an  opening  was  made  into  the  lower  part  of  the  theca  verte- 
bralis  purulent  matter  flowed  out,  and  the  entire  surface  of  the  pia  mater 
was  covered  with  a  coating  of  thin  purulent  matter,  which,  like  a  thin 
layer  of  butter,  remained  adherent  to  it."  Occasionally  the  cavity  of  the 
spinal  arachnoid  contains  blood.  Softening  of  the  spinal  cord  has  been 
often  noticed.  Chauffard  states  that  in  some  cases  of  particularly  long 
duration  it  was  reduced  to  a  mere  pulp,  and  he  adds,  "  in  the  place  o? 
portions  of  the  spinal  marrow,  completely  destroyed,  was  found  only  a 
yellowish  liquid,  or  the  empty  membranes  fell  into  contact  where  it  was 

1  Dublin  Quart.  Jour.,  xliii.  414. 


824  EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

wanting."  Similar  disorganization  has  been  described  by  Ames,  Klebs, 
and  others.  Fronmuller  reports  the  case  of  a  girl  aged  fourteen  years 
in  whom  the  central  canal  of  the  spinal  cord  was  distended  with  pure 
pus. 

The  lesions  of  the  internal  auditory  apparatus  consist  of  softening  in 
the  fourth  ventricle  and  of  the  root  of  the  auditory  nerve,  yet  such  lesions 
are  said  to  have  been  found  even  when  no  defect  of  hearing  had  existed. 
In  other  cases  in  which  deafness  did  occur  the  lesions  consisted  of  inflam- 
matory changes  in  the  cavity  of  the  tympanum  and  suppuration  of  the 
labyrinth.  They  probably  arose  from  an  extension  of  inflammation  from 
the  pia  mater  along  the  trunk  of  the  auditory  nerve  (Von  Ziemssen). 
In  like  manner,  the  inflammatory  and  destructive  changes  in  the  eye 
which  have  been  elsewhere  described  arise  from  an  analogous  cause  affect- 
ing the  optic  nerves. 

It  is  unnecessary  to  dwell  upon  the  condition  in  which  other  organs  are 
found  after  death  from  epidemic  meningitis.  In  cases  that  present  a 
typhoid  type,  and  even  in  such  as  are  rapidly  fatal  with  ecchymotic  dis- 
coloration of  the  skin,  the  various  organs  present  no  distinctive  tissue- 
change,  but  only  such  engorgement  as  is  common  to  all  diseases  of  a  simi- 
lar type.  It  deserves  to  be  particularly  mentioned  that  in  this  affection 
the  spleen  is  not  enlarged,  as  it  always  is  in  a  greater  or  less  degree  in 
diseases  whose  primary  stage  involves  an  altered  condition  of  the  blood. 
This  fact  becomes  all  the  more  important  in  view  of  the  remarkable  con- 
trast which  the  constitution  of  the  blood  presents  in  epidemic  meningitis 
and  in  various  typhous  affections. 

The  state  of  the  blood  in  this  disease  is  one  of  peculiar  interest,  domi- 
nating as  it  does  its  whole  pathology  and  determining  its  nosological  posi- 
tion. It  is  the  blood  of  a  phlegmasia  rather  than  of  a  pyrexia.  This 
fact  was  early  established  by  American  physicians  who  observed  the  dis- 
ease, and  the  opportunities  for  doing  so  were  not  wanting,  since  venesec- 
tion was  used  by  every  one  who  treated  it.  In  1807-09  a  rapidly  fatal 
case  or  two  was  found  in  which  the  "  blood  was  darker  and  had  a  larger 
proportion  of  serum  than  usual,"  but  in  others  "  it  did  not  present  any 
uncommon  appearance,  and  no  inflammatory  buff,  nor  was  it  dissolved" 
(Fish).  In  1811,  Arnell  stated  that  "the  blood  drawn  in  the  early  stage 
appeared  like  that  of  a  person  in  full  health ;  there  was  no  unusual  buffv 
coat,  neither  was  the  crassamentum  broken  down  or  destroyed."  In  the 
epidemic  studied  by  Mannkopff  (1866)  he  found  that  blood  obtained  by 
venesection  gave  a  clot  with  a  thick  buffy  coat.  Andral,  seeking  to  estab- 
lish the  law  that  in  every  acute  inflammation  there  is  an  increase  in  the 
fibrin  of  the  blood,  remarks  that  in  a  case  of  cerebro-spinal  meningitis  it  was 
very  marked.1  Ames  states  that  "  the  blood  taken  from  the  arm  and  by 
cups  from  the  back  of  the  neck  "  "  coagulated  with  great  rapidity."  "  Its 
color  was  generally  bright — in  a  few  cases  nearly  approaching  to  that  of 
arterial  blood ;  it  was  seldom  buffed ;  in  thirty-seven  cases  in  which  its 
appearance  was  noted  it  was  buffed  in  only  four."  Analyses  were 
made  in  four  cases,  "the  blood  being  taken  early  in  the  disease 
from  the  arm,  and  was  the  first  bleeding  in  each  case.  They  fur- 
nished the  following  results : 

1  Path.  Hcematoloyy,  p.  73. 


MORBID  ANATOMY.  825 

Fibrin.  Corpuscles. 

1 6.40 140.29 

II • 5.20 112.79 

HI 3.64 123.45 

IV 4.56 129.50 

The  first  was  from  a  laboring  man  thirty-five  years  old ;  the  second  from 
a  boy  twelve  years  old,  while  comatose ;  and  the  two  others  from  stout 
women  between  thirty  and  thirty-five." 1  Tourdes,  whose  analyses  follow, 
states  that  "  blood  drawn  from  a  vein  was  rarely  buffed ;  if  a  buify  coat 
existed,  it  was  thin,  and  generally  a  mere  iridization  upon  the  surface  of 
the  clot."2 

Fibrin.  Corpuscles. 

1 4.60 134.0ft 

II 3.90 ]  35.54 

III 3.70 143.00 

IV 5.63 137.84 

Maillot  gives,  as  the  result  of  an  analysis  of  six  cases,  an  increase  of  fibrin 
to  six  parts  and  more  in  a  thousand.  This  summary  represents,  as  far  as  is 
known,  all  of  the  analyses  of  blood  taken  from  living  patients  in  this  disease, 
and  it  shows  that  in  every  case  the  proportion  of  fibrin  exceeded  that  of 
healthy  blood,  and  corresponded  exactly  to  that  observed  in  the  blood  of 
inflammatory  diseases,  while  the  proportion  of  red  corpuscles  varied  within 
the  normal  limits.  How  different  is  this  condition  of  the  blood  from  that 
of  typhus  fever,  in  which  there  is  a  marked  diminution  of  fibrin,  and  a 
falling  off  in  the  red  corpuscles  as  well,  or  from  that  of  typhoid  fever,  in 
which  neither  element  declines  until  the  disease  affects  the  body  by  inani- 
tion !  (Murchison). 

In  regard  to  the  condition  of  the  blood  after  death  the  historians  of 
the  disease  are  not  so  well  agreed  ;  nevertheless,  the  preponderance  of  the 
testimony  is  in  favor  of  the  statement  that  the  blood  presents  appearances 
resembling  those  belonging  to  the  continued  fevers  rather  than  to  the 
inflammations.  It  is  true  that  even  in  this  the  agreement  is  neither 
general  nor  complete.  Tourdes,  for  example,  states  that  in  an  autopsy 
"  the  blood  was  remarkable  for  the  abundance  and  toughness  of  the 
fibrinous  clots,"  but  the  greater  number  have  reported  it  as  being  dark 
and  liquid.  Such  was  its  condition  in  the  epidemic  which  we  studied  at 
the  Philadelphia  Hospital  in  1866-67,  and  it  has  been  correctly  described 
by  Dr.  Githens  as  follows :  "  The  blood  was  fluid,  of  the  color  and 
appearance  of  port-wine  lees ;  under  the  microscope  the  corpuscles  were 
shrivelled  and  crenated,  and  there  was  a  space  apparent  between  them  as 
they  were  arranged  in  rouleaux.  There  were  in  two  cases  white,  firm, 
fibrinous  heart-clots  extending  through  both  ventricles  and  auricles  and 
into  the  vessels  leading  to  and  from  the  heart." 3  It  may  be  added  that 
the  red  corpuscles  are  often  crenated  and  shrivelled  when  the  case  has 
been  protracted,  and  it  has  been  stated — from  limited  observation,  indeed 
— that  "the  white  corpuscles  are  three  times  more  numerous  than  the 
red."  4  The  blood  has  been  scrutinized  to  discover,  if  possible,  some  of 
those  bodies  which  are  judged  by  Koch  and  his  disciples  to  differentiate 

1  New  Orleans  Med.  and  Surg.  Jour.,  Nov.,  1848.  "  Epidemic  de  Strasbourg,  p.  160. 

3  Amer.  Jour,  of  Med.  Set.,  July,  1867,  p.  23. 

4  Dublin  Quart.  Jour.,  May,  1867,  p.  441. 


826  EPIDEMIC  OEREBEO-SPINAL  MENINGITIS. 

general  diseases,  but  it  is  stated  that  the  investigation  has  been  without 
definite  result.1 

It  does  not  seem  difficult  to  reconcile  the  conflicting  statements  now 
given  of  the  condition  of  the  blood  in  epidemic  meningitis.  One  of 
them  points  to  an  excess  and  the  other  to  a  loss  of  the  spontaneously 
coagulable  element  of  the  blood.  It  is  evident  that  venesection,  which 
was  necessary  for  procuring  the  living  blood  for  analysis,  would  only  be 
performed  when  the  type  of  the  disease  authorized  it — that  is,  when  the 
type  was  sthenic ;  whereas  the  blood  examined  after  death  had  necessarily 
undergone  changes  which  tended  to,  if  they  did  not  actually,  occasion 
death.  Hence  we  find  among  the  former  cases,  when  fatal,  the  most 
extensive  and  massive  exudation,  and  always  among  the  latter  less  evi- 
dence of  inflammation,  but,  on  the  other  hand,  a  greater  or  less  manifes- 
tation of  those  appearances  which  denote  a  loss  of  the  vitality  and  organiza- 
tion of  the  blood.  In  the  one  case  death  may  fairly  be  attributed,  above 
all  other  causes,  to  the  pressure  upon,  and  the  disorganization  of,  the 
cerebro-spinal  organs  essential  to  life ;  in  the  other,  primarily,  to  the 
death  of  the  vital  elements  of  the  blood  produced  by  the  specific  cause 
of  the  disease.  It  is  probable  that  the  post-mortem  fluidity  of  the  blood 
exists  under  two  conditions.  In  the  one  the  morbid  cause  is  powerful 
enough  from  the  very  commencement  rapidly  to  destroy  the  life  of 
that  fluid,  and  in  the  other  it  acts  less  violently,  but  continuously,  to 
exhaust  the  powers  of  life. 

Our  conception  of  the  pathology  of  epidemic  meningitis  is  implicitly 
contained  in  the  foregoing  discussion.  Of  its  essential  cause  and  of  the 
conditions  that  call  it  into  existence  nothing  whatever  is  known.  The 
disease  is  most  probably  due  to  some  atmospheric  agency  that  is  capable 
of  acting  at  the  same  time  upon  widely  separated  localities.  Its  specific 
cause  appears  to  enter  the  blood  first  of  all,  and  doubtless  through  the 
lungs,  and  to  be  capable  of  destroying  life  by  its  action  upon  the  blood 
alone.  Failing  this  effect,  its  force  is  spent  upon  the  cerebro-spinal  pia 
mater,  and  it  may  become  fatal  by  the  mechanical  interference  of  the  prod- 
ucts of  inflammation  with  the  nutrition  of  those  parts  of  the  central 
nervous  system  which  are  essential  to  life.  An  inflammatory  and  a  septic 
element  together  constitute  the  fully-developed  disease  ;  either  may  be  in 
excess  and  overshadow  the  other.  According  to  the  relative  predomin- 
ance of  one  or  the  other,  the  disease  assumes  more  of  a  typhoid  or  more 
of  an -inflammatory  type,  and  it  is  doubtless  this  diversity  in- its  physiog- 
nomy, as  well  as  in  the  lesions  that  attend  it,  which  has  led  to  the  most 
opposite  doctrines  respecting  its  nature  and  its  nosological  affinities. 

DIAGNOSIS. — The  most  distinctive  phenomena  of  epidemic  meningitis 
are  suddenness  of  attack  and  rapidity  of  development  of  the  following 
symptoms :  acute  pain  in  the  head,  neck,  spine,  and  limbs ;  faintness, 
vomiting ;  stiffness  or  spasm  of  the  cervical  or  spinal  muscles ;  hyper- 
sesthesia  of  the  skin ;  delirium,  alternating  with  intelligence  and  merging 
afterward  into  dulness  or  coma ;  occasional  convulsive  spasms  ;  paralysis 
of  the  face  or  of  one  side  of  the  body.  The  evidences  of  associated 
blood-poisoning  are,  the  epidemic  prevalence  of  the  disease,  various  erup- 
tions upon  the  skin  (herpes,  roseola,  petechise,  etc.),  ecchymoses,  debility 
out  of  proportion  to  the  evidences  of  local  disease,  redness  of  the  eyes, 

1  Jaffe.  Phila.  Med.  Times,  xii.  599. 


DIAGNOSIS. 


827 


foulness  of  the  tongue  and  mouth,  and  more  or  less  of  the  other  condi- 
tions which  characterize  the  typhoid  state.  To  these  features  must  be 
added  the  rate  of  mortality,  which  is  greater  in  most  epidemics  of  menin- 
gitis than  that  of  any  disease  with  which  it  is  liable  to  be  confounded. 

It  is  distinguished  from  sporadic  meningitis  by  the  fact  that  the  latter 
disease  is  never  primary,  but  is  always  either  an  epiphenomenon  of  some 
other  and  previous  malady  (various  levers  and  chronic  blood  diseases)  or 
is  traumatic  in  its  origin.  The  thermometer  readily  distinguishes  it  from 
various  functional  nervous  affections,  chiefly  hysterical,  in  which  the  tem- 
perature remains  normal. 

From  typhoid  fever  it  differs  as  widely  as  possible  by  its  rapid  onset, 
the  exquisite  pain  in  the  head,  the  neuralgic  pains,  the  opisthotonos,  and 
the  convulsions.  The  alternate  delirium  or  coma  and  clearness  of  mind 
in  meningitis  contrast  with  the  persistent  hebetude,  stupor,  or  muttering 
delirium  and  the  muscular  relaxation  in  typhoid  fever.  The  sordes  on 
the  tongue,  the  diarrhoea,  the  meteorism,  the  intestinal  hemorrhage  of  the 
latter,  instead  of  the  moist  or  merely  dry  tongue  and  the  transient  vomit- 
ing and  torpid  bowels  of  the  former ;  high  or  continuous  fever  on  the 
one  hand,  slight  or  variable  increase  of  temperature  on  the  other;  difflu- 
ence  of  blood  in  the  one  and  an  increase  in  the  proportion  of  its  fibrin  in 
the  other;  in  the  one  suppurative  inflammation  of  the  cerebro-spinal 
meninges,  in  the  other  specific  lesions  of  the  intestinal  and  mesenteric 
glands, — these,  as  well  as  the  very  different  modes  of  origin  of  the  two 
affections,  draw  a  broad  and  manifest  line  of  distinction  between  them. 

It  would  scarcely  be  necessary  to  point  out  the  contrasts  between  epi- 
demic meningitis  and  typhus  fever  were  it  not  that,  notwithstanding  the 
abundance  of  instruction  on  the  subject  in  medical  treatises  and  lectures, 
a  large  number  of  physicians  confound  typhus  fever,  typhoid  fever,  and 
the  typhoid  state  of  inflammatory  diseases  with  one  another.  The  con- 
fusion was  intensified  at  one  time  by  designating  the  disease  we  are  study- 
ing as  spotted  fever — a  term  originally  applied  and  properly  belonging 
to  typhus  fever  (typhus  petechialis).  It  is  true  that  New  England  phy- 
sicians soon  became  aware  of  their  error,  which  was  distinctly  pointed  out 
and  condemned  by  North,  Strong,  Miner,  Foot,  Fish,  and  others  in  the 
early  part  of  this  century.  A  similar  error  was  at  first  committed  both 
in  Ireland  and  England,  but  was  corrected  by  maturer  experience.  In 
order  to  contrast  the  two  diseases  as  strongly  as  possible,  we  place  their 
distinctive  features  side  by  side  in  the  following  table : 

TYPHUS  FEVER. 

An  endemic  disease,  due  to  local  causes 
and  spreading  by  intercommunication. 


EPIDEMIC  MENINGITIS. 

A  pandemic  disease.  Occurs  simulta- 
neously in  places  remote  from  one  an- 
other and  without  intercommunica- 
tion. 

Attacks  all  classes  of  society.  Is  never 
primarily  developed  by  destitution, 
squalor,  or  defective  ventilation. 

Is  not  contagious. 

Attacks  more  males  than  females. 

Attacks  more  young  persons  than  adults. 

Generally  occurs  in  winter. 

Eruptions  are  absent  in  at  least  half  of 
the  cases ;  they  occur  within  the  first 
day  or  two. 


Attacks  the  poor,  filthy,  and  crowded 
alone. 

Contagious  in  a  high  degree. 
Both  sexes  equally  affected. 
More  adults  than  young  persons. 
Epidemics  irrespective  of  season. 
Eruption    rarely  absent,    and    appears 
about  the  fifth  day. 


828 


EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 


TYPHUS  FEVER. 

Eruption  always  roseolous,  and  then 
petechial.  Ecchymoses  are  rare. 

Headache  dull  and  heavy. 

Delirium  rarely  absent ;  usually  mutter- 
ing. Rarely  begins  before  the  end  of 
the  first  week. 


A  slow  pulse  exceedingly  rare, 
usually  between  90  and  120. 


Its  rate 


EPIDEMIC  MENINGITIS. 

The  eruptions  are  various ;  they  include 
erythema,  roseola,  urticaria,  herpes, 
etc.  Ecchymoses  are  common. 

Headache  is  acute,  agonizing,  tensive. 

Delirium  often  absent ;  often  hysterical, 
sometimes  vivacious,  sometimes  mani- 
acal. Generally  begins  on  the  first  or 
second  day. 

Pulse  very  often  not  above  the  natural 
rate;  often  preternaturally  frequent 
or  infrequent.  Is  subject  to  sudden 
and  great  variations. 

"  The  temperature  is  lower  than  that 
recorded  in  any  other  typhoid  or  in- 
flammatory disease."  It  is  also  very 
fluctuating. 

The  body  has  no  peculiar  smell. 

The  tong*ue  is  generally  moist  and  soft, 
and  if  dry  is  not  foul.  Sordes  on  teeth 
rare. 

Vomiting  is  an  almost  constant  and 
urgent  symptom,  especially  in  the  first 
stage. 

Pains  in  the  spine  and  limbs  of  a  sharp 
and  lancinating  character  are  usual. 

Tetanic  spasms  occur  in  a  large  propor- 
tion of  cases  and  within  the  first  two 
or  three  days.  They  are  due  to  an 
exudation  on  the  medulla  oblongata 
and  spinalis. 

Cutaneous  hypersesthesia  is  a  prominent 
symptom. 

Strabismus  is  common. 

The  eyes,  if  injected,  have  a  light  red  or 
pinkish  color. 

The  pupils  are  often  variable  and  un- 
equal. 

Deafness  and  blindness  are  often  com- 
plete and  permanent. 

Duration  very  indefinite,  but  generally 

from  four  to  seven  days. 
Relapses  are  common. 
The  blood  is  often  fibrinous. 
The  lesions,  except  in  the  most  rapid 

cases,  consist  of  a  plastic  or  purulent 

exudation  in  the  meshes  of  the  cerebro- 

spinal  pia  mater. 
Mortality  from  20  to  75  per  cent. 

PROGNOSIS. — In  the  section  relating  to  the  mortality  of  epidemic  men- 
ingitis it  has  been  seen  that  its  death-rate  varies  at  different  times  and 
places  between  widely  remote  extremes.  This  fact  must  be  borne  in 
mind  in  estimating  the  influence  of  various  circumstances  in  controlling 
the  issue  of  the  disease.  The  relative  as  well  as  the  aggregate  mortality 
is  far  greater  in  childhood  than  in  adult  life.  After  the  age  of  thirty  or 
thirty-five  it  decreases  rapidly  until  old  age,  when  recovery  from  the  dis- 
ease is  quite  exceptional.  A  sudden  or  rapidly  developed  attack  is  gener- 
ally unfavorable,  especially  when  the  symptoms  are  adynamic  and  there 
is  a  purplish  discoloration  of  the  skin.  Indeed,  even  apart  from  evidences 


The  temperature  is  always  elevated,  and 
does  not  fall  until  the  close  of  the 
attack.  "The  skin  is  hot,  burning, 
and  pungent  to  the  feel." 

The  mouse-like  smell  is  characteristic. 

The  tongue  is  generally  dry,  hard,  and 
brown,  and  the  teeth  and  gums  fulig- 
inous. 

Vomiting  is  rare  and  not  urgent. 


The  pains,  if  any,  are  dull,  and  appa- 
rently muscular. 

Tetanic  spasms  are  unknown  in  typhus. 
Convulsions  sometimes  occur,  due  to 
pyaemia. 


The  sensibility  of  the  skin  is  generally 

blunted. 

Strabismus  is  rare. 
The  blood  in  the  conjunctival  vessels  is 

dark. 
The  pupils  are  equal  and  contracted. 

Deafness  almost  always  ceases  with  con- 
valescence. Blindness  never  follows 
typhus. 

Duration  from  twelve  to  fourteea  days. 

Relapses  are  rare. 

The  blood  is  never  fibrinous. 

In  typhus  no  inflammatory  lesions  exist. 


Mortality  from  8  to  40  per  cent. 


TREATMENT.  829 

of  blood-change,  cerebral  are,  on  the  whole,  of  graver  importance  than 
spinal  phenomena,  and  the  more  so  the  more  typhoidal  their  type.  Of 
still  more  serious  significance  is  a  want  of  perception  of  the  gravity  of 
the  situation  or  unconcern  about  its  issue.  A  preternaturally  slow  and 
compressible  pulse  implies  danger,  and  so  does  coolness  of  the  skin, 
especially  if  it  grows  purplish  from  a  diffusion  of  blood  beneath  it  or 
even  from  venous  stasis.  The  various  eruptions  that  have  been  described 
including  petechiae,  are  not  necessarily  dangerous  signs.  Profuse  sweats 
during  a  soporose  state,  bullae  and  gangrenous  spots,  obstruction  of  the  bron- 
chia with  mucus  or  serum,  pneumonia  or  pericarditis, — these  are  all  grave 
indications.  So,  too,  are  a  dry,  fissured,  shrivelled,  and  pale  tongue  or  a 
fuliginous  state  of  the  mouth,  swelling  of  the  parotids,  obstinate  vomit- 
ing, and  profuse  diarrhrea  at  an  advanced  stage  of  the  disease.  Among 
the  most  unfavorable  nervous  symptoms  are  great  restlessness,  rigid  retrac- 
tion of  the  head,  spasms  of  other  than  the  spinal  muscles,  general  convul- 
sions, extensive  hypersesthesia,  deep  coma,  dilatation  and  insensibility  of 
the  pupils  or  their  rapid  change  from  a  dilated  to  a  contracted  state,  reten- 
tion or  incontinence  of  urine,  and  all  cerebral  paralyses,  including  that  of 
the  muscles  of  deglutition.  The  favorable  indications  comprise  a  general 
mildness  of  the  symptoms,  a  moderate  loss  of  strength,  a  slight  degree  of 
pain  and  muscular  stiffness,  the  absence  of  petechise  or  vibices  (although 
in  many  grave  epidemics  they  are  of  rare  occurrence),  a  desire  for  food 
and  the  ability  to  digest  it.  Yet  it  is  imprudent  to  make  an  absolute 
prognosis  in  any  grave  case  of  this  disease.  Recovery  has  sometimes 
occurred  when  it  appeared  impossible,  and  some  have  died  when  the 
period  of  danger  seemed  to  have  passed  on  the  sudden  accession  of  cerebral 
or  spinal  nervous  symptoms. 

TREATMENT. — The  difficulties  that  attend  the  solution  of  therapeutical 
questions  regarding  diseases  which  are  comparatively  regular  in  their 
evolution,  and  are  produced  by  definite  causes  acting  in  an  intelligible 
manner,  are  very  numerous  and  often  insuperable.  They  become  multi- 
plied in  relation  to  a  disease  which,  like  this  one,  stands  alone  in  many 
respects ;  whose  causes,  phenomena,  and  lesions — in  a  word,  whose  laws 
— are  specific ;  and  whose  varieties  of  type  are  as  numerous  as  can  be 
formed 'by  the  combination,  in  a  constantly  varying  proportion,  of  a  spe- 
cial (hypothetical)  alteration  of  the  blood,  deranging  the  molecular  actions 
of  the  economy,  and  at  the  same  time  of  an  inflammation  of  the  cerebro- 
spinal  meninges,  and  even  of  the  substance  of  the  great  nervous  centres. 
These  reasons  are  sufficient  to  account  for  the  diverse  and  often  opposite 
methods  of  treatment  that  have  been  applied  to  the  disease.  As  in 
almost  all  other  cases,  the  methods  have  consisted  in  using  remedies  to 
counteract  certain  symptoms — now  a  stimulant  or  tonic  regimen  to  com- 
bat the  debility  which  conferred  the  name  of  "sinking  typhus"  on  the  dis- 
ease ;  now  an  antiphlogistic  course  to  allay  the  inflammation  of  the  brain 
and  spinal  marrow  denoted  by  the  neuralgic  pain  and  the  tetanoid  phe- 
nomena ;  and,  again,  large  doses  of  narcotics  to  blunt  the  pain  and  sub- 
due the  spasm.  Still  other  medications  have  been  used  with  a  similar 
purpose,  and  some,  as  we  shall  see,  with  more  or  less  theoretical  views. 
It  may  be  said,  with  Yon  Ziemssen,  "  that  we  are  far  from  having  it  in 
our  power  to  decide  whether  a  rational  treatment  of  the  symptoms  has 
cured  the  disease  or  lessened  its  mortality ; "  but  a  review  of  the  methods 


830  EPIDEMIC  CEREBBO-SPINAL  MENINGITIS. 

that  have  been  employed  and  their  results  leads  to  no  doubtful  conclusion 
that  some  are  mischievous  and  others  more  or  less  salutary. 

Emetics  were  among  the  first  medicines  used  in  the  treatment  of  this 
affection,  and  were  probably  suggested  by  the  vomiting  which  is  one  of  its 
most  constant  initial  symptoms.  But  we  can  readily  understand  why 
they  failed  to  afford  relief.  The  vomiting  and  retching  are  not  gastric 
symptoms  at  all,  but,  as  already  stated,  are  due  to  the  irritation  of  the 
congestive  or  inflammatory  process  at  the  base  of  the  brain.  These  medi- 
cines may  therefore  be  omitted.  The  employment  of  purgatives  is  even 
less  rational ;  they  debilitate  without  affording  any  relief. 

Venesection  was  probably  employed  as  a  part  of  a  routine  treatment 
which  neither  sound  reason  nor  clinical  experience  justified.  It  was  gen- 
erally found  to  fail  of  its  curative  purpose,  and  often  induced,  especially 
in  young  persons,  dangerous  exhaustion.  No  better  illustration  is  needed 
to  show  that  the  disease  we  have  been  studying  is  far  more  than  a  local 
inflammation  of  the  cerebro-spinal  meninges.  On  the  other  hand,  local 
depletion  is  often  of  marked  utility.  Our  own  experience  would  lead  us 
to  conclude  that  in  the  more  sthenic  cases  scarified  cups,  applied  to  the 
nape  of  the  neck  and  along  the  cervical  vertebrae,  are  of  essential  service 
in  mitigating — and  generally,  indeed,  in  wholly  removing — the  neuralgic 
pains  which  form  so  prominent  and  severe  a  symptom  in  many  cases  of 
this  disease.  When  any  abstraction  of  blood  appears  to  be  contraindi- 
cated  by  the  patient's  debility,  even  dry  cups  will  afford  him  signal  relief. 
Leeches  have  been  applied  to  the  parts  mentioned,  and  over  the  mastoid 
processes  have  sometimes  been  used  with  advantage,  but  their  depletory 
surpasses  their  revulsive  action,  and  is,  so  far,  injurious.  Cold  to  the 
head  and  spine  is  among  the  most  efficient  means  of  relieving  certain 
symptoms.  In  the  Massachusetts  Medical  Society's  Report  of  1810  we 
read :  "  Cold  water,  snow,  and  ice  have  been  applied  to  the  head  when 
there  was  violent  pain  in  that  part  with  heat  and  flushed  face,  and  when 
there  was  violent  delirium.  They  afforded  great  comfort  to  the  patient, 
and  mitigated  or  removed  those  important  symptoms."  It  is  probable, 
however,  that  the  value  of  the  remedy  is  almost  entirely  restricted  to 
the  forming — or  at  least  the  early — stage  of  the  attack,  when  the 
pain  in  the  head  is  most  intense.  Its  soothing  influence  is  then  very 
marked,  as  well  as  its  indirect  action  in  promoting  sleep.  Heat  of 
head  is  not  an  essential  condition  for  its  use,  for  even  in  the  most  violent 
cases  it  is  rarely  extreme,  and  is  often  entirely  wanting.  Pain  calls  more 
distinctly  for  the  application,  and  when  that  symptom  has  subsided  cold  is 
apt  to  be  more  annoying  than  grateful  to  the  patient.  Cold  is  best 
applied  to  the  head  in  the  form  of  pounded  ice  enclosed  in  a  bladder  or 
rubber  bag ;  but  cold  affusions  are  also  very  valuable,  especially  for  chil- 
dren. For  the  application  of  cold  to  the  spine  the  most  efficient  apparatus 
is  the  long,  flat  rubber  bag,  either  single  or  double. 

From  the  earliest  history  of  epidemic  meningitis  in  this  country  blis- 
ters formed  a  conspicuous  element  in  the  treatment.  They  were  used,  as 
they  had  been  in  other  forms  of  meningitis,  to  relieve  the  pain  and  dimin- 
ish the  congestion  in  the  cerebro-spinal  centres.  The  results  of  their 
use  were  by  no  means  uniform,  for  not  only  were  they  employed  in 
many  of  the  cases  which  must  almost  necessarily  have  been  fatal  before 
inflammation  could  be  established,  but  even  in  the  inflammatory  cases 


TREATMENT.  831 

they  were  often  applied  when  time  enough  had  elapsed  to  allow  the 
exudation  to  be  fully  formed,  and  when,  therefore,  they  were  too  late  to 
be  useful.  Again,  they  were  sometimes  used  so  as  to  vesicate  too  deeply, 
and  thus  by  the  pain  they  caused  at  first,  and  by  the  exhaustion  that 
resulted  from  the  excessive  discharges  they  maintained,  the  patient  was 
more  injured  than  benefited.  Our  own  experience  proves  that  in  the 
early  stage  of  the  inflammatory  form  of  the  disease  blisters  applied 
below  the  occipital  ridge  and  upon  the  back  of  the  neck,  and  only  allowed 
to  vesicate  superficially,  not  only  remove  the  pain  in  the  head,  but  dimin- 
ish the  delirium,  spasms,  and  coma,  and  therefore  contribute  as  directly 
as  other  remedies,  if  not  more  so,  to  the  favorable  issue  of  the  attack. 
But  such  salutary  effects  are  not  to  be  looked  for  when  the  disease  assumes 
a  malignant  type  nor  after  its  constitution  has  become  definitely  fixed. 
The  application  of  stimulant  and  even  vesicating  agents  to  the  spine 
below  the  neck  has  not  been  generally  practised  because,  probably,  the 
seat  of  the  spinal  lesions  was  known  to  be  chiefly  at  the  upper  part  of 
the  organ.  Still,  the  neuralgic  pains  felt  in  the  spinal  nerves  may  be 
mitigated  by  stimulant  and  anodyne  liniments  applied  with  friction  to 
the  spinal  column. 

American  physicians  early  recognized  coolness  of  the  skin  among  the 
most  striking  phenomena  of  the  disease ;  and  this  probably  suggested 
their  use  of  diaphoretic  remedies,  among  which  were  the  external  applica- 
tion of  moist  heat  in  baths  and  warm  wrappings,  as  well  as  "  bottles  of 
hot  water  or  billets  of  wood  heated  in  boiling  water  and  wrapped  in  flan- 
nel," or  the  patient  "  was  wrapped  in  flannel  wrung  out  of  boiling  water, 
sinapisms  were  applied  to  the  feet,  while  hot  infusions  were  administered, 
made  from  the  leaves  of  mint,  pennyroyal,  and  other  similar  plants,  and 
also  wine- whey,  wine  and  water,  wine,  brandy,  and  other  ardent  spirits 
more  or  less  diluted,  camphor,  sulphuric  ether,  and  opium.  It  was  not 
generally  thought  useful  to  excite  profuse  sweating,  but  important  to 
maintain  the  activity  of  the  skin  from  twenty  to  forty  hours,  and  even 
longer  in  some  instances.  Soup  and  cordials  were  at  the  same  time  admin- 
istered. Under  this  treatment  most  commonly  the  violent  symptoms,  and 
not  very  rarely  all  the  appearances  of  disease,  have  subsided  "  (Jackson). 
Beyond  all  doubt,  this  method  was  a  rational  one,  for  it  tended  to  promote 
an  elimination  of  the  morbid  poison,  while  it  depleted  the  blood-vessels 
and  acted  revulsively  upon  the  local  inflammation  of  the  cerebro-spiual 
meninges.  Yet  it  seems  not  to  have  been  revived  during  the  more  recent 
epidemics  of  the  disease,  unless,  partially,  by  Gordon  (1867),  who  says  : 
"  What  I  have  seen  most  useful  in  the  stage  of  collapse  is  external  warmth 
applied  to  the  entire  surface  by  means  of  flannel  bags  containing  roasted 
salt,  applied  along  the  spine,  along  the  chest,  inside  the  arms,  and  to  the 
feet  and  legs  and  between  them." 

Except  typhus  fever,  there  is  no  disease  in  which  a  due  administration 
of  alcoholic  stimulants  may  become  more  important.  In  cases  of  the 
inflammatory  type  they  are  rarely  needful,  and  are  frequently  hurtful, 
but  in  those  which  exhibit  signs  of  blood  disorder  with  nervous  exhaus- 
tion they  are  often  indispensable.  Nothing  demonstrates  their  necessity 
more  clearly  than  the  extraordinary  tolerance  of  alcohol  exhibited  in 
some  cases  of  the  disease.  Among  the  earlier  American  authorities 
may  be  found  many  illustrations  of  this  statement.  Woodward  (1808) 


832  .      EPIDEMIC  CEEEBRO-SPINAL  MENINGITIS. 

observed  that  very  large  quantities  of  wine  or  ardent  spirits  may  be 
given  without  injury.  Arnell  said :  "  In  some  cases  I  have  given  a 
quart  of  brandy  in  six  or  eight  hours  with  the  happiest  effect,"  Haskell 
maintained  that  "the  bold  and  liberal  use  of  diffusible  stimuli  is  the 
only  safe  and  efficacious  mode  of  treatment."  In  Ireland  the  habitual 
use  of  alcohol  in  the  treatment  of  typhus  fever  no  doubt  suggested  its 
liberal  employment  in  this  disease,  but  such  stimulants  have  never  been 
in  vogue  among  the  physicians  of  France  or  Germany.  This  difference 
may  in  part  be  accounted  for  by  the  generally  asthenic  type  of  the  disease 
in  the  first-named  country  and  its  mOre  inflammatory  character  in  the 
others.  Similar  contrasts  of  type  mark  different  epidemics,  and  indi- 
vidual cases  during  the  same  epidemic.  We  have  no  doubt  that  while 
these  agents  are  indispensable  in  the  treatment  of  cases  of  the  former 
type,  they  must  even  then  be  exhibited  discreetly,  for  their  too  lavish 
exhibition  entails  the  gravest  peril  by  intoxicating  the  patients  and 
oppressing  instead  of  arousing  their  vital  energies.  In  1866,  on  taking 
charge  of  the  medical  wards  in  the  Philadelphia  Hospital,  we  found  that 
the  patients  were  using  as  large  quantities  of  alcohol  as  are  given  in 
typhus  fever,  but  a  very  short  period  of  observation  showed  that  this 
use  of  the  stimulant  was  excessive ;  consequently  the  dose  of  it  was  first 
reduced,  and  finally  it  was  omitted  altogether  unless  special  indications 
for  it  arose.  This  change  was  followed  by  a  manifest  improvement  in 
the  general  aspect  of  the  sick  and  the  subsidence  of  symptoms  which,  it 
then  became  evident,  were  due  to  a  lavish  use  of  stimulants  rather  than 
to  the  gravity  of  the  disease.  Alcohol  is  no  more  essential  to  the  treat- 
ment of  epidemic  meningitis  than  of  any  other  acute  affection ;  it  is  a  cor- 
dial to  be  held  in  reserve  to  meet  those  signs  of  failure  of  the  heart  and 
nervous  system  which  may  arise  in  all  acute  diseases  attended  with 
changes  in  the  condition  of  the  blood. 

The  use  of  opium  in  the  treatment  of  this  disease  was  strongly  advo- 
cated by  nearly  all  of  the  early  American  writers  upon  the  subject,  and 
by  many  of  them  enormous  doses  were  given.  It  was  observed  not  to 
produce  narcotic  effects  in  ordinary  doses.  In  one  case,  marked  by 
excruciating  pain  in  the  head  and  maniacal  delirium,  sixty  drops  of 
laudanum  were  given  every  hour  until  nearly  half  an  ounce  had  been 
taken  within  eight  hours  (Strong).  Haskell  states :  "  We  have  been 
obliged  frequently  to  exhibit  ten  grains  of  opium  for  a  dose  in  some  of 
the  violent  cases  attended  with  strong  spasms,  and  have  never  known  it 
to  produce  stupor  in  a  single  instance."  Miner  relates  that  "a  few  cases 
imperiously  required  half  an  ounce  of  the  tincture  of  opium  in  an  hour, 
or  half  a  drachm  [of  opium]  in  substance  in  the  course  of  twelve  hours, 
before  the  urgent  symptoms  could  be  controlled,  and  even  some  cases 
required  a  drachm  in  the  same  time.  All  these  patients  recovered."  In 
Europe,  Chauffard  administered  opium  in  doses  of  from  three  to  fifteen 
grains,  and  Boudin  frequently  prescribed  from  seven  to  fifteen  grains  at 
a  single  dose  at  the  commencement  of  the  attack,  and  subsequently  one 
or  two  grains  every  half  hour,  until  the  patient  grew  sleepy  or  his  symp- 
toms subsided.  This  tolerance  of  the  drug  is  remarkable,  and  so  is  the 
fact  that  it  does  not  cause  constipation.  These  and  many  similar 
.statements  agree  entirely  with  our  personal  experience.  We  were  in  the 
habit,  during  the  epidemic  above  referred  to,  of  prescribing  one  grain 


TREATMENT.  833 

of  opium  every  hour  in  very  severe  and  every  two  hours  in  moderately 
severe  cases,  and  in  no  instance  was  narcotism  induced,  or  even  an 
approach  to  that  condition.  Under  the  influence  of  the  medicine  the 
pain  and  spasm  subsided,  the  skin  grew  warmer  and  the  pulse  fuller, 
and  the  entire  condition  of  the  patient  more  hopeful.  It  seemed  probable, 
however,  that  the  benefit  of  the  opium  treatment  was  most  decided  in 
the  early  stages  of  the  attack,  and  hence  in  those  in  which  the  inflamma- 
tory and  spasmodic  elements  predominated.  The  hypodermic  injection 
of  morphia  is  to  be  preferred  before  the  internal  administration  of  other 
preparations  of  opium,  not  only  on  account  of  its  prompter  action,  but 
because  it  avoids  the  rejection  of  the  medicine  by  vomiting.  On  the 
whole,  Von  Ziemssen  is  within  the  bounds  of  truth  when  he  savs, 
"  Beyond  all  doubt  morphia  may  be  considered  the  most  indispensable 
medicine  in  the  treatment  of  epidemic  meningitis." 

There  is  no  evidence  sufficient  to  show  that  epidemic  meningitis  has 
ever  been  cured  by  quinia  alone.  In  the  early  prevalence  of  the  disease 
it  was  treated  by  large  doses  of  cinchona,  but  unavailingly,  and  subse- 
quently smaller  doses  were  given  during  the  convalescence,  as  it  was  in 
that  of  other  acute  diseases.  In  some  parts  of  this  country  where  mias- 
matic diseases  prevail,  and  epidemic  meningitis,  like  all  other  acute,  and 
especially  febrile,  disorders,  displayed  more  or  less  of  a  periodical  or 
paroxysmal  type,  quinia  was  used  in  large  doses,  but  the  expected  result 
was  not  realized.  Upham  states  that  in  some  instances  it  was  given  to 
the  extent  of  sixty,  or  even  eighty,  grains  within  twelve  hours  from  the 
beginning  of  the  attack,  but  without  effect.  In  Europe  it  was  exten- 
sively tried  and  unanimously  condemned.  It  may  very  properly  be  left 
out  of  the  list  of  medicines  suitable  for  this  disease,  particularly  since  it 
is  no  longer  probable  that  any  physician  would  be  rash  enough  to  employ  it 
in  the  so-called  antipyretic  doses  with  or  without  their  usual  associates, 
cold  baths.  According  to  Karl  Jaffe,  the  medicinal  antipyretics  (quinia, 
salicylic  acid,  and  also  sodium  benzoate)  may  be  entirely  discarded, 
because  they  ruin  the  already  weakened  digestion.1 

Common  sense  has  also  proved  stronger  than  theory  in  excluding  mer- 
curials from  the  treatment  of  epidemic  meningitis.  At  one  time  they 
were  extensively  used,  especially  when  it  was  learned  that  the  disease  in 
its  full  development  included  a  paramount  inflammatory  element.  But  it 
was  soon  found  that  the  results  of  their  use  were  far  from  uniform,  and 
farther  still  from  being  demonstrably  beneficial.  In  this,  as  in  many 
other  similar  cases,  it  is  quite  impossible  to  reach  a  definite  judgment 
unless  it  were  known  what  was  the  type  of  the  cases  in  which  the  medi- 
cine was  given,  whether  they  were  asthenic  or  inflammatory,  and  again 
whether  it  was  used  during  the  active  or  during  the  declining  stage 
and  toward  convalescence.  In  the  absence  of  any  trustworthy  testimony 
upon  the  subject  it  is  only  possible  at  present  to  state  that  in  the  treat- 
ment of  this  disease  mercurials  should  not  be  used.  This  conclusion  is 
all  the  more  imperative  because  the  medicine  is  not  an  indifferent  one. 
If  it  is  not  necessary — and  it  certainly  is  not — it  is  too  dangerous  in  its 
immediate  and  ultimate  effects  for  its  employment  to  be  warranted.  ^ 

Since  belladonna  and  ergot  were  shown  to  diminish  vascular  action  in 
the  cerebro-spinal  axis  by  contracting  its  capillary  blood-vessels,  they  have 

1  Phila.  Med.  Times,  xii.  600. 
VOL.  I.— 53 


834  EPIDEMIC  CERERRO-SPINAL  MENINGITIS. 

beeii  put  forward  as  having  a  specific  virtue  in  this  disease.  If  the  fact 
be  so,  how  is  that  other  fact — a  clinical  one,  moreover — to  be  disposed  of, 
which  is  that  opium,  the  physiological  antagonist  of  belladonna  and  ergot, 
is  more  efficient  than  they  are  in  curing  the  disease?  It  is  possible, 
indeed,  that  they  may  have  that  curative  power,  and  that  opium  possesses 
it  also,  and  that  the  explanation  given  of  the  action  of  all  of  these  agents 
is  erroneous.  Upham  states  that,  in  1863,  Haddock  recommended  ergot 
upon  theoretical  grounds,  and  that  during  an  epidemic  at  Newbern,  X.  C., 
several  cases  treated  by  it  recovered.  Three  cases  recovered  in  which  it 
was  prescribed  by  Borland.  Read  used  it  in  1873—74  at  Boston,  Mass., 
and  out  of  19  cases  16  recovered  and  3  died.1  This  mortality  of  about 
1 5  per  cent,  is  not  more  than  half  of  that  which  has  generally  been  met 
with,  and  if  it  can  be  attributed  to  the  treatment  would  go  far  to  prove 
the  efficacy  of  the  latter.  One  grain  of  ergotine,  with  one-tenth  of  a 
grain  of  extract  of  belladonna,  was  administered  every  three  hours. 
Considering  the  exiguity  of  the  dose  of  belladonna,  it  is  not  surprising 
that,  except  in  one  case,  it  did  not  dilate  the  pupil ;  and  the  dose  of 
ergotine  is  likewise  far  smaller  than  the  average  medicinal  dose  of  that 
preparation.  Moreover,  all  of  the  cases  except  the  fatal  ones  appear  to 
have  presented  the  disease  in  a  subacute,  and  certainly  not  in  an  aggra- 
vated, form. 

In  1872,  Dr.  S.  N.  Davis,2  moved  by  the  success  of  Calabar  bean  in 
tetanus,  employed  it  in  this  disease.  A  mixture  of  one  ounce  of  tincture 
of  Calabar  bean  with  one  and  a  half  ounces  of  fluid  extract  of  ergot  was 
administered  in  doses  of  half  a  teaspoonful  every  two  hours,  and  with 
better  results  than  had  followed  other  remedies.  Here,  again,  it  is  to  be 
noticed  that  the  analogy  suggesting  the  use  of  physostigraa  is  not  a 
logical  one.  That  drug  indeed  relieves  the  spinal  spasms  of  tetanus — a 
disease  in  which  there  is  an  irritation  of  the  spinal  axis,  but  no  exudation 
from  its  meningeal  vessels,  as  in  the  aifectiou  we  are  studying.  More- 
over, it  is  a  disease  of  extraordinary  power,  as  shown  not  only  by  the 
spasms,  but  by  the  exceptionally  high  temperature,  and  thus  again  is  in 
direct  contrast  to  epidemic  meningitis.  If,  therefore,  Calabar  bean  bene- 
fits that  disease,  it  cannot  do  so  in  the  manner  suggested  by  the  author. 

Bromide  of  potassium  and  hydrate  of  chloral  have  also  been  employed 
to  allay  the  spasmodic  symptoms ;  but  the  former  is  too  feeble  for  the 
purpose,  and  the  depressing  action  of  the  latter  upon  the  heart  renders  it 
dangerous.  Bromide  of  potassium  has  been  given  to  children  of  two 
and  five  years  in  doses  of  four  and  six  grains  every  two  hours ;  but  these 
doses  appear  to  be  quite  too  small  even  for  the  purpose  in  view — viz.  to 
prevent  convulsive  attacks.  Whatever  remedies  may  be  suggested  here- 
after, none  should  be  employed  that  tend  to  reduce  the  power  of  the 
heart,  which,  as  we  have  seen,  is  dangerously  depressed  by  the  disease. 

During  the  decline  and  convalescence  of  the  aifection  it  is  probable  that 
iodide  of  potassium  may  be  advantageously  used  to  promote  the  removal 
of  the  exudation-matter  on  the  brain  and  spinal  marrow,  and  probably  to 
prevent  the  hydrocephalus  which  sometimes  follows  the  attack,  and  is 
attributable  to  the  pressure  of  effused  lymph  upon  the  cerebral  veins. 

DIET. — The  mildly  febrile  character  of  epidemic  meningitis,  and  the 

1  Philadelphia  Med.  and  Surg.  Reporter,  Jan.,  1875,  p.  68. 
1  Richmond  and  Louisville  tied.  Jour.,  xiii.  711. 


DIET.  835 

remarkable  debility  which  characterizes  so  many  cases  of  the  disease,  and 
which,  as  was  before  pointed  out,  conferred  upon  it  the  name  typhus 
syncopalis,  plainly  justify  what  experience  has  taught,  that  appropri- 
ate food  for  the  subjects  of  this  affection  is  at  once  the  most  digestible  and 
nutritious  that  can  be  taken.  It  is  true  that  this  regimen  is  interfered 
with  by  the  vomiting,  but,  as  that  symptom  is  of  cerebral  and  not  of  gas- 
tric origin,  it  is  more  apt  to  be  allayed  by  suitable  food  than  by  absti- 
nence. It  has  been  our  custom  to  observe  in  this  disease  the  same  rules 
respecting  diet  that  are  recognized  as  the  most  suitable  in  typhus  fever. 
In  doing  so,  indeed,  we  did,  without  at  the  time  knowing  it,  follow  the 
example  of  the  early  American  physicians.  Strong,  who  wrote  in  1811, 
advised  "  soup  made  from  chicken,  veal,  mutton,  and  beef,  richly  seasoned 
with  pepper  and  savory  herbs."  These  articles  were  prescribed  by  him 
during  the  height  of  the  disease.  Later  on  he  says  :  "  The  stomach  soon 
begins  to  crave  something  more  solid  than  soup ;  oysters,  beefsteak,  cold 
ham,  or  neat's  tongue  are  received  with  peculiar  relish.  Often  I  have 
seen  convalescents,  when  they  had  hardly  strength  enough  to  raise  them- 
selves in  bed,  make  a  hearty  meal  of  the  above-mentioned  articles,  which 
were  received  with  great  satisfaction,  sat  well  upon  the  stomach,  and  were 
well  digested  and  assimilated."  This  method  is  substantially  the  same 
that  was  found  successful  in  the  earlier,  as  it  has  been  in  the  later,  epi- 
demics in  this  country,  and  we  have  no  hesitation  in  attributing  to  it 
and  the  appropriate  use  of  opium  and  blisters  the  degree  of  success  we 
enjoyed  in  the  treatment  of  the  disease  in  the  Philadelphia  Hospital  and 
elsewhere. 

During  convalescence  from  epidemic  meningitis  the  patient  should 
carefully  abstain  from  physical  exertion  and  mental  excitement,  and 
before  this  state  is  fully  established  he  should  even  very  cautiously 
change  his  position  from  a  recumbent  to  an  erect  posture.  And,  finally, 
he  should  return  to  his  ordinary  occupations,  mental  or  physical,  as  late 
as  possible,  on  account  of  the  danger  of  a  relapse,  which  has  already 
been  described. 


PERTUSSIS. 

BY  JOHN   M.    KEATING,    M.    D. 


HISTOEY. — A  careful  study  of  this  disease  from  the  various  writings  since 
the  time  of  Hippocrates  leaves  little  doubt  in  the  mind  of  the  reader  as  to 
its  antiquity,  so  little  indeed  has  it  changed  in  its  various  characteris- 
tics. Whether  the  affection  passed  to  continental  Europe  from  Africa,  or 
whether  its  starting-point  was  India,  are  questions  difficult  to  solve,  and, 
except  for  the  medical  historian,  of  little  import.  Desruelles  probably 
truthfully  asserts  that  the  many  differences  which  mark  the  descriptions 
of  the  disease,  especially  by  the  early  Grecian  writers,  may  be  due,  not  to 
the  non-existence  of  the  disease  as  we  know  it,  but  to  the  influence  which 
climate  exerted  then  as  now,  and  to  the  unrecognized  fact  that  it  is  only 
fatal  in  its  complications.  The  writings  of  Hippocrates,  Galen,  and 
Avicenna,  though  undoubtedly  referring  to  the  many  affections  in  which 
paroxysmal  cough  is  a  prominent  symptom,  contain  many  expressions  that 
would  point  clearly  to  the  existence  of  a  specific  disease.  Dr.  Watt 
believed  that  the  disease  was  not  known  to  the  Greeks,  and  other  writers 
claim  that  it  came  from  the  north  and  spread  southward  over  Europe 
about  the  sixth  century  ;  nevertheless,  it  first  appears  on  record  as  a  dis- 
tinct affection,  disentangled  from  the  confused  mass  with  which  it  was 
involved  for  centuries,  about  the  middle  of  the  seventeenth  centuiy. 
Steffen  mentions  the  first  well-established  accounts  as  coming  from  Baillou 
in  the  year  1600,  and  Schenck  in  1650,  and  Ettmiiller  in  1685.  Syden- 
harn  casually  mentions  it  in  1670.  Since  the  time  of  Willis  the  defini- 
tion of  the  disease  has  remained  unaltered,  and  so  accurate  was  the  descrip- 
tion then  given  of  it  that  we  can  but  naturally  conclude  that  for  many 
centuries  at  least  it  has  varied  but  little. 

In  studying  affections  of  this  kind,  occurring  in  epidemic  form  especi- 
ally, and  which  are  increased  in  intensity  by  whatever  means  the  con- 
tagious element,  whether  gaseous  or  parasitic,  is  made  more  virulent, 
much  allowance  is  to  be  made  for  the  climate,  customs,  and  habits  of  the 
people  whence  our  data  are  derived.  Thus,  most  of  the  diseases  of  antiq- 
uity, the  descriptions  of  which  have  reached  us,  have  been  drawn  from 
types  modified  by  mild  climates  where  the  people  have  led  an  out-door 
life,  and  though  the  disease  we  see  at  the  present  day  is  one  and  the 
same  so  far  as  its  causation  is  concerned,  the  indoor  life  and  close  con- 
finement, the  bad  ventilation,  and  the  artificial  existence  in  our  large  cities 
must  weaken  the  individual,  intensify  the  poison,  and  exert  an  influence 
on  the  disease. 

DEFINITION  AND  DESCRIPTION. — Whooping  cough  has  been  charac- 

836 


DEFINITION  AND  DESCRIPTION.  837 

terized  as  an  acute  contagious  affection,  occurring  usually  in  childhood, 
though  it  may  occur  at  any  age,  and  lasting  several  weeks.  It  is  mani- 
fested usually  by  malaise,  catarrh  of  the  respiratory  tract,  and  subse- 
quently by  a  convulsive  cough  occurring  in  paroxysms,  the  peculiarity 
of  which  consists  of  a  series  of  forcible  expirations,  followed  by  a  sonor- 
ous inspiration  or  whoop,  which  may  be  repeated  several  times. 

At  the  beginning  of  these  paroxysms  of  coughing,  there  are  evidences 
of  slight  laryngeal  irritation,  attended  by  an  effort  at  suppressing  the 
cough ;  then  follow  gradually  increasing  and  more  audible  inspiration's, 
which  become  more  and  more  difficult.  The  child  is  agitated,  the  face 
becomes  pale,  and  the  countenance  has  a  mingled  expression  of  suppli- 
cation and  fear.  If  it  is  old  enough  it  will  seize  the  nearest  object  for 
support.  As  the  spell  advances,  the  eyes  become  suffused  and  prominent 
and  the  loose  tissue  surrounding  the  orbits  appears  puffy  and  congested. 
Finally,  the  paroxysm  reaches  its  height ;  the  child,  with  a  livid  counte- 
nance, with  veins  standing  out  like  cords,  gives  a  succession  of  violent 
expiratory  efforts,  followed  by  a  long  inspiratory  whoop.  The  same  is 
repeated  several  times,  until  finally  almost  complete  cyanosis  takes  place ; 
the  spasm  relaxes,  a  glairy,  tenacious  mucus  runs  from  the  mouth,  the 
contents  of  the  stomach  are  vomited,  and  the  child  falls  back  exhausted. 
The  lividity  of  the  countenance  is  succeeded  by  a  deathly  pallor ;  the  face 
still  appears  swollen  and  puffy  beneath  the  eyes ;  the  tears  course  down 
the  cheeks,  and  frequently  hemorrhage  occurs  from  the  eyes,  nose,  ears, 
or  throat,  owing  to  the  terrific  strain  upon  the  circulation.  As  soon  as 
the  child  has  recovered  from  the  fatigue  of  the  paroxysm  all  is  apparently 
over,  and  were  it  not  for  the  characteristic  expression  of  the  eye,  which  is 
pathognomonic  in  a  well-advanced  case,  nothing  would  be  noticed  to  even 
suggest  the  disease  when  uncomplicated.  The  voice  is  clear;  there  is  little 
or  no  elevation  of  temperature. 

The  paroxysms  which  have  given  the  name  to  this  disease  can  only  be 
likened  to  an  epileptic  convulsion,  which  by  gradually  increasing  cyanosis 
is  self-curable,  the  carbonized  blood  finally  bringing  about  an  anaesthetic 
effect.  The  severity  of  the  paroxysms  is  by  no  means  in  proportion  to  the 
local  catarrh,  which  latter  may  be  superficial  and  slight,  not  to  be  detected 
during  life  by  the  most  careful  laryngeal  examinations,  and  only  after 
death  by  the  aid  of  the  microscope.  The  frequency  and  intensity  of  the 
paroxysms  are  dependent  in  a  measure  upon  the  degree  of  excitability  of  the 
nervous  system,  wrhich  of  course  differs  in  individuals.  It  is  evident 
that  the  success  of  treatment  must  be  powerfully  influenced  by  this  cir- 
cumstance, and  it  is  partly  owing  to  it  that  there  are  so  many  opinions  as 
to  the  value  of  remedies  in  this  disease. 

The  complications  are  usually  dependent  upon  outside  causes,  and  have 
nothing  to  do  with  the  poison  proper  of  whooping  cough,  as  far  as  we  can 
tell.  There  are  some  which  depend  on  an  inflammation  of  the  mucous 
membrane,  which  may  be  limited  to  any  portion  of  the  respiratory  tract 
or  may  extend  throughout  it.  Complications  may  arise  from  mechanical 
obstruction  to  inspiration  by  the  swollen  mucous  membrane  or  from  plugs 
of  tenacious  mucus,  which  may  cause  pulmonary  collapse  and  favor  the 
development  of  catarrhal  pneumonia,  and  later  even  of  phthisis ;  or  from 
impediments  to  free  and  easy  expiration,  whether  from  spasm  of  the 
bronchioles,  from  forcible  compression  of  the  thorax  through  reflex 


838  PERTUSSIS. 

nervous  irritation,  or  from  other  obstructions,  all  of  which  tend  to  pro- 
duce emphysema.  Disturbances  of  the  circulation,  in  the  brain  or  else- 
where, may  proceed  from  thrombi  or  emboli  and  give  rise  to  complications 
which  will  render  fatal  an  otherwise  mild  form  of  the  disease.  The  inva- 
riable disturbance  of  nutrition  which  accompanies  every  disease  affecting 
the  nervous  system  is  apt  to  show  itself  in  the  breaking  down  of  products 
which  are  simply  inflammatory.  Vomiting  may  be  a  most  serious  com- 
plication, both  from  its  immediate  and  remote  effects.  It  may  be  due  to 
gastric  catarrh,  or  more  frequently  to  irritation  of  the  pneumogastric 
nerve. 

ETIOLOGY. — Very  numerous  theories  have  been  advanced  as  to  the 
nature  of  this  interesting  disease.  Hufeland,  Lebeustein,  Pinel,  Jahn, 
Todd,  Cullen  and  a  host  of  others  have  regarded  it  as  essentially  a 
neurosis.  By  many  others  it  has  been  supposed  to  be  due  to  a  lesion 
of  the  brain  or  of  its  membranes,  but  careful  investigation  has  estab- 
lished the  fact  that  there  is  no  lesion  in  whooping  cough  at  all  constant 
or  characteristic.  By  still  others,  and  especially  by  Gueneau  de  Mussy, 
it  has  been  regarded  as  essentially  an  affection  of  the  tracheo-brouchial 
glands,  a  bronchial  adenopathy,  causing  irritation  of  the  pneumogastrics 
and  of  their  bronchial  branches  by  pressure  of  the  enlarged  glands.  We 
have,  however,  seen  many  post-mortem  examinations  of  the  bodies  of 
children  who  have  died  of  measles,  where  marked  enlargement  of  these 
glands  was  constantly  found,  but  where  no  symptoms  of  whooping  cough 
had  been  present.  There  are  indeed  many  features  of  the  disease  which 
seem  inexplicable  on  any  other  theory  than  that  the  essential  cause  of 
whooping  cough  is  a  specific  poison,  and  such  is  the  view  now  generally 
adopted.  This  poison  is  capable  of  being  carried  by  fomites,  though 
as  it  is  highly  infectious  it  is  often  communicated  through  the 
atmosphere,  and  is  most  frequently  conveyed  from  individual  to  indi- 
vidual. Dolan,1  who  has  recently  published  a  very  interesting  and  valu- 
able monograph  on  this  affection,  quotes  Linnaeus,  who  ascribed  it  to  the 
irritation  of  insects,  as  the  author  of  the  modern  view  that  whooping 
cough  is  due  to  the  presence  of  a  peculiar  microbe,  though  it  must  be 
conceded  that  as  yet  it  has  not  been  discovered.  Most  observers  hold 
that  the  contagium  is  not  in  the  blood,  but  that  it  resides  in  the  secretions 
of  the  respiratory  passages,  and  is  most  virulent  during  that  stage  of  the 
disease  when  the  secretion  is  abundant.  Letzerich  states  that  he  has 

1  Dolan,  Thos.  M.,  Whooping  Cough,  London,  1882. 

The  following  brief  statement  of  his  conclusions  may  be  quoted  as  presenting  the  most 
important  facts  concerning  the  pathology  of  the  disease : 

1st.  Pertussis  depends  on  a  specific  poison  or  contagion ;  this  is  universally  admitted. 

2d.  This  contagion  is  active  and  highly  infectious ;  this  is  also  granted. 

3d.  The  contagion  is  analogous  to  the  contagia  which  produce  splenic  fever,  measles, 
scarlatina,  variola,  etc. 

4th.  It  has  a  peculiar  determination  to  the  lungs. 

5th.  Like  all  other  contagia,  it  has  its  period  of  activity  and  decline. 

6th.  The  period  of  greatest  activity  is  in  the  first  and  second  stages. 

7th.  Pertussis  runs  a  regular  course  like  measles,  scarlatina,  variola,  etc.,  and  rarely 
attacks  a  person  but  once. 

8th.  It  may  thus  be  classed  among  zymotic  diseases. 

^  9th.  The  fact  that  there  is  no  primary  pathognomonic  morbid  change  supports  this 
view. 

10th.  There  are  various  secondary  lesions  which  are  characteristic,  as  ulcerations  of  the 
fraenum  linguae. 

llth.  The  mode  of  death  harmonizes  with  this  view. 


ETIOLOGY.  839 

succeeded  in  producing  whooping  cough  in  rabbits  by  inoculating  the 
trachea  with  the  sputa  of  the  human  subject.  Dolan  obtained  smiilar 
results  by  injecting  the  nasal  secretions,  and  also  by  compelling  rabbits 
to  inhale  air  impregnated  with  decomposing  sputa  and  vomit  of  patients 
suffering  with  the  disease. 

I  do  not,  however,  feel  entirely  satisfied  in  adopting  the  view  that  the 
contagium  of  whooping  cough  resides  alone  in  the  mucous  membranes  of 
the  air-passages.1  Children  have  been  known  to  be  born  with  the  disease, 
the  mother  having  suffered  from  it  some  time  previous  to  confinement. 

The  following  case  occurred  under  my  own  observation :  Mrs.  F , 

the  mother  of  two  children,  was  in  her  eighth  month  of  pregnancy ;  the 
two  children  had  at  the  time  a  very  severe  attack  of  whooping  cough, 
which  required  the  constant  attendance  of  the  mother.  She,  though  an 
extremely  intelligent  woman,  belonged  to  the  poorer  classes,  and  had  no 
one  to  assist  her  at  this  trying  time.  One  day  she  complained  that 
the  movements  of  her  child  in  utero  had  entirely  changed.  Suddenly, 
without  any  previous  motion,  the  child  would  become  very  active ;  the 
force  of  its  movements  was  such  as  to  make  hazardous  any  attempt  on  her 
part  to  walk  in  the  street.  The  suddenness  with  which  the  movement 
would  come  on  would  oblige  her  to  seize  the  nearest  object  for  support. 
This  continued  until  the  child  was  born.  Shortly  after  labor  my  atten- 
tion was  called  to  the  infant,  which  had  a  curious  attack,  it  became  deeply 
cyanosed,  seemed  asphyxiated,  as  it  were,  for  a  moment,  had  no  convul- 
sions, and  within  a  few  seconds  resumed  its  normal  breathing  and  the  cir- 
culation seemed  once  more  established.  I  saw  the  child  in  several  of 
these  attacks  ;  its  health  did  not  seem  to  be  impaired,  and  without  treat- 
ment, within  a  few  weeks  they  disappeared  altogether.  The  mother 
insisted  upon  the  fact  that  the  child  had  whooping  cough,  and  the  absence 
of  the  characteristic  whoop  was  the  only  thing  that  prevented  the  diag- 
nosis from  being  positive.  This  would  show — and  there  are  enough  cases 
on  record  to  warrant  our  basing  an  opinion  upon  them — that  the  conta- 
gium of  whooping  cough  is  found  not  alone  in  the  matters  expectorated, 
notwithstanding  the  statement  of  Dolan  and  others  that  their  experi- 
ments failed  to  show  its  existence  in  the  blood. 

It  must  not  be  forgotten,  in  reference  to  cases  which  seem  to  have 
arisen  without  any  exposure  to  the  specific  poison,  that  the  characteristic 
whoop  is  not  always  present,  and  that  consequently  the  true  nature  of 
mild  cases  of  the  disease  which  may  infect  other  individuals  may  have 
been  overlooked.  Childhood  probably  acts  as  a  predisposing  cause,  though 
the  disease  occurs  at  all  periods  of  life,  and  as  it  usually  occurs  but  once 
in  the  same  individual,  it  is  clear  that  the  apparent  diminution  of  sus- 
ceptibility in  later  years  may  be  largely  due  to  the  fact  that  most  persons 
have  had  the  disease  in  child  hood.  More  children  are  attacked  from  one 
to  five  years,  and  the  disease  is  more  prevalent  in  summer  and  fall  months. 
Causes  which,  like  exposure  to  inclement  weather,  give  rise  to  irritation 
of  the  bronchial  mucous  membrane,  or  diseases  which,  as  measles,  are 
accompanied  with  catarrhal  symptoms  and  susceptibility  of  the  bronchial 
mucous  membrane,  also  may  serve  as  predisposing  causes.  Sex  appears 
to  exert  some  positive  influence.  Of  360  cases  of  pertussis  by  Dessau,* 
the  total  number  of  males  were  154,  that  of  females  206.  Girls  are  more 
1  Colson,  Lancet,  July  2d.  2  N,  Y.  Jour,  of  Obst.,  1881,  xiv.  490-503. 


810  PERTUSSIS. 

frequently  attacked  than  boys,  in  proportion  of  2  to  1.50;  this  seems  true 
at  all  ages ;  this  statement  is  substantiated  by  Unruh  of  Dresden,  based 
on  an  analysis  of  1952  cases. 

SYMPTOMS. — The  disease  begins  usually  with  an  ordinary  catarrh,  pre- 
ceded by  malaise  and  slight  laryngeal  irritation,  which  may  be  overlooked; 
in  fact,  during  the  first  stage  there  is  nothing  to  attract  special  attention, 
unless  a  direct  history  of  exposure  be  known  and  suspicion  be  aroused 
on  that  account.  Meigs  and  Pepper  state  that  the  earliest  period  at 
which  they  have  known  the  distinctive  whoop  of  the  disease  was  three 
days,  though  in  a  great  many  instances  it  was  delayed  as  late  as  three 
weeks.  The  same  authors  state  that  the  ordinary  duration  of  a  paroxysm 
or  kink  is  from  one-fourth  to  three-fourths  of  a  minute.  They  mention  a 
case  where  the  paroxysm  lasted  fifty-five  minutes.  Ordinarily  they  num- 
ber about  thirty-five  or  forty  during  the  twenty-four  hours  at  the  height 
of  the  disease,  differing  greatly  in  individuals.  Their  number  is  most 
frequent  in  the  course  of  the  third  or  fourth  week,  after  which  they 
remain  stationary,  and  then  gradually  decline.  The  paroxysms  may 
occur  spontaneously,  or  they  may  follow  some  irritation,  either  direct  or 
reflex,  or  they  may  be  induced  by  nervous  excitement.  Toward  the  end  of 
the  attack,  after  the  catarrhal  irritation  has  greatly  subsided,  or  in  fact 
has  entirely  disappeared,  the  paroxysmal  kinks  may  be  provoked  by 
irritation  of  the  fauces,  and  also  by  nervous  excitement ;  and  there  is 
no  question  but  that  at  this  time  they  can  be  controlled  by  will-power. 
In  many  cases  a  distinct  relapse  occurs  after  the  disease  has  been  appar- 
ently cured. 

Dolan  believes  the  phenomena  of  the  cough  or  kinks  to  be  due,  as 
suggested  by  Laenuec,  to  a  "  spasmodic  condition  of  the  muscular  or  con- 
tractile fibres  of  the  bronchi  and  their  branches."  He  remarks  that  the 
lungs  are  supplied  from  the  anterior  and  posterior  pulmonary  plexuses, 
formed  chiefly  of  branches  from  the  sympathetic  and  pneumogastrics. 
The  filaments  from  these  accompany  the  bronchial  tubes  upon  which  they 
are  lost.  Irritation  of  these  nerves  is  said  to  have  the  effect  of  producing 
contractions  of  the  bronchial  canals  sufficient  to  expel  a  certain  quantity 
of  air.  If  this  theory  is  true,  it  helps  us  in  explaining  why  the  large, 
mediate,  and  smaller  bronchi  are  closed  during  the  expiratory  stage  of 
the  paroxysmal  cough  of  pertussis.  The  general  opinion  seems  to  be  that 
the  pneumogastric  nerve  is  not  inflamed,  as  has  been  asserted  by  some. 

The  highly  sensitive  condition  of  the  nervous  system,  which  is  probably 
in  a  great  measure  intensified  by  the  anaemia,  and  by  the  interference 
with  nutrition  due  to  the  disturbance  of  the  circulation  by  the  cough, 
will  show  itself  in  many  ways,  and  even  when  no  secondary  nervous  affec- 
tions complicate  the  attack  or  follow  it.  Some  time  will  elapse  after  the 
disease  has  passed  away  before  the  child  will  recover  its  self-control,  or 
its  nutrition  will  show  the  influence  of  a  healthy  nervous  system. 
The  total  duration  of  the  affection  is  said  to  vary  from  six  weeks  to  three 
months  in  ordinary  cases ;  though  probably,  if  active  treatment  could  be 
instituted  early  enough  and  kept  up  with  thoroughness,  there  is  no  spe- 
cific disease  more  capable  of  being  shortened  in  its  course  than  the  one 
under  consideration;  this  remains,  however,  for  future  statistics  to 
decide. 

During  the  second  stage  of  the  disease  the  symptoms  are  sufficiently 


MORTALITY.  841 

marked  to  attract  attention  and  render  a  diagnosis  easy  to  make.  Fre- 
quently the  catarrh  seems  to  extend  to  the  bronchioles,  and  gives  rise  to 
symptoms  that  are  alarming;  and  the  intensity  of  the  paroxysm  will 
cause  the  engorgement  of  the  blood-vessels  to  get  relief  in  profuse  hemor- 
rhage; this  is  the  period  for  caution.  Complications  may  arise,  the 
strength  may  fail,  the  secretions  may  become  too  abundant,  and  asphyxia 
may  ensue ;  emphysema  may  show  itself,  or  catarrhal  pneumonia  may 
gradually  supervene. 

The  period  of  decline  is  very  gradual ;  the  secretions  become  less  in 
quantity  and  more  viscid,  the  paroxysmal  cough  is  less  frequent,  but  may 
at  times  be  equally  severe,  the  child's  strength  is  usually  exhausted,  and 
its  nutrition  is  greatly  impaired.  The  expected  paroxysm  throws  it  into 
a  state  of  intense  nervous  excitement ;  it  is  sleepless — in  fact,  worn  out. 
Probably  at  this  period  of  the  disease  treatment  will  show  the  most 
marked  results,  and  the  long  lists  of  sedatives,  tonics,  etc.  which  are  pre- 
sented to  us  by  their  zealous  advocates  owe  much  of  their  popularity  to 
their  value  at  this  stage  of  the  disease.  The  catarrhal  symptoms  are  the 
first  to  subside ;  the  nervous  disturbances  remain  for  some  time,  and 
gradually  fade,  and  the  constitutional  symptoms,  or  those  from  exhaus- 
tion, are  the  last  to  leave  the  patient. 

Strange  as  it  may  seem,  the  heart  appears  to  suffer  but  little  in  the 
long  run  from  the  great  strain  upon  it ;  the  palpitation  and  irregularity 
of  its  actions  are  not  followed  by  structural  changes  as  a  rule,  though  we 
may  state  that  feebleness  of  the  circulation  has  remained  in  most  of  our 
bad  cases  for  some  months  after  recovery. 

As  regards  the  ulceration  of  the  frsenum  linguse,  which  has  given  rise 
to  so  much  discussion  as  to  its  exact  value  as  a  symptom  of  this 
disease,  our  own  experience  leads-  us  to  believe  that  though  it  is  nearly 
always  present  in  the  severe  cases,  its  almost  invariable  absence  before 
dentition  and  in  milder  cases  shows  it  to  be  of  traumatic  origin. 
Roger's  exhaustive  report  before  the  French  Academy  supported  this 
view,  and  showed  how  clearly  it  is  caused  by  the  violent  rubbing  of  the 
frsenum  on  the  free  border  of  the  incisors.  On  the  other  hand,  Delthil 
of  Paris  and  Blake  of  England  believe  that  it  is  a  pathological  feature 
of  the  disease.  The  former  reported  cases  in  which  it  occurred  before 
dentition.  The  ulcer  is  not  always  found  on  the  frsenum  linguse,  but  is 
found  on  either  side  of  it.  Bouffier  noted  severe  cases  of  ulceration  in 
children  who  had  no  teeth,  but  he  attributed  it  to  the  injury  produced 
by  the  mother  in  detaching  the  mucus  with  the  finger. 

Examinations  of  the  urine  have  been  carefully  made  by  many  observers. 
The  appearance  of  sugar,  about  which  so  much  has  been  said,  does  not  seem 
to  be  constant,  or  even  very  frequent.  Out  of  50  cases,  Dolan  found  traces 
of  it  in  but  13.  This  coincides  with  our  experience  also,  for  we  have 
frequently  tested  the  urine  in  seven  cases  with  negative  results.  Since, 
as  is  well  known,  irritation  of  the  pneumogastric  centre  may  cause  gly- 
cosuria,  it  was  at  one  time  attempted  to  show  that  the  paroxysms  in 
whooping  cough  were  due  to  congestion  of  the  pneumogastric  nerves,  a 
condition  which  is  said  to  have  been  occasionally  found  in  this  disease. 
Dolan  says  he  has  never  seen  hemorrhage  from  the  kidneys  during  the 
course  of  whooping  cough,  nor  blood  in  the  urine. 

MORTALITY. — It  is  an  extremely  difficult  matter  to  reach,  with  any 


842  PERTUSSIS. 

degree  of  certainty,  the  true  mortality  of  this  affection.  Meigs  and 
Pepper  say :  "  Of  the  208  cases  observed  by  ourselves,  143  \vere  simple, 
all  of  which  recovered;"  and,  again,  "Some  form  of  complication 
occurred  in  the  65  of  the  208  cases  observed  by  ourselves ;  of  these  65, 
12  died."  The  mortality  seems  greater  under  five  years;  thus:  Of  the 
9008  deaths  attributed  to  it  in  the  United  States  during  the  census  year 
ending  June  1,  1870,  the  number  of  persons  under  one  year  of  age  was 
4424,  and  8396  were  under  five  years.  There  were  1784  deaths  from  it 
recorded  in  Philadelphia  from  1860  to  1876 ;  of  this  number,  1724  were 
under  five  years  of  age.  The  census  of  the  United  States  for  1880  gives 
a  return  of  11,102  deaths  from  this  disease. 

Females  seem  more  liable  to  die  of  it  than  males ;  of  the  1 784  deaths 
in  this  city,  766  were  males  and  1018  females.  As  we  have  already 
seen,  females  are  more  liable  to  the  disease  than  males. 

Robt.  J.  Lee,  M.  D.,1  says  that  from  the  Registrar-General's  report  of 
1876  it  is  seen  that  in  a  total  mortality  in  England  of  510,315,  whooping 
cough  was  returned  as  the  cause  of  death  in  1 0,554  cases,  or  nearly  2  per  cent. 

As  for  the  time  of  year,  we  quote  the  following  :  "  Thus,  according  to 
the  census  statistics,  most  deaths  occur  in  the  spring,  there  being  a  rise  up 
to  the  middle  of  May.  From  the  middle  of  May  the  number  lessens 
largely  until  August,  when  a  rise  occurs  and  continues  until  October, 
when  a  decline  sets  in  and  continues  until  December,  when  a  rise  begins 
and  goes  on  increasing  until  the  middle  of  May.  This  rise  in  mortality 
from  August  to  October  is  attributed  to  the  wear  and  tear  of  a  hot 
summer  and  the  intestinal  troubles  then  so  prevalent." 

The  mortality  statistics  of  this  disease  are  uncertain.  It  is  fatal  in  its 
complications  or  by  inducing  a  debilitated  condition  which  invites  degener- 
ative processes.  The  severity  of  the  symptoms  is  no  guide  for  prognosis 
as  far  as  uncomplicated  cases  are  concerned,  and  there  is  no  doubt  but  that 
at  present  we  are  able  to  greatly  reduce  the  mortality-rate  by  care  and 
medical  treatment,  as  well  as  to  shorten  the  attack.  Sporadic  cases  are 
apt  to  be  neglected  until  they  become  complicated.  When  the  disease 
occurs  in  epidemic  form,  measles  is  often  prevalent  simultaneously,  and 
in  consequence  children  who  become  affected  by  both  diseases  have  a 
greater  tendency,  from  debility,  to  become  the  victims  of  those  affections 
of  the  respiratory  organs  which  are  such  frequent  and  fatal  complications 
of  both  maladies. 

Instead  of  surprise  at  the  mortality  of  this  affection,  the  marvel  is 
that  so  large  a  percentage  of  recoveries  take  place,  when  we  consider 
that  we  are  dealing  with  a  disease  whose  lesion  is  a  catarrh  of  the 
air-passages  which  seldom  lasts  less  than  two  months,  with  a  tend- 
ency to  involve  the  lungs  in  one  way  or  another,  and  then  witness 
the  carelessness  with  which,  among  the  loAver  classes,  the  child  is 
often  treated — exposed  to  all  weathers,  under-clothed,  under-fed,  and 
probably  allowed  to  pass  through  the  whole  attack  without  medical  treat- 
ment. Taking  this  into  consideration,  the  probability  is  that  the  mor- 
tality of  this  disease  could  be  reduced  to  a  very  small  figure  by  careful 
management,  even  if  the  investigations  of  those  now  seeking  the  microbe 
of  pertussis  do  not  lead  to  any  plan,  in  accordance  with  Pasteur's  teach- 
ings, which  will  still  further  lessen  the  gravity  of  the  disease.  Until 
1  In  a  paper  in  the  British  Med.  Jour.,  1879,  vol.  i.  p.  307. 


MORBID  ANATOMY.— PROPHYLAXIS.  843 

then,  we  can  but  insist  upon  a  rigid  quarantine  of  schools,  a  registration 
of  all  cases,  and  the  seclusion  of  them,  as  we  have  done  to-day  in  the 
the  case  of  variola  and  scarlatina. 

MOEBID  ANATOMY. — Although  whooping  cough  is  a  serious  dis- 
ease, the  cause  of  death  is  generally  found  to  be  dependent  upon  its 
complications,  and  there  is  no  lesion  at  all  characteristic  of  it.  The  chief 
complications  and  sequelse  are — bronchitis,  which  may  become  capillary ; 
lobular  collapse,  which,  according  to  Alderson,1  is  frequently  found ;  em- 
physema, usually  marginal,  probably  due,  as  suggested  by  Jenner,  to  violent 
expiratory  exertions;  rupture  of  air-vesicles,  with  subcutaneous  emphy- 
sema; catarrhal  pneumonia,  pleurisy,  phthisis,  acute  tuberculosis,  croup,  cer- 
ebral apoplexy,  meningitis,  etc.  As  any  of  these  complications,  and  others 
which  may  arise  from  debility,  may  be  the  cause  of  death,  independent  of 
the  action  of  the  specific  poison  itself,  it  is  usual  to  divide  the  post- 
mortem appearances  into  those  that  are  the  result  of  the  extension  of  the 
catarrh  itself  and  those  produced  by  the  interference  with  the  circulation 
and  with  nutrition  from  mechanical  violence.  Of  the  former,  the  usual 
causes  of  death  are  pneumonia,  gastritis  and  enteritis.  Of  the  latter, 
we  have  thrombosis  of  the  cerebral  sinuses,  hemorrhages,  emphysema, 
and  exhaustion  following  constant  vomiting. 

Tubercular  disease  of  the  lungs  or  of  the  brain  is  apt  to  be  a  cause  of 
death.  Convulsions  carried  oft'  5  of  the  12  fatal  cases  reported  out  of 
208  by  Meigs  and  Pepper.  This  may  be  due  to  congestion  of  the  brain, 
especially  in  teething  children.  Spasm  of  the  glottis  with  sudden  death 
is  occasionally  found.  In  such  cases  there  is  found  intense  congestion  of 
the  brain,  also  of  the  liver  and  kidneys,  and  at  times  of  the  mucous 
membrane  of  the  stomach  and  intestines,  as  well  as  of  that  of  the 
respiratory  tract. 

In  all  cases,  especially  at  the  teething  age,  sudden  death  may  occur 
because  effusion  into  the  ventricles  of  the  brain  or  the  formation  of 
heart-clot  has  taken  place.  It  is  important  to  know  this,  that  active 
treatment  applied  early  enough  may  save  the  patient. 

PROPHYLAXIS. — Should  the  interesting  and  seemingly  conclusive  state- 
ments of  Dolan  and  the  microscopic  investigations  of  Carl  Bruger2 
receive  the  endorsement  of  future  workers,  the  subject  of  prophylaxis 
will  assume  a  degree  of  importance  which  hitherto  it  has  only  maintained 
with  the  medical  profession.  No  one  has  doubted  that  the  disease  was 
contagious,  and  yet  there  is  no  affection  which  has  attached  to  it  a  corre- 
sponding fatality  that  is  so  carelessly  dealt  with  as  pertussis. 

Within  the  past  few  days  we  have  heard  on  two  occasions  in  crowded 
railway-cars  the  characteristic  paroxysm  of  the  third  stage  of  the  disease, 
and  yet  people  will  endeavor  to  convince  themselves  that  unless  contact 
with  the  child  takes  place  the  danger  is  little. 

1  Medico-Chir.  Trans.,  pp.  90,  91,  1830. 

2  Bruger  of  Bonn,  in   the  Berliner  klinische  Wochen.,  describes  at  length   the  special 
micro-organisms  of  pertussis.     They  appear  as  small  elongated  elliptical  bodies  of  unequal 
length,  the  smallest  being  double  "as  long  as  broad.     High  powers  show  subdivisions  in 
the  largest  specimens.     They  are  generally  isolated,  but  may  appear  in  groups.    They 
bear  some  resemblance  to  Leptothrix  buccalis,  the  spores  of  which  are  often  found  in  whoop- 
ing-cough sputa.     Occasionally  the  bacillus  is  seen  inside  the  mucous  corpuscle  in  the 
sputum.      They  stain  in  the  usual  way,   fuschin  and  methyl  violet.      This^  bacillus   is 
not  found  in  any  other  kind  of  sputum,  is  very  abundant  in  pertussis,  and  increases  in 
direct  proportion  to  the  severity  of  the  disease. 


844  PERTUSSIS. 

The  atmosphere  in  school-rooms,  railway-cars,  and  places  of  amuse- 
ment which  are  badly  ventilated,  is  an  excellent  medium  for  the  propaga- 
tion of  the  contagious  matter,  and  many  extraordinary  cases  are  on  record 
of  momentary  exposure  being  sufficient  to  contract  the  disease.  Believ- 
ing that  the  contagium  or  virus  resides  in  the  mucus  and  air  thrown  off  by 
the  child,  and  also  in  the  vomited  matters,  which  contain  a  large  amount 
of  ropy  mucus,  and  also  that  it  gains  entrance  by  means  of  the  respiratory 
organs,  protection  from  contagion  divides  itself  as  follows :  thorough 
disinfection  of  the  exhaled  air,  of  the  mucus  remaining  within  the  bron- 
chial tubes  and  air-passages,  and  of  the  clothing,  together  with  exposure 
to  fresh  air  and  thorough  cleansing  of  all  furniture  and  household  utensils, 
including  cups,  silverware,  and  toys,  used  by  the  child.  Oxygen  is  said  to 
have  this  effect,  and  thorough,  constant  ventilation,  with  the  breathing  of 
fresh  air  by  the  child,  the  thorough  washing  of  its  surface,  and  disinfection 
of  its  clothing,  are  the  first  indications ;  while  the  impregnation  of  the 
atmosphere  with  the  spray  of  well-known  germicides  by  means  of  the 
steam  or  other  atomizer  and  the  frequent  inhalation  of  such  materials 
by  the  patient  are  no  less  important.  Every  case  of  whooping  cough 
should  be  compelled  to  use  two  or  three  times  daily  the  spray  impreg- 
nated with  a  substance  of  this  sort,  either  carbolic  acid,  the  oil  of 
eucalyptus,  a  solution  of  quinia,  or  thymol.  Chlorine  (from  chloride 
of  lime)  used  thus  has  of  late  been  followed  by  excellent  results,  and 
the  spray  of  a  solution  of  corrosive  sublimate  or  of  ammonium  chlo- 
ride has  been  found  very  useful.  The  protective  treatment  should 
be  applied  to  those  exposed  to  contagion.  Such  children  should  be 
guarded  from  exposure  to  colds;  their  diet  should  be  simple  and  nour- 
ishing, their  clothing  warm;  they  should  be  kept  as  much  as  possible  in 
the  open  air.  The  breathing  of  air  impregnated  with  such  substances  as 
above  mentioned  will  no  doubt  act  upon  the  virus  before  it  comes  in  con- 
tact with  the  mucous  membranes  so  as  to  be  absorbed,  and  probably  the 
severity  of  the  attack  might  be  mitigated  by  modifying  the  germ  of  the 
disease. 

TREATMENT. — As  can  be  readily  imagined,  a  disease  which  is  so  uni- 
versal, so  distressing,  and  at  the  same  time  so  ob'scure  in  its  pathology,  as 
the  one  under  consideration,  would  have  in  its  literature  a  mass  of  rec- 
ommendations for  treatment  from  zealous  advocates,  based  upon  theory 
or  experience,  as  numerous  as  the  authors  themselves.  It  would  be 
impossible  for  us  to  dwell  at  length  upon  all  of  these,  but  we  will 
confine  ourselves  especially  to  the  consideration  of  a  few  of  the  most 
important,  It  will  be  convenient  to  consider  first  those  remedies  which 
have  been  used  with  the  view  of  relieving  the  congestion  and  irritability 
of  the  respiratory  mucous  membrane  and  of  promoting  more  free  secre- 
tion. It  will  also  be  observed  that  many  of  these  remedies  may  now  be 
regarded  as  of  value  for  destroying  the  special  germ  which  is  thought  to 
be  the  essential  cause  and  real  virus  of  pertussis.  Allusion  has  been 
made  above  to  the  importance  of  inhalations  as  a  prophylactic  for  those 
who  have  been  exposed  to  the  contagion,  as  well  as  for  the  purpose  of 
rendering  the  secretions  less  contagious;  and  so  too  we  find  that  the 
inhalation  of  various  substances  has  received  favor  with  many  as  a 
method  of  treatment.  Thus,  hyoscyamus,  belladonna,  ammonium  bro- 
mide have  been  used.  Helenke  and  Serbaud  say  that  bromide  of  potas- 


TREATMENT.  845 

slum  is  best  for  inhalation.  Letzerich  recommended  the  insufflation  of 
quinia  twice  daily,  using  the  quiuia  muriate  with  potassium  bicarbonate 
and  gum-arabic.  Forchheimer1  reports  97  cases  of  whooping  cough 
treated  by  the  insufflation  of  the  quiuia  muriate ;  of  the  97  cases,  52  were 
females,  45  males — the  youngest  three  weeks,  the  oldest  nine  years  old. 
Five  cases  gave  no  results,  while  in  the  others  benefit  was  shown  by  a 
shortening  or  amelioration  of  the  disease.  The  vapor  of  benzole  has  been 
used  with  good  results.  The  vapor  of  carbolic  acid  lias  of  late  been  highly 
recommended,  either  administered  with  the  atomizer  several  times  daily, 
or  used  by  saturating  flannels  in  carbolic  acid  solution  and  placed  around 
the  child's  bed  at  night.  It  is  said  that  the  inhalation  of  the  vapor  of  a 
few  drops  of  carbolic  acid  on  some  hot  coals  will  ensure  a  night  of  free- 
dom from  violent  coughing.  Probaby  in  this  way  we  may  account  for 
the  belief  that  proximity  to  gas-works  is  beneficial  to  a  child  with  this 
disease.  As  is  well  known,  Niemeyer  and  others  in  the  north  of  Ger- 
many believed  in  the  value  of  the  inhalation  of  oxygen,  and  the  experi- 
ence of  every  one  who  has  had  much  to  do  with  this  disease  favors  an 
out-door  life.  We  may  here  also  mention  the  value  of  a  small  quantity 
of  chloroform  or  ether,  by  inhalation,  in  allaying  the  severity  of  the  par- 
oxysms of  cough.  We  have  also  tried  the  nitrate  of  amyl,  but  without 
marked  result. 

Others  have  recommended  the  use  of  solutions  of  various  substances, 
applied  directly  by  a  brush  to  the  interior  of  the  larynx.  Quinia  has 
been  used  in  this  way  also  by  Hagenbach;  but  the  most  satisfactory 
results  have  been  obtained  by  the  application  of  very  weak  solutions 
of  nitrate  of  silver,  as  first  recommended  by  Watson  in  1849. 

After  the  secretions  have  been  fully  established  and  the  characteristic 
whoop  has  appeared,  the  indications  in  the  treatment  are  to  relieve  the  res- 
piratory tract  of  its  burden  by  occasional  emesis  with  alum  or  ipecacuanha, 
to  give  freely  anti  spasm  odics  and  sedatives,  as  belladonna,  chloral,  the  bro- 
mides, hydrobromic  acid,  or,  as  recommended  by  some,  digitalis ;  to  give 
quiuia  freely,  and  to  use  counter-irritants  to  the  neck  and  chest  with 
liniments  composed  of  oil  of  amber,  croton  oil,  or  turpentine. 

The  value  of  emetics  has  been  long  recognized  in  this  affection,  although 
we  are  told  by  Vogel  that  the  continuous  use  of  emetics  in  the  early  stage 
for  several  days  causes  harm.  Copeland  ordered  an  emetic  every  third  day 
in  ordinary  cases.  All  writers  agree  that  the  milder  emetics  should  be  used 
by  preference ;  that  tartar  emetic  should  be  avoided,  except  as  an  external 
application  where  a  counter-irritant  is  desired ;  and  that  ipecacuanha  is  the 
safest,  though  alum  is  also  safe  and  as  an  astringent  useful.  Trousseau 
preferred  the  sulphate  of  copper.  In  the  earlier  stages  of  the  disease  emetics 
are  not,  as  a  rule,  indicated ;  it  is  only  when  the  secretion  has  become  ex- 
tremely tenacious,  and  the  paroxysms  so  frequent  and  severe  as  to  greatly 
strain  the  patient  and  endanger  his  lungs,  that  they  are  of  value.  There 
seems  to  be  a  close  connection  between  the  amount  and  tenacity  of  the  secre- 
tion and  the  severity  of  the  paroxysm.  The  potassium  carbonate  has  been 
recommended  as  an  active  agent  in  the  amelioration  of  this  affection  ;  it 
is  probably  valuable  in  rendering  the  secretion  less  tenacious.  Alum 
has  been  used  with  success,  as  has  tannin,  probably  owing  to  their  local 
action  on  the  mucous  membrane.  Macartan2  says  that  in  the  East 

1  New  York  Jour.  Obsiet.,  1882.  2  Dictionnaire  des  Sciences  Med.,  1813,  vol.  vi. 


846  PERTUSSIS. 

Indies  the  disease  is  treated  in  the  first  stages  by  astringent  and  tonic 
gargles. 

Belladonna  certainly  receives  the  endorsement  of  the  greatest  num- 
ber of  writers.  Vogel  considers  it  superior  to  all  other  drugs,  and 
regards  dilatation  of  the  pupil  as  the  only  sure  guide  in  its  administra- 
tion. He  says  it  does  not  cut  short  the  attack,  but  mitigates  the  parox- 
ysm. Trousseau  was  also  an  advocate  of  this  form  of  treatment.  When 
combined  with  alum l  it  is  considered  by  Meigs  and  Pepper  to  be  one  of 
the  most  valuable  drugs  recommended.  They  also  advise  the  use  of 
potassium  carbonate.  Seiner  trusted  belladonna  more  than  any  other 
remedy ;  so  also  Kllliet  and  Barthez.  William  Lee,  in  an  interesting 
paper  in  the  New  York  Medical  Journal,  1883,  advocates  the  use  of 
atropia  hypodermically ;  he  believes  that  atropia  chiefly  acts  in  these 
cases  on  the  laryngeal  branches  of  the  pneumogastric  nerves,  and  that  it 
is  probable  that  it  has  a  decided  effect  also  on  the  medulla  oblongata 
itself,  and  renders  it  less  capable  of  exciting  reflex  action.  Kroon's 
experiments  led  him  to  conclude  that  the  valerianate  of  atropia  was  the 
most  useful.  Evans 2  gave  the  y^j-  of  a  grain  of  atropia  to  a  child  aged 
three  years  until  the  pupils  were  dilated,  then  reduced  the  dose ;  this 
stopped  the  paroxysm  in  twenty-one  days.  At  the  commencement  of 
the  treatment  the  child  had  twenty-three  paroxysms  in  the  day,  and 
twenty-seven  at  night.  Case  No.  2  under  same  circumstances  recovered 
in  fourteen  days.  In  case  No.  3  the  paroxysms  were  reduced  from 
twenty-six  to  two  or  three  a  day.  Arthur  Wiglesworth 3  used  a  solu- 
tion of  sulphate  of  atropia,  administered  in  the  morning  fasting ;  the 
dose  he  advises  for  children  from  one  to  four  years  is  gr.  y^,  given  only 
once  a  day  except  in  some  cases.  The  results  are  as  follows  :  There  is  a 
steady  diminution  in  the  number  of  paroxysms ;  a  change  in  the  character 
of  the  whoop  as  if  the  vocal  cords  were  not  so  closely  approximated.  If 
atropia  is  withheld,  the  beneficent  effect  derived  from  it  subsides. 

West  advises  dilute  hydrocyanic  acid,  and  many  writers  agree  with 
him,  ranking  it  next  to  belladonna. 

Harley  and  others  are  strong  advocates  for  the  bromide  of  ammonium; 
it  is  supposed  to  have  a  local  anaesthetic  action  on  the  pharyngeal  and 
laryngeal  mucous  membrane.  Fordyce  Grinnell4  during  four  months 
treated  223  cases  with  this  remedy,  and  highly  recommends  it.  The 
doses  were  in  accordance  with  those  of  Dr.  Konnann — f  to  4  grains,  as 
indicated  by  age,  three  or  four  times  a  day  and  at  night  when  the  parox- 
ysms were  severe.  No  other  treatment  was  used  in  these  223  cases,  except 
camphorated  oil  to  the  throat  and  chest  in  some  cases.  Potassium  bro- 
mide has  been  recommended  by  Helenke,  Beaufort,  Erlenmeyer,  and 
others.  Henry  Field5  recommends  sodium  bromide. 

Probably  next  to  belladonna  in  the  treatment  of  this  disease  we 
should  place  chloral  hydrate. 

Hebner,  after  an  elaborate  study  of  the  relative  value  of  potassium 
bromide,  quinia,  salicylic  acid,  chloral,  and  belladonna,  says:  "Sali- 
cylic acid  and  chloral  tend  to  relieve  the  paroxysms — belladonna  and 
quinia  to  shorten  the  disease."  Kennedy6  writes:  "I  cannot  doubt 

1  Golding  Bird,  Guy's  Hosp.  Rep.,  April,  1845.  J  Glasgow  Med.  Jour.,  1880. 

s  Lancet,  April  12,  1879.  «  Med.  News,  1882.  6  Brit.  Med.  Jour. 

•  Dublin  Jour.  M.  S.,  1881. 


TREATMENT.  847 

its  specific  effects  on  the  cough.  Chloral  seems  to  me  to  yield  the  best 
and  most  constant  results.  The  advantage  of  chloral  hydrate  seems  to 
exist  in  producing  sleep ;  it  should  be  given  in  from  2-  to  5-gr.  doses, 
at  night."  If  there  is  much  irritability  or  fretfulness,  or  any  premonition 
of  eclampsia,  it  should  be  associated  with  potassium  bromide. 

Croton  chloral  has  received  much  praise  from  those  who  have  used  it ; 
we  have  had  110  experience  with  it. 

We  have  already  alluded  to  the  value  of  quinia,  which  has  been  used 
largely  in  this  disease,  both  internally  and  as  a  local  application.  Orig- 
inally recommended  in  the  latter  manner  on  account  of  its  power  of 
controlling  the  development  of  low  organisms,  it  has  not  proved  so  satis- 
factory or  valuable  as  when  given  internally.  Binz  in  1870  was  perhaps 
the  first  to  recommend  quinia  given  frequently  and  in  solution,  and 
Dawson  in  1873 l  reports  excellent  results  from  the  sulphate  or  muriate 
of  quinia  given  in  full  and  frequent  doses,  and  in  such  solutions  as  will 
not  prevent  its  acting  on  the  mucous  membrane  in  its  passage  through 
the  pharynx.  Breidenbach2  gives  the  quinia  muriate  in  larger  doses — 
one  and  a  half  to  fifteen  and  a  half  grains  per  diem.  The  effects  were 
surprising  as  soon  as  the  proper  dose  for  each  person  had  been  deter- 
mined ;  this,  he  says,  is  the  keynote  of  success.  To  prevent  complications 
he  continued  it  for  a  long  time  in  small  doses. 

Our  own  experience  favors  the  view  that  quinia,  when  given  in  solu- 
tion or  suspended  in  mixture,  is  valuable  in  many  cases  of  this  disease  ; 
it  can  be  ordered  in  powder,  and  given  in  a  spoonful  of  simple  syrup 
or  of  the  preparation  known  as  the  syrup  of  yerba  santa,  which  makes  an 
excellent  vehicle.  Liquorice  also  disguises  the  taste  of  quinia  admirably 
for  children. 

Albrecht3  has  found  from  an  experience  of  ten  cases  of  whooping 
cough  in  children  between  the  ages  of  one  and  a  half  and  nine  years,  all 
of  a  marked  scrofulous  type,  much  benefit  from  the  muriate  of  pilocarpine, 
given  in  small  doses  after  every  fit  of  coughing.  To  prevent  collapse,  he 
advises  that  it  should  be  given  in  a  mixture  containing  a  little  brandy. 
After  twenty-four  hours  of  its  administration  an  obvious  change  for  the 
better  takes  place  in  the  appearance  of  the  mucous  membrane  of  the 
throat,  velum  palati,  and  uvula,  which  becomes  paler,  less  swollen,  and 
more  moist;  laryngoscopic  examination  shows  a  similar  improvement. 
During  the  catarrhal  period  cold  compresses  to  the  neck  and  sweetened 
milk  containing  potassium  chlorate  are  used  instead  of  the  pilocarpine, 
which  is  to  be  resumed  as  soon  as  a  whoop  recurs. 

Dr.  Tordeus,  of  the  Hospice  des  Enfants  Assisted,  Brussels,  states 
that  he  has  found  the  sodium  benzoate  useful  in  whooping  cough, 
diminishing  the  frequency  and  violence  of  the  paroxysms,  and  by  its 
action  on  the  pulmonary  mucous  membrane  preventing  those  pulmonary 
complications  which  so  frequently  supervene  and  constitute  the  danger  of 
the  disease. 

Sulphur  has  been  largely  used  by  the  Germans  in  two-  or  three-grain 
doses,  and  is  said  to  be  greatly  esteemed  by  them.  Cautharides  has  been 
recommended,  and  it  is  stated  that  when  strangury  is  produced  the 
whoop  will  cease ;  we  should  consider  this  rather  severe  treatment.  The 

1  Am.  Jour.  Obstetrics.  *  Practitioner,  Feb.,  1871. 

8  London  Med.  Rec.,  March  15,  1882,  p.  110. 


848  PERTUSSIS. 

fluid  extract  of  castanea  is  used  by  many  with  undoubtedly  good  results, 
though  this  also  has  been  somewhat  of  a  disappointment  in  the  way  of 
treatment,  as  at  one  time  it  was  looked  upon  almost  as  a  specific.  Many 
claim  that  an  infusion  of  the  fresh  leaves  gives  a  better  result.  Dewar l 
regards  ergot  with  great  favor  in  the  treatment  of  pertussis.  Certainly  in 
those  cases  where,  from  violent  straining,  hemorrhages  have  taken  place  we 
have  found  it  to  be  highly  valuable.  We  have  had  no  experience  with 
it  in  the  treatment  of  ordinary  cases,  though  Dewar  claims  that  it  shortens 
the  attack.  The  ammonium  picrate,  and  recently  resorcine,  have  been  used 
with  success. 

Counter-irritation  to  the  neck  and  chest  has  always  been  found 
useful  in  the  treatment  of  this  disease.  Autenreith2  recommends  tartar 
emetic  to  the  epigastrium  till  vesicles  appear  and  even  ulcerate.  Milder 
forms  of  counter-irritation  over  the  chest  seem  equally  efficacious  if  con- 
tinued for  some  time.  The  oil  of  amber,  when  used  in  liniment  with 
camphor  or  turpentine,  is  by  some  considered  almost  a  specific.  Great 
care  should  also  be  observed  in  the  dress  of  children  with  whooping 
cough.  Warmth  about  the  chest  is  always  indicated,  while  there  should 
be  nothing  close  or  tight  about  the  throat  allowed. 

In  the  third  stage,  when  there  is  the  nervous  element  remaining, 
tonics,  such  as  cod-liver  oil,  iron,  the  phosphates  and  hypophosphites, 
are  required. 

The  diet  should  be  nutritious,  easy  of  digestion,  and  abundant,  and  the 
bowels  should  be  kept  regular  by  fruits  or  laxatives.  Over-feeding 
should  of  course  always  be  avoided,  and  the  attempt  at  weaning  a 
babe  with  this  disease  would  certainly  meet  with  unfavorable  results. 

Bicarbonate  of  soda  or  lime-water  should  be  given  freely  with  the  milk 
taken  by  children  with  this  disease.  Milk  certainly  should  form  the 
basis  of  the  diet  of  children  with  pertussis,  and  reliable  meat-extracts  are 
to  be  recommended  in  this  disease  even  for  older  children,  who  from  the 
severity  of  the  attack  would  vomit  more  solid  food.  If  the  vomiting  be 
so  severe  as  to  affect  nutrition,  the  child  should  be  sustained  by  pepton- 
ized  milk,  soup,  or  gruel,  given  by  the  bowel. 

The  importance  of  a  proper  regulation  of  the  temperature  of  the  air 
which  the  patient  breathes  is  especially  recognized  in  France.  If  the 
attack  occurs  in  mid-winter  and  the  seashore  be  inaccessible  or  inexpe- 
dient, the  child  should  be  restricted  to  a  well-ventilated  nursery  or  suite 
of  rooms,  the  temperature  of  which  should  be  kept  uniform. 

Salt  air  is  recognized  to  be  of  great  value  in  advanced  cases  of  this 
disease ;  this  has  been  attributed  partly  to  the  effects  of  stimulation  of 
the  mucous  membrane  in  rendering  less  viscid  and  more  copious  the  bron- 
chial secretions,  and  also  to  the  balmy  softness  and  great  purity  of  the 
atmosphere  at  the  sea-shore.  But  probably  there  is  another  element  in 
the  local  action  of  the  chloride  of  sodium,  either  in  establishing  a  resist- 
ance on  the  part  of  the  patient  or  in  modifying  the  germ  of  the  disease. 

The  most  serious  complication  of  whooping  cough  is  pneumonia.  It 
occasionally  happens  that  an  attack  of  croupous  pneumonia  may  develop 
during  the  course  of  whooping  cough,  but  in  the  vast  majority  of  cases 
the  disease  is  of  the  catarrhal  type.  When,  indeed,  it  is  remembered  that 
a  bronchial  catarrh,  which  is  the  invariable  precursor  or  accompaniment 

1  The  Practitioner,  London,  May,  1882.  2  Diet,  des  Sciences  Med.,  1813. 


TREATMENT.  849 

of  catarrhal  pneumonia,  is  a  constant  factor  in  whooping  cough,  and, 
further,  that  all  conditions  of  debility,  and  especially  of  enfeebled  or 
embarrassed  respiration,  dispose  to  this  form  of  pneumonia,  it  is  not  sur- 
prising that  this  complication  should  be  of  such  frequent  occurrence.  It 
is  not  impossible  that  in  aiming  at  securing  sufficient  fresh  air  and  out-door 
exercise  to  maintain  the  general  health,  an  injudicious  degree  of  exposure 
may  be  permitted  which  will  aggravate  the  existing  bronchitis  and  induce 
an  extension  of  inflammation  to  the  alveoli.  But  usually  the  catarrhal 
pneumonia  develops  in  a  subacute  and  more  or  less  insidious  manner,  and 
without  being  traceable  to  any  such  exposure.  It  may  happen  occasion- 
ally that  in  the  violent  inspiratory  efforts  at  the  close  of  the  paroxysms 
irritating  secretions  may  be  sucked  from  the  bronchioles  into  the  alveoli, 
and  there  excite  inflammation.  Or,  again,  it  doubtless  happens  frequently 
that,  with  the  existence  of  swelling  of  the  bronchial  mucous  membrane 
and  of  viscid  secretions  in  the  bronchial  tubes,  collapse  of  portions  of 
lung  tissue  is  developed  by  the  forcible  expulsion  of  air  during  the  par- 
oxysms of  cough,  which  cannot  be  replaced  owing  to  the  relative  weak- 
ness of  inspiration  and  to  the  ball-valve  action  of  the  plugs  of  mucus  in 
the  obstructed  bronchioles.  The  intimate  relation  between  pulmonary 
collapse  and  catarrhal  pneumonia  is  familiarly  known.  It  is  not  to  be 
considered  that  the  mere  occurrence  of  collapse  will  induce  pneumoaia  in 
the  areas  affected,  but  certainly  it  will  aid  in  rendering  effective  the  other 
irritating  causes.  As  a  consequence,  it  usually  happens  that  when 
catarrhal  pneumonia  occurs  in  whooping  cough  it  is  associated  with 
more  or  less  collapse.  When,  then,  especially  in  children  of  debilitated 
or  rachitic  constitution,  or  in  those  who  are  subjected  to  unfavorable 
hygienic  influences,  such  as  overcrowding,  bad  air,  and  the  like,  there  is 
a  rather  gradual  development  of  dyspnoea,  with  increasing  debility,  ema- 
ciation, and  evidences  of  impaired  oxygenation  of  the  blood,  it  is  to  be 
feared  that  this  serious  complication  has  developed.  The  physical  signs 
are  often  difficult  of  interpretation,  but  if  careful  examination  of  the 
chest  be  conducted,  together  with  thermometric  observations,  the  ap- 
proach of  this  danger  or  its  actual  presence  may  be  detected.  The  result 
is  fatal  in  a  large  proportion  of  cases,  so  that  suitable  treatment — for  the 
details  of  which  reference  is  made  to  the  appropriate  section — must  be 
instituted  without  delay. 

Our  investigations  of  this  disease  have  led  us  to  the  conclusion  that  we 
have  to  deal  with  an  affection  caused  by  a  specific  germ,  which  is  usually, 
after  a  period  of  incubation,  made  manifest  by  a  catarrh  of  a  portion  of 
the  air-passages ;  that  this  catarrh,  existing  for  an  indefinite  period,  is 
capable  of  being  influenced  by  medication,  applied  either  by  means  of 
inhalation  or  by  acting  on  the  mucous  membrane  after  absorption  by  the 
stomach.  In  this  way  we  have  known  the  administration  of  quinia  and 
of  alum  diminish  the  number  of  paroxysms,  to  all  appearance  check- 
ing the  excessive  secretion  to  a  marvellous  extent.  The  other  element 
of  the  disease,  the  neurosis,  which  soon  follows  the  initial  catarrh,  and 
seems  to  last  for  an  indefinite  time  after  the  mucous  membrane  has 
regained  its  normal  appearance,  is  also  capable  of  being  controlled  by  the 
use  of  drugs,  especially  belladonna,  chloral,  the  bromides,  and  hydrocyanic 
acid,  not  to  speak  of  the  other  antispasmodics  and  sedatives,  and  by  the 

VOL.  I.— 54 


850  PERTUSSIS. 

analgesic  effect  of  carbonic  acid  gas,  or  by  the  spray  of  bromide  of 
ammonium, .  carbolic  acid,  and  other  substances  upon  the  larynx. 

Vogel  tells  us  in  his  classical  work  on  children,  "  If  now,  as  a  resume", 
I  would  give  an  explanation  of  my  views,  it  would  go  to  show  that  there 
never  has  been,  and  most  probably  never  will  be,  a  remedy  by  which 
whooping  cough  may  be  abridged,  any  more  than  we  are  able  to  cut  short 
the  acute  exanthemata  or  typhus  fever  or  pneumonia."  And  yet  the 
experience  of  many  whom  we  have  quoted  in  this  article  tends  to  support 
the  view  that  by  a  form  of  treatment  calculated  to  act  on  the  two 
elements  of  the  disease  which  we  have  just  noted,  the  affection  can  be 
greatly  modified  in  its  intensity,  and  probably  the  attack  be  somewhat 
shortened.  Certain  it  is  that  the  recent  studies  of  this  disease  give  us 
hope  that  the  day  is  not  far  distant  when  the  cause,  whatever  it  is,  will  be 
definitely  known,  and  if  it  is  found  to  reside  in  the  secretions  from  the 
larynx,  that  treatment  by  inhalation  or  atomization  will  modify  or  destroy 
it,  and  prevent  its  dissemination. 


INFLUENZA. 

BY  JAMES   C.    WILSON,    M.  D, 


DEFINITION. — A  continued  fever,  occurring  in  widely-extended  epidem- 
ics, and  due  to  a  specific  cause ;  it  is  characterized  by  early  catarrh  of  the 
mucous  membrane  of  the  respiratory  tract,  and  in  many  cases  also  of  the 
digestive  tract ;  by  quickly  oncoming  debility  out  of  proportion  to  the  inten- 
sity of  the  fever  and  the  catarrhal  processes ;  and  by  nervous  symptoms. 
There  is  a  strong  tendency  to  inflammatory  complications,  especially  of 
the  lungs.  Uncomplicated  cases  are  rarely  fatal  except  in  feeble  and 
aged  persons.  An  attack  does  not  confer  immunity  from  the  disease  in 
future  epidemics. 

SYNONYMS. — Febris  catarrhalis ;  Defluxio  catarrhalis  epidemicus ; 
Catarrhus  a  contagio ;  Rheuma  epidemicum  ;  Cephalalgia  contagiosa ; 
Epidemic  catarrhal  fever;  Tac;  Horion;  Quinte;  Coqueluche;  Ladendo, 
also  written  La  Dando  ;  Baraquette  ;  G6uerale ;  Coquette  ;  Cocotte  ; 
Allure  ;  Follette  ;  Petite  poste  ;  Petit  courier  ;  Grenade  ;  La  Grippe  ; 
Ziep ;  Schaff husten  and  Schaff krankheit ;  Huhner-Weh ;  Blitz-Katarrh ; 
Modefieber ;  Mai  del  Castrone.  There  are  also  several  names  indicating 
its  supposed  origin ;  thus  it  has  been  called  in  Russia,  Chinese  catarrh ; 
in  Germany  and  Italy,  the  Russian  disease;  in  France,  Italian  fever, 
Spanish  catarrh,  and  so  forth. 

It  is  a  remarkable  fact  that  in  two  instances  at  least  the  popular  name 
for  the  disease  under  consideration  has  found  its  way  widely  into  medicine 
and  medical  literature,  almost  to  the  exclusion  of  the  studied  terms  .by 
which  science  has  sought  to  designate  it;  these  are  influenza  and  la 
grippe. 

Such  obsolete  and  now  meaningless  terms  as  Peripneumonia  notha 
(Sydeuham,  Boerhaave),  Peripneumonia  catarrhalis  (Huxham),  Pleuritis 
humida  (Stoll),  have  been  omitted  from  this  list  of  synonyms  as  being 
of  interest  rather  to  the  student  of  medical  history  than  to  the  student 
of  medicine. 

Febris  catarrhalis,  Defluxio  catarrhalis  epidemicus,  Rheuma  epidemicus 
are  terms  which  no  longer  retain  the  place  given  them  in  the  literature  of 
influenza  by  the  older  medical  authorities. 

Catarrhis  a  contagio  (Cullen)  and  Cephalalgia  contagiosa  are  derived 
from  a  view  of  the  nature  of  the  disease,  which  has  been  the  cause  of  no 
little  controversy. 

Epidemic  catarrhal  fever  is,  with  its  Latin  equivalent,  the  most  satis- 
factory of  the  so-called  scientific  names  by  which  the  disease  is  at  present 
known. 

In  the  popular  names  for  the  affection  there  is  to  be  noted  an  indica- 

851 


852  INFLUENZA. 

tioii  of  the  national  character  of  some  of  the  peoples  who  have  suffered 
from  its  frequent  visitations. 

Among  the  English  it  is  known  as  cold  or  epidemic  cold,  or,  in  defer- 
ence to  medical  authority,  as  catarrh  or  epidemic  catarrh ;  and  at  present, 
both  among  the  folk  and  the  doctors,  as  influenza.  Englishmen  are 
neither  quick  to  see  in  the  disease  a  resemblance  to  some  common  cir- 
cumstance or  thing,  nor  are  they  disposed  to  make  a  joke  about  it. 

The  Germans  find  obvious  resemblances.  In  the  labored  respiration 
and  the  character  of  the  cough  they  find  a  suggestion  of  a  common  epi- 
zootic affecting  the  sheep,  hence  Schaffhusten  and  Shaff krankheit ;  or, 
because  the  cough  is  like  the  crowing  of  a  cock  and  the  disturbance  of 
respiration  and  rapid  prostration  suggest  some  resemblance  to  a  common 
disease  of  the  domestic  fowl,  it  has  been  called  Hulmer-AYeh  (chicken 
disease,  whooping  cough),  and  Ziep,  which  is  about  equivalent  to  pip. 
They  call  it  also,  from  its  rapid  invasion,  Blitz-Katarrh,  and  from  its 
diffusion,  Modefiebcr. 

The  French  are  disposed  to  make  a  jest  of  everything,  and  the  more 
serious  the  subject  the  better  the  joke.  Hence  they  have  found  a  new 
name  for  almost  every  great  epidemic,  and  each  more  trivial  than  the 
last.  Thus,  tac  (rot);  horiou  (in  jest,  a  blow);  qtiinte,  because  the  spells 
occur  at  intervals  of  five  hours  (sic) ;  coqueluche  (a  hood  or  cowl),  from 
the  cap  worn  by  those  suffering  from  the  malady ;  and  so  on  through  the 
long  list  given  above. 

La  grippe  is  said  to  be  derived  from  the  Polish  Chrypka  (Rauceclo) ;  it 
may,  however,  be  derived  from  agripper  (to  seize). 

Influenza  is  of  Italian  derivation.  It  is  said  that  the  disease  received 
this  name  because  it  was  attributed  to  the  influence  of  the  stars,  or  from 
a  secondary  signification  of  the  word  indicating  something  fluid,  transient, 
or  fashionable. 

HISTORICAL  SKETCH.  1 — Epidemics  of  influenza  have  been  clearly 
recorded  only  since  the  beginning  of  the  sixteenth  century.  There  are 
numerous  accounts  of  earlier  epidemic  diseases  resembling  it,  but  they 
are  not  sufficiently  particular  to  warrant  us  in  inferring  its  undoubted 
existence.  It  is  supposed  to  be  referred  to  in  the  writings  of  Hippocrates, 
who,  however,  gives  no  exact  description.2  An  outbreak  in  the  Athenian 
army  in  Sicily  (415  B.C.),  recorded  by  Diodorus  Siculus,  has  been  supposed 
to  have  been  influenza.  Despite  these  statements,  and  those  of  others  to 
the  effect  that  it  is  a  disease  known  from  a  remote  antiquity,  it  may  be 
said  that  no  accounts  can  be  confidently  established,  as  referring  to  the 
to  the  disease  now  known  as  influenza,  in  the  writings  of  classical 
antiquity.* 

As  early  as  the  ninth  century  several  epidemics  of  catarrhal  fever,  Italian 
fever,  and  the  like,  which  were  probably  influenza,  were  made  matter  of  his- 
tory. In  the  year  A.  ix  827  a  cough  which  spread  like  the  plague  was  re- 
corded. In  876  there  appeared  in  Italy  a  similar  epidemic,  which  spread 
with  great  rapidity  over  all  Europe.  It  is  related  that  dogs  and  birds  suf- 
fered with  symptoms  not  unlike  those  characterizing  the  affection  in  man. 
In  97G,  Germany  and  all  France  suffered  from  a  fever  of  which  the  chief 

1  See  also  The  CmUinued  Fevers,  by  the  author  of  this  paper,  New  York,  1881. 

1  Parkes,  Reynold Vs  System  of  Medicine,  vol.  i.,  1868. 

8  Zuelzer,  Ziemasen's  Cyclopaedia  of  Medicine,  vol.  ii.,  1875. 


HISTORICAL  SKETCH.  853 

symptom  was  cough.  No  further  epidemic  is  noted  until  two  centuries 
later,  when,  in  1173,  a  widespread  malady,  of  which  the  symptoms  were 
chiefly  catarrhal,  raged  throughout  Europe;  while  less  important  epi- 
demics of  a  like  character  are  recorded  as  having  occurred  during  the 
following  century  (1239-99). 

In  the  medical  writings  of  the  fourteenth  century  there  are  to  be 
found  records  of  six  epidemics,  and  in  the  fifteenth  seven  great  visita- 
tions of  influenza  are  described  (Parkes). 

Aitkeu l  speaks  of  a  very  fatal  prevalence  of  influenza  throughout  France 
in  1311,  and  of  an  epidemic  in  1403  in  which  the  mortality  was  so  great 
that  the  courts  of  law  in  Paris  were  closed  in  consequence  of  the  deaths. 

Influenza  is  mentioned  in  the  Annals  of  the  Four  Masters  as  having 
prevailed  in  Ireland  in  the  fourteenth  century,  and  a  disease  characterized 
by  similar  symptoms  is  alluded  to  in  early  Gaelic  manuscripts  under  the 
name  of  Creatan  (crcat,  the  chest).  The  disease  is  described  also  in  an 
Irish  manuscript  of  the  fifteenth  century  under  the  terms  Fuacht  and 
Slaodan.2 

The  earliest  epidemic  that  prevailed  in  the  British  Isles  of  which  any 
accurate  description  remains  is  that  of  the  year  1510.  The  disease  came 
from  Malta,  and  invaded  first  Sicily,  then  Italy  and  Spain  and  Portugal, 
whence  it  crossed  the  Alps  into  Hungary  and  Germany  as  far  as  the 
Baltic  Sea,  extending  westward  into  France  and  Britain.  Its  track 
widened  over  the  whole  of  Europe  from  the  south-east  to  the  extreme 
north-west,  and  it  is  said  that  not  a  single  family  and  scarce  a  person 
escaped  it.  It  was  attended  by  a  "  grievous  pain  in  the  head,  heaviness, 
difficulty  of  breathing,  hoarseness,  loss  of  strength  and  appetite,  restless- 
ness, retchings  from  a  terrible  tearing  cough.  Presently  succeeded  a 
chilliness,  and  so  violent  a  cough  that  many  were  in  danger  of  suffocation. 
The  first  day  it  was  without  spitting,  but  about  the  seventh  or  eighth 
day  much  viscid  phlegm  was  spit  up.  Others  (though  fewer)  spat  only 
water  and  froth.  When  they  began  to  spit,  cough  and  shortness  of 
breath  were  easier.  None  died  except  some  children.  In  some  it  went 
off  with  a  looseness,  in.  others  by  sweating.  Bleeding  and  purging  did 
hurt." 3  Blisters  were  commonly  employed — two  each  upon  the  arms 
and  legs,  and  one  to  the  back  of  the  head.  The  description  is  sufficiently 
clear  to  place  the  nature  of  this  epidemic  beyond  all  doubt. 

The  epidemic  of  1557,  starting  westward  from  Asia,  spread  over 
Europe,  and  then  crossed  the  Atlantic  to  America.  The  malady  broke 
out  in  England,  after  a  season  of  unusual  rain  and  great  scarcity  of 
corn,  in  the  mouth  of  September.  "Presently  after  were  many  catarrhs, 
quickly  followed  by  a  more  severe  cough,  pain  of  the  side,  difficulty  of 
breathing,  and  a  fever.  The  pain  was  neither  violent  nor  pricking,  but 
mild.  The  third  day  they  expectorated  freely.  The  sixth,  seventh,  or 
at  the  farthest  the  eighth'  day,  all  who  had  that  pain  of  the  side  died, 
but  such  as  were  blooded  on  the  first  or  second  day  recovered  on  the 
fourth  or  fifth;  but  bleeding  on  the  last  two  days  did  no  service." 
"  Some,  but  very  few,  had  continual  fevers  along  with  it ;  many  had 

1  Aitken's  Practice  of  Medicine,  vol.  i.,  1872. 

2  Theophilus  Thompson,  Annals  of  Influenza,  1852. 

3  Thomas  Short,  A  General  Chronological  History  of  the  Air,  Weather,  Meteors,  etc.,  Lon- 
don, 1749  ;  quoted  in  the  Annals  of  Influenza. 


854  INFLUENZA. 

double  tertians;  others  simply  slight  intermittent.  All  were  worse  by 
night  than  by  day ;  such  as  recovered  were  long  valetudinary,  had  a 
weak  stomach,  and  hypped."  Gravid  women  either  aborted  or  died. 
This  epidemic  spread  with  frightful  rapidity.  Thousands  were  attacked 
at  the  same  time.  The  entire  population  of  Nismes,  with  scarcely  an 
exception,  fell  ill  of  it  upon  the  same  day.  It  was  extremely  fatal.  In 
Mantua  Carpentaria,  a  small  town  near  Madrid,  it  broke  out  in  August, 
and  so  fatal  were  the  bloodletting  and  purging  which  constituted  the 
treatment  at  first,  that,  of  the  two  thousand  persons  who  were  bled, 
all  died.  The  disease  raged  in  some  parts  till  the  middle  of  the  follow- 
ing year  (1558),  and  carried  off,  in  Delft  alone,  five  thousand  of  the 
poor.  In  all  cases  mild  treatment  was  called  for,  with  warm  broths  and 
speedy  immersals,  "  to  recall  the  appetite  and  keep  the  vessels  of  the 
throat  open." 

In  1580  a  great  epidemic  of  influenza  spread  from  the  south-east 
toward  the  north-west  over  Asia,  Africa,  and  Europe.  From  Constan- 
tinople and  Venice  it  overran  Hungary  and  Germany,  and  reached  the 
farthest  regions  of  Norway,  Sweden,  and  Russia.  It  spread  into  England, 
and  has  been  described  by  Dr.  Short.  In  Italy  it  prevailed  during 
August  and  September,  in  England  from  the  middle  of  August  to  the 
end  of  September,  and  in  Spain  during  the  whole  summer.  In  most 
places  its  duration  was  about  six  weeks.  As  a  rule,  the  termination  was 
favorable,  although  the  disease  ran  a  somewhat  protracted  course.  In  the 
account  of  Dr.  Short  it  is  stated  that  "  few  died  except  those  that  were  let 
blood  of  or  had  unsound  viscera."  In  some  places,  on  the  contrary,  the 
course  of  the  disease  was  very  severe.  In  Rome  two  thousand  died  of  it, 
according  to  the  author  just  cited,  but  Zuelzer  informs  us  that  the  victims 
of  this  epidemic  in  the  Eternal  City  were  not  less  than  nine  thousand,  and 
adds  that  Madrid  must  have  been  almost  depopulated  by  it.  This  high 
mortality  has  been  attributed  to  the  bloodletting  practised  in  the  treat- 
ment of  the  disease.  The  symptoms  were  similar  to  those  of  the  previous 
epidemics,  with  a  greater  shortness  of  breath,  which  continued  in  many 
cases  for  some  time  after  the  disappearance  of  the  catarrhal  trouble. 
There  was  great  sweating  at  the  end  of  the  attack.  The  plague,  measles, 
and  small-pox  prevailed  also,  and  with  considerable  violence,  during  the 
year  1580. 

Influenza,  unfelt  for  several  years,  reappeared  in  Germany  in  1591; 
an  epidemic  extending  from  Holland  through  France  and  into  Italy 
occurred  in  1593.  In  1610  catarrh  is  said  to  have  prevailed  throughout 
Europe.  In  1626-27  epidemic  catarrhal  fever  made  its  appearance  in 
Italy  and  France;  in  1642-43  in  Holland;  in  1647  in  Spain  and  in  the 
colonies  of  the  Western  World ;  and  again,  in  1655  in  North  America. 
According  to  Webster,1  this  epidemic  of  1647  was  the  first  catarrh  men- 
tioned in  American  annals. 

In  1658  and  1675  it  again  visited  Austria,  Germany,  England,  etc. 
The  first  of  these  two  epidemics  is  described  by  Willis,2  and  the  second 
by  Sydeuham,3  as  they  occurred  in  England,  and  the  accounts  are  to  be 

1  Noah  Webster,  A  Brief  History  of  Epidemic  and  Pestilential  Diseases,  London,  1800. 

2  Dr.  Willis,  The  Description  of  a  Catarrhal  Fever  Epidemical  in  the  Middle  of  the  Spring 
in  the  Year  1658:  Practice  of  Physick,  1684. 

3  The  Epidemic  Couyhs  of  the  Year  1675,  with  the  Pleurisy  and  Peripneumony  that  super- 
vened: from  the  Works  of  Thomas  Sydenham,  M.  D. 


HISTORICAL  SKETCH.  855 

found  in  the  Annals  o/  Influenza.  It  is  about  this  period  that  the  disease 
began  to  be  known  as  influenza,  and  it  is  not  without  interest  to  observe 
that  the  influence  of  the  stars  suggested  itself,  in  connection  with  its 
sudden  appearance  and  wide  prevalence,  to  the  minds  of  the  physicians 
of  this  date.  Willis  writes  that  "about  the  end  of  April  (1658),  sud- 
denly a  distemper  arose,  as  if  sent  by  some  blast  of  the  stars,  which  laid 
hold  on  very  many  together ;  that  in  some  towns  in  the  space  of  a  week 
above  a  thousand  people  fell  sick  together." 

Epidemics  are  recorded  as  having  occurred  in  Great  Britain  and 
Europe  in  1688,  1693,  and  in  1709.  The  disease  raged  in  1712  widely 
over  Europe  from  Denmark  to  Italy. 

In  1729—30  a  widespread  epidemic  swept  over  Europe.  In  five 
mouths  it  extended  over  Russia,  Poland,  Germany,  Sweden,  and  Den- 
mark. In  Vienna  sixty  thousand  persons  fell  ill  of  it.  In  the  autumn 
it  spread  to  England,  and  reached  France  and  Switzerland ;  from  there 
it  extended  to  Italy,  and  by  February  it  had  reached  Rome  and  Naples. 
Spain  did  not  escape  its  ravages,  and  it  is  said  to  have  found  its  way  to 
Mexico.  The  symptoms  did  not  differ  in  any  important  respect  from 
those  already  described  as  characterizing  previous  epidemics.  Pains  in 
the  limbs  and  fever  marked  the  onset  of  the  attack ;  catarrh,  oppression, 
hoarseness,  cough  followed.  In  some  cases  delirium,  drowsiness,  and 
faintings  occurred.  A  petechial  eruption  was  observed,  in  some  instances, 
between  the  fourth  and  seventh  days.  This  renders  it  probable  that 
typhus  or  cerebro-spinal  fever  prevailed  at  the  same  time.  Turbid  urine, 
copious  sweats,  bilious  stools,  and  nose-bleeding  were  often  noted.  In 
Switzerland  only  children  and  old  persons  died.  The  disease  was  not 
very  fatal. 

Two  years  later  (1732-33)  an  epidemic,  starting  from  Saxony  and 
Poland,  overran  Germany,  Switzerland,  and  Holland,  and  invaded  Great 
Britain  in  the  month  of  December.  Toward  the  end  of  January  it 
spread  in  a  south-easterly  direction  to  France,  Italy,  Spain,  and  westward 
to  North  America,  thence  southward  to  the  islands  of  the  West  Indies, 
and  on  to  South  America.  The  course  of  the  disease  in  this  epidemic  was 
favorable.  The  attack  terminated  in  from  three  to  fourteen  days,  with 
sweating,  bleeding  from  the  nose,  or  an  abundant  discharge  from  the 
nasal  passages.  The  aged  and  those  suffering  from  chronic  pulmonary 
diseases  mostly  perished.  In  Scotland  three  forms  of  the  affection  were 
described — namely,  the  cephalic,  the  thoracic,  and  the  abdominal.  The  epi- 
demic slowly  spread  over  Eastern  Europe  and  in  a  south-easterly  direc- 
tion, and  may  be  said  to  have  lasted  till  1737. 

Concerning  this  epidemic  John  Huxham  of  Plymouth  wrote  as  fol- 
lows :  *  "  About  this  time  a  disease  invaded  these  parts  which  was  the 
most  completely  epidemic  of  any  I  remember  to  have  met  with ;  not  a 
house  was  free  from  it ;  the  beggar's  hut  and  the  nobleman's  palace  were 
alike  subject  to  its  attacks,  scarce  a  person  escaping  either  in  town  or 
country ;  old  and  young,  strong  and  infirm,  shared  the  same  fate."  The 
malady  had  raged  in  Cornwall  and  the  western  parts  of  Devonshire  from 
the  beginning  of  February ;  it  reached  Plymouth  on  the  10th,  which  was 
on  a  Saturday,  and  that  day  numbers  were  suddenly  seized.  The  next 
day  multitudes  were  taken  ill,  and  by  the  18th  or  20th  of  March  scarcely 

1  Observations  on  the  Air  and  Epidemical  Diseases,  translated  from  the  Latin,  London,  1758. 


856  INFLUENZA. 

any  one  bad  escaped  it.  "The  disorder  began  at  first  with  a  slight  shiver- 
ing; this  was  presently  followed  by  a  transient  erratic  heat  and  headache 
and  a  violent  and  troublesome  sneezing ;  then  the  back  and  lungs  were, 
seized  with  flying  pains,  which  sometimes  attacked  the  heart  likewise, 
and  though  they  did  not  long  remain  there,  yet  were  very  troublesome, 
being  greatly  irritated  by  the  violent  cough  which  accompanied  the  dis- 
order, in  the  fits  of  which  a  great  quantity  of  a  thin,  sharp  mucus  was 
thrown  out  from  the  nose  and  mouth.  These  complaints  were  like  those 
arising  from  what  is  called  catching  cold,  but  presently  a  slight  fever  came 
on,  which  afterward  grew  more  violent ;  the  pulse  was  now  very  quick, 
but  not  in  the  least  hard  and  tense  like  that  in  a  pleurisy;  nor  was  the 
urine  remarkably  red,  but  very  thick,  and  inclining  to  a  whitish  color ; 
the  tongue,  instead  of  being  dry,  was  thickly  covered  with  a  whitish 
mucus  or  slime ;  there  was  an  universal  complaint  of  want  of  rest  and  a 
great  giddiness.  Several  likewise  were  seized  with  a  most  racking  pain 
in  the  head,  often  accompanied  by  a  slight  delirium.  Many  were 
troubled  with  a  tinnitus  aurium,  or  singing  in  the  ears ;  and  numbers 
suffered  from  violent  earaches  or  pains  in  the  meatus  auditorius,  which  in 
some  turned  to  an  abscess.  Exulcerations  and  swellings  of  the  fauces 
were  likwise  very  common.  The  sick  were  in  general  very  much  given 
to  sweat,  which,  when  it  broke  out  of  its  own  accord,  was  very  plentiful 
and  continued  without  striking  in  again,  and  did  often  in  the  space  of 
two  or  three  days  wholly  carry  off  the  fever.  You  have  here  a  descrip- 
tion of  this  epidemic  disease  such  as  it  prevailed  hereabouts,  attacking 
everyone  more  or  less;  but  still,  considering  the  great  multitude  that 
were  seized  by  it,  it  was  fatal  to  but  few,  and  that  chiefly  infants  and  con- 
sumptive old  people.  It  generally  went  off  about  the  fourth  day,  leaving 
behind  a  troublesome  cough,  which  was  very  often  of  long  duration,  and 
such  a  dejection  of  strength  as  one  would  hardly  have  suspected  from  the 
shortness  of  the  time. 

"On  the  whole,  this  disorder  was  rarely  mortal,  unless  by  some  very 
great  error  arising  in  the  treatment  of  it ;  however,  this  very  circum- 
stance proved  fatal  to  some,  who,  making  too  slight  of  it,  cither  on 
account  of  its  being  so  common  or  not  thinking  it  very  dangerous,  often 
found  asthmas,  hectics,  or  even  consumptions  themselves,  the  forfeitures 
of  their  inconsiderate  rashness." 

Arbuthnot  also  described  this  visitation  of  the  disease.1  He  regarded 
the  uniformity  of  the  symptoms  in  every  place  as  most  remarkable,  and 
tells  us  that  during  the  whole  season  in  which  it  prevailed  there  was  "  a 
great  run  of  hysterical,  hypochondriacal,  and  nervous  distempers ;  in 
short,  all  the  symptoms  of  relaxation." 

During  the  years  1737-38  influenza  again  swept  over  England,  North 
America,  the  islands  of  the  West  Indies,  and  France;  in  1712—43  it  pre- 
vailed in  Western  Europe  and  the  British  Isles ;  in  1757-58  in  North 
America,  the  West  Indies,  France,  and  Scotland.  In  1761  it  overran  the 
North  American  colonies  and  the  West  Indies. 

The  epidemic  of  1762  extended  very  generally  over  Europe  and  Great 
Britain.  In  Germany  nine-tenths  of  the  population  were  attacked  by  the 
disease. 

Widely  extended  epidemics  prevailed  in  Europe  and  America  in  1767 

1  An  Essay  concerning  the  Effects  of  Air  on  Human  Bodies,  London,  1751. 


HISTORICAL  SKETCH.  857 

and  1775;  in  1772  it  raged  in  North  America;  in  1778-80,  in  France, 
Germany  and  Russia.  Noah  Webster  found  influenza  prevalent  in  North 
America  in  1781 ;  the  next  year  one  of  the  most  remarkable  epidemics 
of  this  disease  (described  as  the  epidemic  of  1782)  appeared  in  Europe. 
It  came  from  the  East,  from  Asia  into  Russia.  From  St.  Petersburg  it 
spread  during  the  winter  and  spring  over  Sweden,  Germany,  Holland, 
and  France.  In  the  autumn  it  was  in  Italy,  Spain,  and  Portugal.  The 
crews  of  Dutch  and  English  ships  were  taken  ill  with  the  disease  upon 
the  high  seas. 

In  Vienna  three-fourths  of  the  population  fell  ill  of  it  with  such  sud- 
denness that  it  got  here  for  the  first  time  its  name  of  "  Blitz  Katarrh  " 
(lightning  catarrh).  It  was  characterized  by  great  pain  in  the  back, 
breast,  and  throat,  and  by  extraordinary  enfeeblement.  Relapses  occurred, 
and  inflammation  of  the  lungs  and  bowels  was  common.  Children  re- 
mained relatively  exempt  from  its  seizure.  This  epidemic  broke  out  in 
England  about  the  end  of  April  and  raged  until  the  end  of  June.  "The 
duration  of  the  malady  in  some  was  not  above  a  day  or  two,  but  it  usu- 
ally lasted  near  a  week  or  longer.  In  a  few  the  symptoms  seemed  to 
abate  in  two  or  three  days,  but  some  returned  and  raged  with  more  vio- 
lence than  at  first."1  The  disease  was  not  regarded  as  in  itself  fatal,  and 
few  could  be  said  to  have  died  of  it  "but  those  Avho  were  old,  asthmatic, 
or  who  had  been  debilitated  by  some  previous  indisposition." 

Numerous  recurring  outbreaks  took  place  in  Europe  and  America  dur- 
ing the  years  1788-90.  One  of  these,  as  it  occurred  in  America,  is  well 
described  by  Dr.  John  Warren2  of  Boston  in  a  letter  to  Lettsom.  This 
letter  is  dated  May  30,  1790,  and  among  other  matters  of  great  interest 
respecting  the  disease  it  is  stated  that  "Our  beloved  President  Washing- 
ton is  but  now  on  the  recovery  from  a  very  severe  and  dangerous  attack 
of  it  in  that  city"  (New  York). 

Webster  mentions  an  epidemic  in  America  in  1790,  one  in  Europe  in 
1795,  and  another  in  Europe  in  1797,  but  there  seems  to  have  been  no 
general  epidemic  of  sufficient  importance  to  attract  the  attention  of  other 
writers  upon  the  subject  until  1798,  when  the  malady  again  broke  out  in 
Russia  and  spread  over  the  greater  part  of  Europe,  continuing  to  prevail 
in  various  regions  till  1803,  when  it  again  appeared  in  England,  and  is 
described  by  several  writers  of  that  country. 

From  1805  to  1827  influenza  prevailed  (according  to  Zuelzer,  who 
tells  us  that  few  years  during  this  interval  were  free  from  it)  in  frequent- 
ly-recurring epidemics  in  Europe  and  America.  Thompson  mentions  no 
visitation  in  England  between  1803  and  1831. 

In  the  year  1830  began  a  series  of  epidemics  remarkable  for  their 
wide  diffusion  and  the  rapid  succession  with  which  they  followed  one 
upon  another.  The  disease  began  in  China;  in  September  it  reached 
the  Indian  Archipelago ;  it  swept  into  Russia,  and  invaded  Moscow  in 
November;  in  January,  1831,  it  was  raging  in  St.  Petersburg;  March 
found  it  in  Warsaw ;  April  in  Eastern  Prussia  and  Silesia;  in  May  it 
prevailed  in  Denmark,  Finland,  and  a  great  part  of  Germany,  and  in 
.471  Amount  of  the  Epidemic  Disease  called  the  Influenza  of  the  Year  1782.  Cullerted  from 

*   *  i      •¥-»»         ••  •         r          _»___        _  __  _i      •         j  I.  _    SY-. . ..  t /.  - .    „    /"T«.~.«~,  *ti  „„    ,,f    iJ.a 


isr 


858  INFLUENZA. 

the  same  month  it  fell  upon  Paris ;  in  June  it  affected  England  and  Swe- 
den ;  it  was  still  creeping  about  Middle  Europe  and  lingering  in  Great 
Britain  at  the  end  of  July ;  in  the  early  winter  it  swept  southward  into 
Italy,  and  westward  across  the  Atlantic  to  North  America,  and  was  still 
harassing  the  inhabitants  of  certain  regions  of  the  United  States  in  Janu- 
ary and  February,  1832.  Meanwhile  it  continued  in  the  East,  spreading 
to  Java,  Farther  India,  and  the  Indian  Archipelago.  It  continued  in 
Hindostan  after  it  had  died  out  in  Europe.  But  in  January,  1833,  it 
again  visited  Russia,  and  rolled  thence  southward  and  eastward  over  the 
most  of  Europe.  It  is  recorded  that  by  February  it  had  reached  Galicia 
and  Eastern  Prussia ;  in  March  it  was  in  Prussia,  Bohemia,  and  War- 
saw, and  had  extended  to  Syria  and  Egypt ;  in  April  to  many  parts  of 
Germany  and  Austria  and  to  France  and  Great  Britain.  Midsummer 
found  the  disease  yet  prevailing  in  some  districts  of  Germany  and  North- 
ern Italy,  and  in  the  early  autumn  it  was  in  Switzerland  and  Eastern 
France;  in  November  it  visited  Naples. 

Epidemics  so  frequent,  so  widespread,  and  so  unsparing  of  individuals 
wherever  the  disease  appeared  could  not  fail  to  excite  a  deep  and  general 
interest.  From  this  period  the  literature  of  the  subject  has  been  volum- 
inous. 

A  brief  period  of  repose  ensued.  For  three  years  no  epidemic 
occurred  which  was  of  sufficient  importance  to  attract  the  attention  of 
medical  historians. 

In  December,  1837,  influenza  reappeared,  and  first,  as  so  often  before, 
in  Russia ;  Sweden  and  Denmark  were  almost  simultaneously  affected  ; 
in  January,  1837,  it  broke  out  in  London,  and  rapidly  swept  over  all 
England  and  into  France  and  Germany.  In  January  it  appeared  in 
Berlin,  and  shortly  afterward  in  Dresden,  Munich,  and  Vienna.  The 
disease  spread  by  February  into  Switzerland,  and  into  Spain  as  far  as 
Madrid  by  the  end  of  March.  In  London  almost  the  whole  population 
was  attacked,  and  the  mortality  was  enormous.  It  is  stated  that  the 
deaths  were  quadrupled  during  the  prevalence  of  the  disease.  Large 
populations  suffered  most.  This  epidemic  spread  into  the  southern  hemi- 
sphere, and  prevailed  at  the  same  time,  and  consequently  at  exactly  thp 
opposite  season  that  it  prevailed  north  of  the  equator,  in  Sydney  and  at 
the  Cape  of  Good  Hope. 

From  1837  to  1850-51  numerous  epidemics  of  influenza  occurred. 
Few  years  were  exempt  from  them.  The  epidemic  of  1847—48  has 
been  described  by  many  writers,  and  more  particularly,  as  it  occurred  in 
London,  by  Peacock1  with  great  exactitude.  It  is  estimated  that  one- 
fourth  of  the  entire  population  of  that  city  were  more  or  less  affected  by 
the  disease.  The  epidemic  prevailed  in  London  for  six  months,  and, 
although  the  deaths  registered  for  the  entire  period  as  from  influenza 
amounted  to  only  1739,  it  is  stated  in  the  report  of  the  registrar-general 
that  during  the  six  weeks  the  epidemic  was  at  its  height  not  less  than 
five  thousand  persons  died,  in  the  metropolitan  districts,  in  excess  of  the 
average  mortality  of  the  period,  the  excess  showing  itself  in  nearly  every 
class  of  disease,  the  local  maladies  which  had  been  the  predominant  affecr 
tions  being  doubtless  in  many  cases  assigned  as  the  cause  of  death.  This 

1  On  the.  Influenza,  or  Epidemic  Catnrrhal  Fever  of  18Ll-lf8.  Thomas  Berill  Peacock. 
M.  D.,  1848. 


ETIOLOGY.  859 

epidemic  affected  between  one-fourth  and  one-half  of  the  population  of 
Paris,  and  in  Geneva  the  proportion  of  those  attacked  was  not  less  than 
one-third  of  the  entire  population. 

More  or  less  widespread  epidemics  of  influenza  are  recorded  as  havino1 
occurred  in  1857-58  and  1860;  in  1864  in  Switzerland;  in  1867  in 
Paris  in  the  spring;  and  at  various  times  in  the  United  States  and 
Canada. 

A  mild  epidemic  occurred  in  1874  in  Berlin. 

Influenza  prevailed  over  a  wide  area  in  the  United  States  during  the 
early  months  of  1879.  The  characteristics  of  this  visitation  have  been 
well  described  by  Da  Costa.1 

The  disease,  since  the  great  epidemic  of  1847-48,  has  affected  a  smaller 
proportion  of  the  inhabitants  of  the  localities  visited,  and  has  run  a  less 
dangerous  course,  than  in  the  earlier  epidemics.  It  has  for  this  reason 
occupied  a  less  conspicuous  place  in  the  medical  literature  of  recent  years. 
It  is  nevertheless  true  that  even  in  the  mildest  epidemics,  when  a  rela- 
tively small  number  of  persons  are  seized  and  the  symptoms  are  in  most 
cases  almost  insignificant,  cases  do  here  and  there  occur  which  are  of  a 
serious  or  even  fatal  character,  and  that  the  death-rate  from  other  diseases 
is  for  the  time  considerably  increased. 

Catarrhal  affections  have  often  prevailed  among  the  domestic  animals 
when  influenza  has  been  epidemic.  Horses,  dogs,  and  cats  are  subject 
to  these  disorders  ;  neat  cattle,  goats,  and  sheep  have  been  less  commonly 
affected ;  chickens  and  pheasants  have  suffered,  and  it  is  stated  by  some 
of  the  older  writers  that  birds,  and  particularly  the  sparrow,  have 
deserted  localities  in  which  influenza  was  prevailing,  and  that  migra- 
tory birds  have  taken  flight  earlier  than  usual. 

These  epizootics  have  sometimes  preceded  the  appearance  of  influenza 
among  men  by  a  period  of  some  weeks  or  days ;  in  other  instances  they  have 
appeared  at  the  same  time ;  and  in  a  widespread  outbreak  among  horses 
in  the  United  States  in  1872,  in  which  the  symptoms  and  morbid  anat- 
omy, accurately  observed,  were  undoubtedly  those  of  influenza,  the  dis- 
ease did  not  affect  man  except  to  a  very  limited  extent.  A  want  of 
fulness  of  description,  and  the  inaccuracy  of  diagnosis  too  common  in 
the  consideration  of  the  general  diseases  of  the  lower  animals,  leave  the 
precise  nature  of  most  of  the  epizootics  descrijbed  by  the  earlier  writers 
doubtful. 

An  extensive  influenza  of  moderate  intensity  prevailed  as  an  epizootic, 
chiefly  affecting  horses,  during  the  latter  part  of  the  summer  and  the  autumn 
of  1 880  in  Canada  and  the  United  States  east  of  the  Mississippi  River.  Dogs 
were  also  affected,  but  less  generally,  and  human  beings  to  a  still  slighter 
extent.  In  several  localities  where  this  invasion  was  observed  by  the 
writer  the  horses  were  first  affected,  the  dogs  next,  and  after  the  lapse  of 
some  weeks,  as  the  animals  were  recovering,  the  disease  became  epidemic ; 
but  those  persons  who  took  care  of  horses  and  were  much  in  contact 
with  them  rfeither  suffered  earlier  nor  more  severely  than  others  not  so 
exposed. 

ETIOLOGY. — 1.    Predisposing   Influences. — There  are  no  well-estab- 

1  "The  Prevailing  Epidemic  of  Influenza— Its  Characteristic  Phenomena— Pulmonary, 
Gastro-intestinal,  Cerebral,  and  Nervous — Its  Wide  Distribution,  Mortality,  and  Treat- 
ment," Medical  and  Surgical  Reporter,  Philadelphia,  March  8,  1879. 


860  INFLUENZA. 

lished  facts  pointing  to  the  existence  of  individual  peculiarities  that  can 
be  regarded  as  predisposing  influences.  When  the  disease  appears  a  large 
proportion  of  the  population  is  attacked  without  distinction  of  age,  sex, 
social  condition,  or  occupation.  Previous  illness,  whether  acute  or 
chronic,  local  or  constitutional,  affords  no  protection.  Aged  and  infirm 
persons  and  those  of  nervous  temperament  are  peculiarly  liable  to  attack, 
but  the  robust  possess  no  immunity.  All  races  and  dwellers  in  every 
climate  are  the  victims  of  influenza.  In  a  community  invaded  by  the 
disease  females  are  apt  to  be  the  first  attacked,  adult  males  next,  and 
children  last.  It  has  been  observed  that  in  some  epidemics  children  are 
but  little  liable  to  contract  the  disease. 

An  attack  confers  no  exemption  from  the  disease  in  another  epidemic, 
and  independently  of  relapses,  which  are  not  infrequent,  persons  have 
been  known  to  experience  a  second  attack  during  the  prevalence  of  the 
same  epidemic. 

Persons  dwelling  in  overcrowded  and  ill-ventilated  habitations  and  in 
low,  damp  and  unhealthy  situations  have,  in  certain  epidemics,  especially 
suffered,  and  the  increase  of  deaths  by  influenza  is  proportionately  much 
greater  in  districts  in  which  there  is  ordinarily  a  high  mortality  than  in 
healthier  places. 

Influenza  appears  at  all  seasons  of  the  year  and  affects  the  inhabitants 
of  every  latitude.  It  has  no  connection  with  known  atmospheric  condi- 
tions. Many  of  the  earlier  writers  sought  to  establish  a  relation  between 
low  temperatures  and  sudden  variations  of  temperature  and  influenza,  and 
by  reason  of  the  confusion  among  the  people  between  these  diseases  and 
common  "colds"  there  has  always  existed  an  opinion  that  such  a  relation 
obtains.  There  is,  however,  no  evidence  to  sustain  this  view;  neither 
low  temperature  nor  abrupt  changes  give  rise  to  the  affection.  It  has 
prevailed  in  hot  and  dry  seasons,  in  the  West  Indies,  on  the  coast  of  Java, 
in  India,  in  Egypt,  at  the  Cape  of  Good  Hope,  on  the  Ilivcira  in  summer. 

The  condition  of  the  air  as  regards  moisture,  or  dryncss,  docs  not  in- 
fluence the  spread  of  the  disease.  It  has  occurred  at  sea,  on  low  sea- 
coasts,  and  in  the  dryest  climates,  as,  for  example,  in  Upper  Egypt. 

Its  spread  is  not  much  influenced  by  local  winds.  It  does  not  travel 
with  the  same  velocity,  and  even  sometimes  advances  against  them.  In 
several  well-authenticated  instances  a  dense  and  foul  fog  has  preceded  and 
attended  the  local  outbreak  of  epidemics.  The  much  greater  number  of 
epidemics  that  have  occurred  altogether  without  such  manifestations  make 
it  in  a  high  degree  probable  that  this  has  been  a  coincidence.  Ozone  in 
large  quantities  artificially  produced  may  give  rise  to  the  symptoms  of 
ordinary  catarrh,  but  it  is  not  a  cause  of  influenza.  The  disease  is  not  in 
any  way  connected  with  the  condition  of  the  soil,  elevation,  volcanic 
eruption,  or  any  other  local  <"ause.  The  history  of  every  epidemic  may  be 
adduced  in  proof  of  this  statement. 

Before  taking  up  the  consideration  of  the  exciting  causes  of  influenza, 
it  is  important  to  review  the  known  facts  concerning  the  march  of  epidemics 
and  the  spread  of  the  disease  in  affected  localities.  It  has  prevailed  with 
greater  or  less  frequency  in  almost  every  region  of  the  globe.  Epidemics 
recur  at  irregular  periods.  It  was  at  one  time  suppose!  that  the  course  of 
the  disease  was  cyclical,  with  a  return  at  intervals  of  about  one  hundred 
years.  This  view  was  long  ago  proved  to  be  unfounded.  About  every 


ETIOLOGY.  861 

twenty-five  or  thirty-five  years  great  epidemics  have  swept  over  vast 
areas  of  the  globe,  and  influenza  may  be  said  to  be,  at  such  times,  pan- 
demic. Less-widely  extended  epidemics  have  taken  place  with  greater  or 
less  frequency  in  the  intervals  between  the  great  outbreaks.  But  it  is  not 
possible  to  establish  anything  like  a  regular  periodicity  in  the  returns 
of  the  disease. 

It  has  been  supposed  in  some  instances  to  prevail  within  restricted 
localities,  as,  for  example,  in  a  single  city.  Such  local  epidemics  are  with- 
out doubt  due  to  local  causes,  and  are  of  the  nature  of  simple  ordinary 
catarrhal  fever,  rather  than  true  influenza. 

The  epidemics  have  extended  over  great  areas,  usually  in  a  direction 
from  the  east  or  north-east  toward  the  west  and  south.  At  other  times 
they  take  the  opposite  course,  and  in  some  years  they  have  appeared  to 
radiate  in  various  directions  from  several  centres.  It  is  in  consequence 
of  these  facts  that  two  views  have  arisen  concerning  the  origin  of  the 
affection.  The  first  of  these  is,  that  each  epidemic  starts  out  from  some 
single  unknown  source,  and  spreads  thence  from  point  to  point,  invading 
more  distant  localities  successfully  as  it  advances,  until  at  length  it  dies 
out  in  regions  remote  from  the  starting-point.  This  opinion  is  in  accord 
with  the  popular  belief.  Thus,  the  Italians  have  called  it  the  German 
disease;  the  Germans,  the  Russian  pest;  the  Russians,  the  Chinese  catarrh. 
The  geographical  relation  of  these  nations  indicates  the  usual  track  of  the 
great  epidemics,  as  shown  in  the  foregoing  historical  sketch.  The  other 
opinion  is,  that  it  arises  not  from  some  single  particular  place,  but  that  it 
may  start  anywhere,  and  that  widespread  epidemics  are  due  to  the  suc- 
cessive outbreaks  of  the  disease  at  many  distinct  points  of  origin. 

The  evidence  that  the  great  epidemics  of  influenza  are  due  to  some 
general  and  pandemic  influence  is  conclusive.  The  point  of  origin  of  the 
great  epidemics  has  not  yet  been  indicated  with  precision,  and  must 
remain  beyond  conjecture  until  further  facts  bearing  upon  the  question 
of  their  source  are  brought  to  light.  When  it  has  prevailed  over  a  large 
portion  of  the  earth's  surface  its  progress  from  place  to  place  has  usually 
been  rapid.  In  this  respect,  however,  the  epidemics  show  a  great  diver- 
sity. It  sometimes  travels  exceedingly  slowly.  It  is  said  to  have  overrun 
Europe  in  six  weeks,  and  it  has  again  taken  six  months  to  do  so.  It 
sometimes  attacks  places  widely  remote  from  each  other  within  short 
intervals  of  time,  and  it  has  appeared  at  the  same  time  in  different  quarters 
of  the  globe.  It  does  not  follow  the  great  lines  of  travel  and  commercial 
intercourse. 

When  influenza  enters  a  city  it  continues  to  prevail,  as  a  rule,  from 
four  weeks  to  two  months,  but  exceptionally  it  remains  a  longer  time; 
for  example,  the  epidemic  of  1831  was  prevalent  in  Paris  for  the  greater 
part  of  the  year.  It  in  all  instances  finally  disappears,  and  sporadic  cases 
do  not  occur  in  the  intervals  between  the  epidemics. 

In  rare  instances  the  epidemics  are  heralded  by  scattered  cases.  But 
as  a  rule  this  disease  attacks  simultaneously  great  numbers  of  the 
inhabitants  of  affected  districts,  so  that,  when  the  epidemics  severe,  the 
sick  are  in  a  short  time  to  be  counted  by  thousands  and  business  is  para- 
lyzed as  by  a  blow.  Epidemics  rapidly  reach  their  height,  and  subside 
almost  as  suddenly  as  they  began.  In  a  large  city  the  disease  frequently, 
perhaps  always,  makes  its  appearance  nearly  at  the  same  time  in  several 


862  INFLUENZA. 

different  localities,  affecting  certain  streets  and  quarters  solely  or  more 
generally  than  others  for  a  time,  and  spreading  thus  from  several  centres 
through  the  entire  community.  Large  towns  and  cities  are  generally 
affected  earlier  than  the  villages  around  them,  and  the  latter,  though 
closely  adjacent,  sometimes  escape  for  weeks.  The  crews  of  ships  upon 
the  high  seas,  not  sailing  from  an  infected  port,  are  said  to  have  suffered 
from  the  seizure,  and  epidemics  have  many  times  crossed  the  Atlantic 
from  the  Old  World  to  the  New,  and  more  than  once  in  the  opposite 
direction. 

2.  The  Exciting  Cause. — Large  as  has  been  the  place  in  medical  litera- 
ture occupied  by  the  histories  of  epidemics  of  influenza,  the  nature  of  the 
"  epidemic  influence "  which  gives  rise  to  the  disease  is  still  unknown. 

The  question  of  the  contagiousness  of  influenza  is  one  of  grave  interest, 
and  has  been  the  subject  of  much  controversy.  The  great  rapidity  of  the 
spread  of  epidemics,  the  vast  area  they  overrun,  the  fact  that  they  do  not 
follow  the  lines  of  human  intercourse,  the  suddenness  with  which  great 
numbers  of  the  inhabitants  of  an  invaded  district  or  city  are  seized,  the 
fact  that  the  most  complete  seclusion  from  intercourse  with  affected 
persons,  or  even  the  shutting  up  of  houses,  affords  in  most  instances  no 
protection  whatever, — all  go  to  show  that  the  disease  spreads,  in  the  main, 
independently  of  direct  contact.  This  opinion  has  been  almost  universally 
entertained.  There  is  evidence,  however,  to  show  that  the  disease  is  to 
some  extent  contagious ;  and  so  convincing  have  the  facts  bearing  upon 
this  point  appeared  to  some  that  they  have  believed  it  to  be  propagated 
entirely  by  human  intercourse.  Haygarth1  declares,  as  the  result  of  his 
observations  during  the  epidemics  of  1775  and  1782,  that  the  influenza 
spreads  "  by  the  contagion  of  patients  in  the  distemper ;"  and  Falconer,2 
writing  of  the  epidemic  of  1803,  says,  "I  have  no  doubt  that  it  is  con- 
tagious in  the  strictest  sense  of  the  Mrord."  Watson3  regards  the  instances 
in  which  the  complaint  has  first  broken  out  in  those  particular  houses  of 
a  town  at  which  travellers  have  arrived  from  infected  places  as  too  numer- 
ous to  be  attributed  to  mere  chance.  Very  often  those  dwelling  near  the 
invalids  are  attacked  next  in  the  order  of  time,  and  when  the  disease 
affects  a  household  all  do  not  usually  manifest  the  symptoms  at  the  same 
time,  but  one  member  after  another  is  stricken  down  with  it. 

In  a  few  rare  cases  the  isolation  or  seclusion  of  a  community  has 
appeared  to  give  protection,  as  in  cloisters,  prisons,  garrisons,  and  the 
like ;  at  all  events,  there  are  instances  on  record  where  segregated  com- 
munities of  this  kind  have  escaped  attack. 

The  following  observation,  conducted  under  unusual  circumstances, 
establishes  the  fact  that  influenza  may  be  brought  from  an  infected  city  in 
such  a  way  as  to  give  rise  to  a  localized  outbreak  in  a  remote  community. 
Drs.  Guiteras  and  White4  narrate  that,  influenza  prevailing  in  Europe, 
and  particularly  in  Paris  and  London,  an  American  gentleman  in  bad 
health  contracted  the  disease  in  London,  improved,  suffered  a  relapse 

1  John  Haygarth,  M.  D.,  F.  E.  S.,  On  the  Manner  in  which  the  Influenza  of  1775  and  1782 
spread  by  Contagion  in  Chester  and  its  Neighborhood. 

*  William  Falconer,  M.  D.,  F.  E.  S.,  An  Account  of  the  Epidemic  Catarrhal  Fever,  com- 
monly called  the  Influenza,  as  it  appeared  at  Bath  in  the  Winter  and  Spring  of  the  Year  1S03, 
Bath,  1803.  3  Principles  and  Practice  of  Medicine. 

4  John  Guiteras,  M.  D.,  and  J.  W.  White,  M.  D.,  "A  Contribution  to  the  History  of 
Influenza,  being  a  Study  of  a  Series  of  Cases,"  Philadelphia  Medical  Times,  April  10,  1880. 


ETIOLOGY.  863 

shortly  afterward  in  Paris,  and  died  there  at  the  end  of  December,  1 879. 
His  body  was  embalmed  and  sent  home.  Following  the  exposure  of  the 
remains  of  this  person  to  the  view  of  his  family  in  Philadelphia  there  was 
an  outbreak  of  influenza  with  characteristic  symptoms,  which  affected,  in 
the  first  place,  members  of  that  family ;  afterward,  friends  living  in  close 
intercourse  with  them ;  next,  the  medical  attendant  of  some  of  them ;  and 
finally,  the  housekeeper  and  a  patient  or  two  of  one  of  the  physicians  who 
wrote  the  paper,  the  whole  number  affected  in  Philadelphia  being  eighteen 
at  the  time  of  the  publication  of  the  account.  Subsequently  two  or  three 
other  cases  were  developed,  but  the  disease  did  not  extend  beyond  the 
immediate  circle  of  those  in  direct  communication  with  the  invalids. 

It  was  at  one  time  thought  that  influenza  developed  at  once,  without 
a  period  of  incubation,  persons  in  perfect  health  being  struck  down  with 
it  as  by  lightning-stroke.  It  is,  however,  now  known  that  a  period  of 
incubation,  varying  from  a  few  hours  to  several  days,  and  usually  without 
subjective  symptoms,  exists.  Many  instances  are  recorded  in  which  per- 
sons coming  into  an  infected  city  have  remained  well  for  one,  two,  or 
three  days,  but  have  eventually  shared  the  sufferings  of  those  into  whose 
midst  they  have  come.  There  are  cases  also  in  which  the  period  of  incu- 
bation could  not  have  been  less  than  two  or  three  weeks. 

There  is  no  sufficient  evidence  of  a  causal  relation  between  influ- 
enza and  any  other  epidemic  disease.  The  statement  that  other  prev- 
alent diseases  abate  in  frequency  and  intensity  upon  its  outbreak  is 
not  sustained  by  well-observed  facts.  Graves l  holds  that  those  suffering 
with  acute  diseases  are  less  liable  during  the  febrile  stage,  but  that  they 
are  attacked  as  convalescence  sets  in. 

The  facts  in  reference  to  the  spread  of  epidemics  of  influenza  and  the 
course  of  the  disease  in  infected  localities  are  comprehensible  upon  no 
other  theory  than  that  of  a  specific  infecting  principle  as  its  exciting 
cause.  What  this  principle  may  be  is  not  yet  known ;  where  it  originates 
is  equally  unknown  ;  and  our  knowledge  of  the  influences  that  from  time 
to  time  call  it  into  activity  and  send  it  forth  in  definite  directions  over 
the  earth  is  no  less  negative. 

So  general  a  disease  can  only  be  disseminated  by  the  most  general 
medium,  the  atmosphere,  and  its  exciting  cause  must  be  capable  of  repro- 
ducing itself  in  that  medium,  otherwise  it  would  be  lost  by  dispersion  in 
traversing  distances  measured  by  the  boundaries  of  continents  and  oceans. 
The  rapid  diffusion  of  influenza,  sweeping  over  continents  in  a  few  weeks 
at  one  time,  its  slow  migration,  creeping  about  a  city  and  its  environs  for 
months,  at  another,  are  to  be  most  easily  explained  upon  the  theory  of  a 
living  miasm  capable  of  being  transmitted  by  the  air,  and  possessing  at 
the  same  time  an  independent  existence.  Such  an  entity  would  find  cer- 
tain localities  more  favorable  to  its  growth,  reproduction,  and  prolonged 
existence  than  others.  From  this  point  of  view  influenza  is  a  miasmatic 
disease.  The  infecting  principle  of  this  disease  is  also,  to  a  slight  extent, 
capable  of  being  reproduced  in  or  about  the  human  body  and  transmitted 
by  personal  intercourse,  as  well  as  conveyed  from  place  to  place  by  the 
persons  or  clothing  of  those  affected  or  those  travelling  from  localities  in 
which  the  disease  prevails.  We  are  thus  led  to  the  conclusion  that  it  is 
also  contagious,  though  feebly  so. 

1  Clinical  Medicine. 


364  INFLUENZA. 

CLINICAL  HISTORY. — Influenza,  in  individual  cases,  presents  the 
greatest  variation  as  regards  intensity,  from  the  most  trifling  indisposi- 
tion to  an  illness  of  the  gravest  kind,  terminating  in  death.  These 
variations  are  dependent  upon — 1st,  the  previous  health  of  the  indi- 
vidual, his  age,  and  the  power  of  resisting  depressing  influences  which  he 
possesses ;  2d,  the  energy  and  the  amount  of  the  specific  cause  of  the 
oisease  to  which  he  has  been  exposed — in  other  words,  the  dose  of  the 
fever-producing  poison ;  and  3d,  the  character  of  the  prevailing  epidemic. 

It  is  important  to  observe  that  cases  of  very  great  severity  are  occa- 
sionally encountered  during  the  prevalence  of  mild  epidemics.  In  every 
epidemic,  on  the  contrary,  a  considerable  part  of  the  community  suffers 
from  influenza  in  the  mildest,  or  what  has  been  called  the  rudimentary, 
form.  This  is  characterized  by  general  malaise,  an  easily  oncoming 
weariness  upon  bodily  and  mental  effort,  a  disinclination  for  business, 
some  inability  to  fix  the  attention,  and  slight  mental  confusion ;  to  these 
nervous  disturbances  are  added  catarrhal  symptoms,  as  coryza,  sore 
throat,  a  tickling  cough,  and  the  like ;  but  the  indisposition  is  subfebrile 
— it  does  not  amount  to  a  fully-developed  fever.  Other  cases  present  the 
symptoms  of  an  ordinary  attack  of  acute  coryza,  laryngitis,  bronchitis, 
pharyngitis,  with  unusual  constitutional  disturbance,  distressing  headache, 
and  pains  in  the  back  and  limbs.  The  fever  in  this  class  of  cases  does 
not  range  high,  yet  the  patients  are  ill  enough  to  betake  themselves  to 
bed. 

In  severe  cases  the  onset  is  usually  abrupt.  The  attack  begins  with 
shivering  or  a  chill,  or  with  fits  of  chilliness  alternating  with  heat. 
Fever  is  rapidly  established.  It  is  usually  moderate ;  sometimes  it 
reaches  a  high  grade.  It  shows  a  tendency  to  morning  remissions. 
Sensations  of  chilliness  occur ;  they  are  called  forth  by  slight  changes  in 
the  external  temperature.  They  are  often  followed  by  flushes  of  heat, 
and  are,  in  many  cases,  attended  by  annoying  sweats.  The  febrile  out- 
break is  sometimes  preceded  by  intense  frontal  headache,  with  pain  in  the 
orbits  and  at  the  root  of  the  nose.  In  other  cases  these  pains  quickly 
follow  the  chill.  Sneezing,  redness  of  the  eyes  and  edges  of  the  nostrils, 
a  more  or  less  abundant  thin  discharge  from  the  nose,  and  lachrymation, 
now  occur.  In  some  instances  there  is  bleeding  from  the  nose.  The 
throat  becomes  sore;  there  is  a  tickling  sensation  in  the  upper  air- 
passages  ;  a  dry  cough  sets  in,  attended  by  more  or  less  hoarseness  and 
shortness  of  breath.  The  cough  is  paroxysmal,  hard,  distressing.  It 
sometimes  causes  vomiting,  like  that  which  occurs  in  the  paroxysms  of 
whooping  cough.  Chest-pains,  stitches  in  the  side,  frequent  sneezing,  loss 
of  the  sense  of  smell  and  of  taste,  attend  the  development  of  the  general 
catarrhal  manifestations. 

The  fever  is  attended  by  great  depression,  pains  in  the  limbs,  loss  of 
appetite,  thirst,  constipation,  and  diminished  secretion  of  urine.  The 
pulse  is  full,  but,  as  a  rule,  only  moderately  increased  in  frequency. 
There  is  in  many  cases  slight,  or  even  decided,  blueness  of  the  lips  and 
finger-tips.  The  patient  is  distressed  by  restlessness  and  want  of  sleep. 
At  the  end  of  four  or  five  days  the  febrile  symptoms  decline,  at  times 
gradually,  oftener  rapidly,  with  copious  sweats  or  spontaneous  flux  from 
the  bowels.  The  fever  continues,  however,  when  severe  complications 
have  taken  place,  ten  or  twelve  days.  The  defervescence  is  marked  by 


SYMPTOMATOLOGY.  865 

an  increased  flow  of  sedime  Mary  urine  and  considerable  amelioration  of 
the  subjective  symptoms.  The  catarrlial  symptoms  outlast  the  fever  two 
or  three  days,  but  cough  and  expectoration  may  not  disappear  for  some 
time. 

With  these  symptoms  are  associated  the  evidences  of  functional  dis- 
turbance of  the  nervous  system.  There  is  remarkable  nervous  depres- 
sion ;  loss  of  strength  and  lowness  of  spirits  are  combined  with  mental 
weakness,  or  even  stupor  and  delirium.  In  some  cases  slight  convulsions 
take  place/  Cutaneous  liypersesthesia  occasionally  occurs,  and  areas  of 
burning  pain  in  the  skin  are  to  be  met  with.  Neuralgia,  muscle-pain, 
and  aching  referred  to  the  bones  are  very  common  and  often  severe. 

In  other  cases  abdominal  symptoms  are  prominent,  while  those  refer- 
able to  the  head  and  chest  are  less  urgent.  The  disease  assumes  the  guise 
of  a  more  or  less  severe  catarrh  of  the  gastro-enteric  mucous  membrane, 
with  disturbance  of  the  functions  of  the  liver.  .The  fever  and  the 
peculiar  nervous  depression  are,  however,  the  same.  Cases  likewise  pre- 
sent themselves  in  which  but  little  of  the  usual  tendency  to  localization 
of  the  catarrlial  processes  is  to  be  observed ;  there  is  fever  of  varying 
intensity,  with  great  depression,  and  simultaneous  and  equal  implication 
of  the  head  and  the  organs  of  the  chest  and  abdomen. 

Many  writers  have  sought  to  arrange  the  foregoing  different  forms  of 
influenza  in  definite  categories.  It  would  be  a  useless  task  to  reproduce 
their  views  upon  the  subject,  or  even  to  enumerate  the  varieties  that  have 
been  described.  In  practice,  the  various  described  types  merge  so  gradu- 
ally into  each  other,  and  are  so  modified  by  the  individual  peculiarities 
of  the  sick,  and  by  the  complications  which  arise  in  the  course  of  the 
attack  iii  consequence  of  such  peculiarities  or  of  previously  existing 
diseases  or  tendencies  to  special  forms  of  disease,  that,  in  point  of  fact, 
particular  cases  cannot  usually  be  referred  to  theoretical  categories. 
Hysterical  persons  and  those  of  a  nervous  constitution  are  prone  to  suffer 
especially  from  the  peculiar  nervous  symptoms  of  influenza.  The  disease 
is  also  modified  by  the  age  of  the  subject  of  the  attack ;  children  manifest 
in  a  high  degree  the  signs  of  cerebral  congestion,  while  old  persons  are 
subject  in  a  peculiar  manner  to  dangerous  pulmonary  complications,  and 
those  of  a  gouty  or  rheumatic  constitution  suffer  more  than  others  from 
muscular  pains. 

The  duration  of  the  mildest  form  of  influenza  is  from  two  to  three 
days ;  in  well-developed  cases  without  complications  convalescence  sets  in 
between  the  fourth  and  tenth  days ;  while  severe  cases  with  complica- 
tions last  much  longer,  several  weeks  often  elapsing  before  recovery  is 
complete. 

SYMPTOMATOLOGY. — ANALYSIS  OF  THE  SYMPTOMS. — For  the  purpose 
of  separate  consideration  it  is  convenient  to  take  up  the  symptoms  belong- 
ing to  the  fever  first,  then  those  of  the  special  catarrh,  and  finally  those 
more  particularly  referable  to  the  nervous  system ;  but  we  encounter  in 
the  present  state  of  our  knowledge  of  the  pathology  of  influenza — or  our 
ignorance  of  its  pathology — no  little  difficulty  in  deciding  under  which 
of  these  headings  particular  symptoms  are  properly  to  be  classed,  by 
reason  of  the  close  interdependence  of  the  chief  processes  of  the  disease 
and  the  anomalies  of  its  phenomena  viewed  as  a  whole. 

The  Fever. — The  fever  is  of  the  sub-continuous  or  remittent  type, 

VOL.  I.— 55 


866  INFLUENZA. 

but  its  range  is  very  irregular.  Irregularity  of  temperature  is  character- 
istic of  influenza  and  may  assume  diagnostic  importance. 

The  intensity  of  the  fever  is  variable.  As  a  rule,  it  is  moderate  or 
slight ;  occasionally  it  is  severe.  I  observed  in  several  cases  during  the 
epidemic  of  1879  in  Philadelphia  an  evening  temperature  of  only  39°  C. 
(102.2°  F.).  Da  Costa  in  the  same  outbreak  found  the  febrile  movement 
not  high;  the  highest  temperature  he  observed  was  40°  C.  (104°  F.). 
Biermer  found  a  temperature  of  over  39°  C.  in  moderate  cases  of 
catarrhal  fever,  and  does  not  doubt  that  under  certain  transient  con- 
ditions the  temperature  may  reach  the  height  of  that  of  pneumonia  or 
typhus.  In  weakly  persons  and  the  aged  the  fever  is  adynamic. 

The  pulse  has  no  constant  characters.  Its  frequency  is  moderately 
increased ;  it  is  apt  to  be  less  forcible  than  in  health,  is  generally  com- 
pressible, sometimes  full,  often  irregular,  changing  in  character  in  the 
course  of  a  few  hoars. 

The  urine  is  usually  diminished ;  sometimes  its  secretion  is  temporarily 
suppressed ;  as  a  rule,  it  shows  little  change,  and  is  rarely,  as  in  other 
fevers,  concentrated  and  high-colored.  It  deposits  on  cooling  a  sediment 
of  urates,  which  toward  the  close  of  the  fever  is  often  very  abundant. 
The  defervescence  is  in  many  instances  attended  by  a  copious  secretion 
of  urine.  Albumen  is  not  present  except  as  a  result  of  some  compli- 
cation. 

At  first  the  skin  is  hot  and  dry;  later,  frequent  sweats  occur;  sweating 
generally  attends  the  febrile  remissions  and  the  defervescence  not  rarely  sets 
in  with  copious,  acid,  ill-smelling  sweats.  In  some  cases  a  tendency  to 
sweat  shows  itself  early  and  continuous  throughout  the  attack.  Sudamina 
occur  in  great  numbers. 

The  face  is  often  flushed,  and  irregular  mottliugs  of  the  skin,  espe- 
cially upon  the  neck  and  chest,  have  been  frequent  in  some  of  the  epi- 
demics. An  outbreak  of  herpes  about  the  lips  is  occasionally  seen. 

Disturbances  of  the  digestive  tract  are  more  or  less  prominent  in 
almost  all  cases.  Only  in  a  rudimentary  and  sub-febrile  form  are  they 
absent.  In  many  cases  they  are  such  as  are  usually  seen  in  febrile  dis- 
orders— namely,  loss  of  appetite,  thirst,  impaired  taste,  pasty  tongue, 
tenderness  in  the  epigastrium,  and  constipation.  Nausea  and  vomiting 
sometimes  usher  in  the  attack.  In  other  cases  (the  so-called  abdominal 
form)  all  the  above  symptoms  are  more  severe,  and  diarrhoea,  colicky 
pains,  and  vomiting  are  superadded.  In  certain  epidemics  the  intestinal 
catarrh  has  shown  a  tendency  to  run  into  dysentery. 

The  expression  of  the  countenance  is  changed,  in  part  by  the  appear- 
ance characterizing  an  ordinary  attack  of  coryza  of  considerable  or  great 
severity,  and  in  part  by  anxiety  and  depression.  It  is  pale.  Where  the 
pulmonary  catarrh  is  excessive  and  dyspnoea  great  the  lips  become 
bluish.  The  facies  sometimes  suggests  that  of  typhoid  fever. 

The  Catarrh. — A  more  or  less  extensive  hyperaemia  of  the  mucous 
membrane  of  the  respiratory  tract  is  invariably  present,  and  may  be  said 
to  characterize  the  disease. 

There  is  cold  in  the  head,  more  severe  in  most  cases  than  ordinary 
simple  coryza.  The  eyelids  are  swollen  and  reddened,  there  is  laclirvma- 
tion,  sneezing  is  frequent,  and  the  discharge  from  the  nose  is  abundant. 
Epistaxis  is  not  rare.  Sore  throat,  with  tickling  sensations  and  difficulty 


SYMPTOMATOLOGY.  867 

in  swallowing,  is  due  to  inflammation  of  the  pharynx  and  neighboring 
parts.  In  many  instances  the  catarrhal  symptoms  are  due  to  a  pharyn- 
gitis and  tonsillitis  only,  the  lower  air-passages  escaping.  Hoarseness  is 
common. 

Cough  is  a  prominent  symptom.  It  is  apt  to  be  frequent  and  dis- 
tressing— somtimes  paroxysmal  from  the  beginning  of  the  sickness, 
almost  always  so  at  some  period  of  its  course.  Its  spasmodic  character 
in  some  of  the  older  epidemics  led  to  the  confounding  of  epidemic  catar- 
rhal fever  with  whooping  cough.  It  is  apt  to  be  worse  toward  evening 
and  at  night,  but  the  sick  are  often  tormented  day  and  night  by  the  loud 
racking  cough.  It  often  leads  to  vomiting,  and  by  its  violence  and  per- 
sistence gives  rise  to  pain  and  soreness  in  the  muscles  of  respiration 
(myalgia),  and  occasionally  to  hernia.  It  is  at  first  dry  or  attended  with 
a  scanty  muco-serous  expectoration ;  later  on  the  sputa  become  opaque 
and  muco-purulent,  and  in  consumptive  or  full-blooded  persons  or  those 
having  mitral  disease  they  are  sometimes  streaked  or  mingled  with  blood. 
Toward  the  close  of  the  attack  the  cough  becomes  less  urgent  and  loses 
its  spasmodic  character.  In  some  epidemics  cough  is  not  a  prominent 
symptom,  and  a  few  cases  are  encountered  in  most  epidemics  in  which 
well-developed  influenza  runs  its  course  without  unusual,  peculiar,  or . 
excessive  cough.  If  the  cough  be  due  to  bronchitis,  we  find  on  ausculta- 
tion the  physical  signs  of  that  affection.  They  are  of  course  wanting 
when  it  is  due  simply  to  laryngo-tracheal  irritation.  Hence  we  fre- 
quently detect  sonorous  and  sibillant  or  mucous  and  subcrepitant  rales 
upon  both  sides  of  the  chest  in  the  course  of  the  attack,  as  in  non-epi- 
demic acute  bronchitis ;  and,  on  the  other  hand,  cases  occur  where  the 
auscultatory  signs  are  but  little  or  not  at  all  altered  from  those  of  health. 
It  is  scarcely  necessary  to  add  that  there  are  no  special  physical  signs  that 
can  be  regarded  as  diagnostic  of  influenza. 

Many  patients  suffer  from  dyspnoea.  Although  due  in  some  instances 
to  complications,  it  occurs  with  remarkable  frequency  in  those  in  whom 
none  of  the  objective  signs  of  any  pulmonary  lesion  can  be  discovered. 
It  is  here  of  nervous  origin.  Graves  assumes  a  direct  disturbance  in  the 
function  of  the  vagus  as  its  cause.  This  view  is  sustained  by  the  obser- 
vation that  the  dyspnoea  is  now  and  then  intermittent,  or^shows  rhythm- 
ically recurring  remissions,  which  are  unattended  by  alteration  of  ^  the 
physical  signs.  To  Biermer  it  appears  more  probable  that  the  congestions 
so  common  in  influenza,  not  attended  by  marked  physical  signs  until  they 
lead  to  oedema,  are  to  be  regarded  as  the  cause  of  the  dyspnoea.  It  varies 
greatly  in  intensity.  In  many  patients  it  goes  on  to  marked  oppression, 
great  shortness  of  breath,  precordial  pain,  and  the  like.  In  certain  epi- 
demics orthopncea  and  suffocative  attacks  were  very  common.  Stitches 
in  the  side  and  pain  under  the  sternum  are  observed  without  appreciable 
physical  signs. 

Symptoms  Keferable  to  the  Nervous  System. — Great  prostration  ot 
muscular  strength  is  a  very  early  symptom,  and  constitutes,  in  most  epi- 
demics, one  of  the  remarkable  features  of  the  disease.  Patients  from  the 
onset  feel  extremely  weak,  and  are  exhausted  by  the  slightest  bodily 
effort.  The  ordinary  strength  is  not  regained  until  convalescence  is  far 
advanced.  , 

Headache  is  a  constant  symptom.     Severe  frontal  pains  are  scarcely 


868  INFLUENZA. 

ever  absent.  They  extend  across  the  brow  and  deeply  about  the  orbits 
and  at  the  root  of  the  nose,  having  their  seat  in  the  Schneiderian  mucous 
membrane  and  its  prolongations  lining  the  frontal  sinuses  and  the  nasal 
ducts.  Sometimes  the  pain  is  referred  also  to  the  region  of  the  antrum 
of  Highinore  and  to  the  Eustachian  tube  and  the  middle  ear.  It  occa- 
sionally extends  over  the  whole  head.  Cutaneous  hypersesthesia  of  the 
head  and  neck  and  stiffness  of  the  neck-muscles  are  also  met  with.  The 
headache  is  often  most  intense;  it  lasts  commonly  till  the  end  of  the 
attack,  and  may  even  outlast  it.  It  increases  in  severity  with  the  fever 
and  mental  agitation  toward  evening.  The  occurrence  of  epistaxis  affords 
some  relief. 

Among  the  more  constant  symptoms  of  influenza  are  very  severe  pains 
in  the  limbs.  Patients  experience  sensations  of  soreness  and  bruising, 
such  as  follow  the -most  severe  and  unaccustomed  muscular  effort.  Dull, 
tearing,  and  burning  pains  are  felt  sometimes  in  particular  muscles  or 
tendons ;  sometimes  they  are  diffused  over  the  whole  body.  Distressing 
pains  of  a  dragging  or  boring  character  in  the  loins  and  calves  of  the 
legs  are  complained  of.  These  pains  are  neither  relieved  nor  aggravated 
by  gentle  movement  or  by  moderate  pressure.  A  sense  of  contraction 
.  of  the  chest  and  precordial  distress  also  occurs,  and  stitches  in  the  side 
(pleurodynia),  substerual  pain,  and  pains  in  the  throat  and  nape  of  the 
neck  are  common.  When  the  attack  is  severe  the  patient  is  usually  rest- 
less, sleepless,  and  anxious.  Dizziness  and  a  tendency  to  faint  occur  on 
rising,  particularly  in  women'.  Mild  delirium  is  not  uncommon,  but  the 
more  intense  forms  are  occasionally  observed.  Active  delirium  was 
thought  to  be  a  mortal  symptom  in  some  of  the  older  epidemics. 

The  inability  to  sleep  bears  no  direct  relation  to  the  intensity  of  the 
fever.  It  is  seen  in  some  cases  where  fever  is  slight  or  even  absent. 

Somnolent  states  also  occur.  Great  hebetude  and  torpor  have  marked 
some  epidemics.  That  of  1712  was  called  the  sleepy  sickness,  by  reason 
of  the  prevalence  of  these  symptoms. 

In  grave  cases  painful  muscle-cramps,  subsultus  tendinum,  twitchiugs 
of  particular  muscles,  and  tremblings  of  the  hands  occur. 

The  mental  power  is  enfeebled,  and  the  acuteness  of  the  special  senses 
is  diminished.  , 

COMPLICATIONS  AND  SEQUELS. — The  most  important  complications 
of  influenza  are  inflammatory  diseases  of  the  lungs.  The  hyperaemia 
and  intense  bronchitis  already  described  as  occurring  in  the  severer  cases 
cannot  properly  be  looked  upon  as  complications.  They  constitute  rather 
essential  processes  of  particular  forms  of  the  disease.  But  capillary 
bronchitis,  catarrhal  pneumonia,  and  less  frequently  croupous  pneu- 
monia, arise  as  complications  in  the  course  of  the  disease.  Satisfac- 
tory statistics  are  wanting,  but  Biermer  estimates  that  from  5  to  10  per 
cent,  of  the  whole  number  of  patients  suffer  from  inflammatory  lung- 
complications,  and  holds  that  the  bloodletting  so  frequently  practised  by 
the  older  physicians  was  due  to  a  desire  to  combat  inflammation.  The 
comparative  frequency  of  chest  complications  in  different  epidemics  varies 
greatly,  but  the  estimate  of  Biermer  may  be  accepted  as  an  approximate 
average. 

Owing  to  the  masking  of  the  physical  signs  in  the  early  stages  and  the 
pre-existing  pulmonary  oadema,  it  is  not  always  easy  to  recognize  at  once 


COMPLICATIONS  AND  SEQUELS.  869 

the  occurrence  of  capillary  bronchitis.  This  complication  is  attended 
with  increasing  dyspnoea,  decided  lividity  of  the  face  and  extremities,  and 
great  prostration.  Crepitant  and  subcrepitant  rales  at  the  lower  portions 
of  the  posterior  dorsal  regions,  rapidly  spreading  to  all  parts  of  the  chest, 
without  fulness  at  first  and  with  increased  resonance  later,  instead  of  the 
signs  of  consolidation  which  are  met  with  in  pneumonia,  are  the  signs 
which  attend  its  appearance. 

Catarrhal  pneumonia  occurs  insidiously,  with  gradual  intensification 
of  the  bronchitic  symptoms  about  the  fourth  or  fifth  day,  but  it  may  set 
in  as  early  as  the  second  day,  or  much  later,  during  convalescence.  It  is, 
as  a  rule,  developed  without  chill  or  great  increase  in  the  fever. 

Old  persons  and  those  of  feeble  constitutions  are  most  liable  to  the 
foregoing  complications. 

Lobar  pneumonia  is  less  common.  It  is  a  late  complication,  occurring 
toward  the  close  of  the  attack  or  even  when  the  patient  is  beginning  to 
get  about.  It  is  easily  recognized,  and  differs  in  no  wise  from  acute  lobar 
pneumonia  occurring  under  other  circumstances. 

In  October,  1880,  influenza  being  prevalent  in  Philadelphia,  both  epi- 
zootic and  epidemic,  but  very  mild  both  among  horses  and  men,  I 
attended  a  medical  student  who,  having  had  what  he  regarded  as  a 
cold  for  about  a  week,  had  kept  at  his  work  without  treatment,  until, 
upon  the  occurrence  of  a  chill  followed  by  grave  thoracic  symptoms,  ne 
was  obliged  to  betake  himself  to  bed.  I  first  saw  him  the  following  day 
in  the  hospital  of  the  Jefferson  College.  There  were  the  symptoms  of 
acute  lobar  pneumonia,  with  the  signs  of  extensive  consolidation  of  the 
left  lung  and  pleurisy  of  the  right  side.  Moreover,  there  were  delirium 
and  jaundice.  The  urine  was  non-albuminous.  The  next  evening  he 
died.  At  the  same  time  many  members  of  the  class  suffered  from  influ- 
enza, and  a  careful  inquiry  into  the  history  of  the  case  of  this  young 
gentleman  satisfied  me  that  the  pneumonia  had  arisen  as  a  complication 
in  a  neglected  and  moderate  severe  catarrhal  fever.  Until  the  eighth 
day  before  his  death  he  was  in  excellent  health.  No  examination  of  the 
body  was  permitted. 

Graves1  thought  that  a  kind  of  paralysis  of  the  lungs,  with  great 
oedema,  takes  place  in  some  cases,  and  attributed  it  to  an  affection  of  the 
vagus.  It  was  his  conviction  "  that  the  poison  which  produced  influenza 
acted  on  the  nervous  system  in  general,  and  on  the  pulmonary  nerves  in 
particular,  in  such  a  way  as  to  produce  symptoms  of  bronchial  irritation 
and  dyspnoea,  to  which  bronchial  congestion  and  inflammation  were  often 
superadded." 

It  is  certain  that  localized  collapse  of  the  lung  often  occurs.  White 
and  Guite'ras  attributed  the  consolidations  of  the  lung  to  congestive  col- 
lapse due  to  enlargement  of  the  tracheal  and  bronchial  glands  and  "  dis- 
turbance of  the  great  nervous  tract  about  the  root  of  the  lung."  They 
were  enabled  to  satisfy  themselves  of  the  existence  of  glandular  enlarge- 
ment— adenopathie  bronchique — in  nine  of  their  eighteen  cases  by  per- 
cussion practised  in  the  method  of  M.  Geneau  de  Mussy,2  who  was  the 
first  to  call  attention  to  the  importance  of  percussing  the  spinous  processes 
of  the  vertebrae  over  the  course  of  the  trachea.  Following  this  line  in 
the  healthy  subject,  a  distinct  tubular  (high-pitched  and  slightly  tympan- 
1  Annah  of  Influenza.  *  Chirurgie  midicde,  Paris,  1874. 


870  INFLUENZA 

itic)  sound  is  elicited  by  percussion  down  to  the  point  of  bifurcation  of 
the  trachea  on  the  level  of  the  fourth  dorsal  vertebra.  Opposite  the 
fifth  and  downward  we  get  the  lower-pitched  pulmonary  resonance.  When 
the  tracheal  and  bronchial  glands  are  enlarged,  the  tubular  sound  over 
the  upper  dorsal  vertebra  is  replaced  by  dulness,  which  may  contrast 
sharply,  above  with  the  tracheal,  and  below  with  the  vesicular  reso- 
nance. 

Some  well-recognized  peculiarities  of  the  so-called  pneumonias  of  influ- 
enza give  weight  to  the  view  that  the  consolidations  are  not,  in  the  begin- 
ning, pneumonic  at  all.  Thus,  we  have  at  first  weakness  of  the  vesicular 
murmur,  then  its  absence ;  the  respiration  soon  becomes  bronchial,  with- 
out being  preceded  by  dulness  or  the  crepitant  rale ;  the  extension  of 
those  consolidations  from  one  part  of  the  lung  to  another  is  very  irreg- 
ular ;  the  process  is  more  apt  to  involve  both  sides  than  one ;  the  disap- 
pearance of  the  consolidation  is  frequently  very  rapid. 

The  relations  of  cause  and  effect  between  collapse  and  catarrhal  pneu- 
monia are  so  close  that  it  is  not  difficult  to  see  how  the  condition  spoken 
of  may  lead  to  secondary  lobular  or  catarrhal  pneumonia.  In  truth,  this 
is  a  frequent  result  of  collapse  from  any  cause. 

White  and  Guite'ras  do  not  adduce  any  post-mortem  facts  in  support 
of  their  theory.  Peacock,  however,  observed  in  the  epidemic  of  1847 
softening  and  enlargement  of  the  bronchial  glands  in  several  cases,  and 
in  one  instance  where  there  was  no  antecedent  disease  of  the  lungs,  and 
where  the  physical  signs  corresponded  to  some  extent  with  those  of  the 
cases  upon  which  White  and  Guit4ras  base  their  views. 

Gangrene  of  the  lungs  must  be  named  as  one  of  the  less  common  com- 
plications. 

These  complications  are  the  chief  cause  of  the  danger  of  influenza  in 
the  aged,  the  debilitated,  and  those  suffering  from  previous  disease  of  the 
thoracic  organs. 

Pleurisy  is  rare  except  where  there  is  coexisting  inflammation  of  the 
lungs.  It  may  be  associated  with  pericarditis.  In  old  persons  serous 
effusions  into  the  pleural  sac  are  now  and  then  encountered. 

Troublesome  laryngitis  and  chronic  bronchitis  may  follow  the  attack. 
In  consequence  of  the  extension  of  the  catarrhal  processes  along  the 
Eustachian  tube  an  actual  inflammation  of  the  middle  ear  is,  in  rare 
instances,  set  up.  Parotitis  with  salivation  sometimes  occurs,  likewise 
aphthous  inflammations  of  the  mouth. 

Herpes  labialis  occasionally  occurs  toward  the  end  of  the  attack ;  it  is 
then  a  favorable  indication. 

Phthisis  may  be  developed  in  consequence  of  an  attack  of  influenza, 
and  if  phthisis  be  already  established  it  is  apt  to  run  a  more  rapid  course. 
Emphysematous  affections  are  aggravated ;  diseases  of  the  heart  are 
unfavorably  influenced ;  chronic  nervous  affections  are  made  worse,  and, 
in  particular,  neuralgias  are  aggravated.  Old  neuralgias,  that  have  long 
ceased  to  give  trouble,  occasionally  reappear  during  the  convalescence. 

Persons  subject  to  latent  or  chronic  Bright's  disease  are  especially 
liable  to  the  more  serious  manifestations  of  influenza.  The  fatal  ter- 
mination of  such  cases  not  unfrequently  occurs  in  consequence  of  an 
attack. 

Many  of  the  older  observers  speak  of  the  intermittent  character  of 


PATHOLOGY.  871 

influenza  in  certain  epidemics,  and  its  tendency  to  run  into  intermittents, 
particularly  of  a  certain  type,  during  convalescence.  This  has  not  been 
observed  in  the  outbreaks  of  later  years,  and  it  is  probable  that  in  such 
instances  an  endemic  malaria  has  modified  the  epidemic  catarrhal  fever, 
or  the  former  has  broken  out  as  the  latter  passed  away. 
•  Pregnant  women  are  in  danger  of  aborting. 

PATHOLOGY. — Our  'knowledge  of  the  pathology  of  influenza  is  as 
yet  very  imperfect.  ^  Biermer  has  described  it  as  the  sum  of  a  series  of 
catarrhal  manifestations  developed  under  a  common  epidemic  influence. 
The  close  association  of  the  various  local  affections  arises  from  their 
almost  simultaneous  occurrence  as  results  of  primary  pathological  pro- 
cesses common  to  them  all.  Each  of  the  three  groups  of  symptoms 
which  make  up  the  clinical  picture  of  the  disease — namely,  the  fever, 
the  catarrh,  and  the  symptoms  referable  to  the  nervous  system — consti- 
tutes a  distinct  factor  of  influenza,  and  is  a  direct  outcome  of  the  action 
of  the  infecting  principle.  There  is  no  constant  interdependence  among 
these  groups,  either  in  the  order  of  their  succession  or  in  their  intensity. 
Thus,  while  all  three  groups  are  commonly  present  from  the  beginning 
of  the  attack,  any  one  of  them  may  be  the  first  to  appear  or  have  an 
intensity  out  of  all  proportion  to  each  of  the  others.  The  fever  is  not  a 
result  of  the  catarrhal  inflammation,  nor  are  the  nervous  symptoms  the 
result  of  both  the  others.  They  all  spring  directly  from  the  action  of 
the  same  cause. 

This  view  is  at  variance  with  the  opinion — basqd  upon  the  fact  that 
ordinary  acute  local  inflammatory  diseases,  tonsillitis,  bronchitis,  and  the 
like,  sometimes  run  their  course  in  a  similar  way  to  influenza,  with  fever, 
nervous  depression,  and  a  serious  sense  of  illness — that  influenza  is  a 
simple  epidemic  catarrhal  inflammation. 

The  sudden  onset  of  influenza,  its  not  infrequent  abrupt  termination, 
which  suggests  crisis,  its  unsparing  seizure  of  great  numbers  of  the 
population,  the  severity  of  the  nervous  symptoms,  and  the  amount  of 
laryngo-bronchial  irritation,  often  out  of  measure  with  the  lesions  of  the 
mucous  membranes, — all  point  to  the  action  of  a  morbid  agent  affecting 
the  body  at  large.  The  severity  of  the  symptoms  also,  in  many  cases,  is 
much  greater  than  in  similar  acute  non-specific  local  affections,  while  the 
complications,  and  in  particular  the  recrudescence  of  fading  neuralgias 
and  the  tendency  to  abortion,  and  the  sequels,  as  cough,  weakness,  head- 
aches, flying  pains,  which  often  remain  long  after  convalescence,  are  evi- 
dences of  its  belonging  to  the  group  of  infectious  diseases  rather  than  to 
that  of  simple  acute  inflammatory  diseases. 

In  conclusion,  it  must  be  urged  that  the  similarity  of  the  symptoms  in 
many  epidemics,  occurring  during  the  course  of  several  centuries  and 
under  different  social  conditions,  and  even  different  degrees  of  civilization, 
forcibly  demonstrates  the  specific  and  definite  character  of  the  causes 
which  give  rise  to  influenza. 

Very  little  light  is  thrown  upon  the  pathology  of  the  disease  by  the 
anatomical  changes  found  after  death.  Uncomplicated  influenza  is  rarely 
fatal.  As  a  rule,  the  unfavorable  termination  is  due  to  lung  complica- 
tions. The  essential  lesions  are  congestion  and  catarrhal  swelling  of  the 
mucous  membrane  of  the  upper  air-passages  and  the  bronchial  tubes. 
These  changes  may  be  restricted,  in  the  lungs,  to  the  trachea  and  larger 


872 

bronchi,  or  they  may  extend  to  the  finest  twigs.  They  may  amount  to 
great  thickening  and  deep  capillary  injections  of  the  raucous  lining  of  the 
tulles,  which  contain  clear,  frothy  mucus  or  thick,  viscid  masses  of  niuco- 
purulent  secretion  unmixed  with  air. 

More  or  less  congestion  of  the  gastric  mucous  membrane,  and  more 
rarely  of  that  of  the  intestine,  is  also  met  with.  The  solitary  and 
agminate  glands  of  the  intestine  are  not  affected,  save  as  the  result  of 
special  complications.  A  few  observations  relate  to  the  finding  of 
enlarged  and  softened  bronchial  glands.  More  extended  researches  are 
needed,  not  only  upon  this  point,  but  also  in  the  whole  domain  of  the 
pathological  anatomy  of  the  disease. 

Hypenemia,  oedema,  hypostatic  congestions,  splenization,  catarrhal 
pneumonia,  and  hepatization  affect  the  lung-tissue  in  cases  fatal  by  the 
complications  which  are  associated  with  such  changes.  The  tissue- 
changes  of  diseases  existing  prior  to  the  attack  of  influenza,  such  as  old 
consolidations,  tubercle,  brown  induration,  emphysema,  and  so  forth,  are 
of  course  frequently  discovered. 

DIAGNOSIS. — The  discrimination  of  influenza  from  other  affections 
having  some  points  of  resemblance  to  it  is,  under  ordinary  circumstances, 
unattended  with  difficulty.  The  march  of  the  epidemic,  the  number  of 
persons  attacked,  the  prominence  of  the  nervous  symptoms,  the  rapidly 
developed  debility,  and  the  character  of  the  cough,  usually  severe  out  of 
proportion  to  the  physical  signs,  distinguish  it  from  all  other  epidemic 
diseases. 

It  is  to  be  differentiated  from  non-specific  catarrhal  affections  attended 
by  fever,  malaise,  weakness,  severe  headache,  and  pain  in  the  ex- 
tremities by  a  due  regard  to  the  causative  relations  of  the  two  affec- 
tions. Simple  catarrhs  not  rarely  present  the  group  of  symptoms 
which  characterize  epidemic  catarrhal  fever,  but  they  occur  almost 
constantly  as  the  result  of  great  and  sudden  changes  in  the  weather, 
and  are  therefore  met  with  in  greatest  frequency  in  bad  seasons,  and 
are  particularly  common  at  the  end  of  winter  and  in  the  spring. 
Influenza  is  not  in  any  way  dependent  upon  the  vicissitudes  of  the 
seasons,  and  may  occur,  as  has  been  shown,  at  all  times  of  the  year,  in 
wet  or  dry,  mild  or  cold  seasons  equally,  and  in  every  variety  of  climate. 
It  is  of  course  diagnosticated  without  difficulty  from  the  sporadic  catar- 
rhal fevers,  which  lack  the  characteristic  depression,  neuralgic  and 
rheumatoid  pains,  the  irritative  cough,  dyspnoea,  and  so  on. 

Cases  of  influenza  are  met  with  that  bear  a  strong  resemblance  to 
beginning  enteric  fever.  The  malaise,  headache,  obtunded  hearing, 
mental  depression,  high  fever,  coated  tongue,  tender  belly,  diarrhoea,  are 
symptoms  to  be  observed  in  both  affections.  But  influenza  lacks  the 
temperature  curve,  the  splenic  enlargement,  and  the  eruption  of  enteric 
fever,  and  the  progress  of  the  disease  will  in  a  few  days  clear  up  the 
most  doubtful  case. 

PROGNOSIS  AND  MORTALITY. — Death  is  rare  in  uncomplicated  cases. 
The  very  young  bear  influenza  badly ;  the  old  bear  it  more  badly  still. 
Nevertheless,  children  have  in  some  epidemics  enjoyed  a  considerable  pro- 
portionate immunity.  Healthy  persons  in  the  middle  periods  of  life  bear  it 
well.  Certain  pre-existing  diseases  modify  its  course  unfavorably  ;  among 
these  are  chronic  bronchitis,  emphysema,  fatty  heart,  and  Bright's  disease. 


TREATMENT.  873 

The  debility  of  advanced  phthisis  and  other  exhausting  diseases  renders 
influenza  dangerous.  Death  takes  place,  in  by  far  the  greater  number  of 
cases,  as  the  result  of  the  complication  of  the  attack,  either  by  some  pre- 
existing affection  or  by  an  acute  disease  arising  in  its  course.  The  com- 
monest of  the  latter  are  inflammations  of  the  parenchyma  of  the  lungs. 

Patients  presenting  very  severe  symptoms  generally  recover  if  they  be 
not  the  subjects  of  complicating  maladies  or  very  young  or  very  old." 

Relapses  are  not  uncommon ;  independently  of  relapses,  second  attacks 
have  been  known  to  occur  during  the  continuance  of  an  epidemic ;  it  is 
often  the  case  that  an  individual  in  the  course  of  his  life  passes  through . 
several  epidemics  of  influenza,  and  is  the  subject  of  the  disease  in  each 
of  them. 

The  prognosis  is  greatly  modified  by  the  character  of  the  prevailing 
epidemic.  In  some  epidemics  the  deaths  are  few,  and  the  mortality  from 
other  diseases  does  not  appear  to  be  greatly  augmented.  In  others  many 
die  of  the  epidemic  disease,  and  the  death-rate  of  certain  endemic  affec- 
tions is  much  increased.  In  some  of  the  older  epidemics  the  high  mor- 
tality was  doubtless  due  to  injudicious  measures  of  treatment,  among 
which  bloodletting  and  other  depressing  agencies  were  conspicuous.  Some 
of  the  older  accounts  also  warrant  the  suspicion  that  a  coexisting  typhus 
had  to  do  with  the  high  death-rate.  It  is  estimated  that  in  the  epidemic 
of  1837,  which  was  a  very  severe  one,  2  per  cent,  of  those  attacked  died. 
The  proportion  of  fatal  cases  in  particular  epidemics  varies  in  different 
countries,  and  even  in  different  quarters  of  the  same  city. 

TREATMENT. — Efficient  measures  of  prophylaxis  are  as  yet  unknown. 
Unfavorable  hygienic  surroundings,  overcrowding,  a  damp,  unhealthy 
locality,  appear  to  increase  the  prevalence  and  severity  of  influenza.  The 
opposite  conditions  of  living  do  not,  however,  secure  immunity  from  the 
attack.  During  an  epidemic  aged  persons,  those  enfeebled  by  chronic  dis- 
eases, and  in  particular  those  subject  to  chronic  bronchitis,  consumption, 
emphysema,  fatty  heart,  and  Bright's  disease  should  be  cared  for  with  un- 
usual diligence  and  solicitude,  since  they  constitute  the  classes  most  prone  to 
the  graver  complications  of  the  disease,  and  from  which  its  fatal  cases  are 
almost  wholly  derived.  Such  individuals  should  be  warmly  clad ;  they 
should  shun,  so  far  as  possible,  the  vicissitudes  of  the  weather,  even,  if 
practicable,  keeping  within  warmed  and  well-ventilated  apartments ;  they 
should  exercise  unusual  prudence  in  diet  and  lead  a  carefully  regulated 
life,  with  long  hours  of  sleep.  It  is  true  that  these  measures  are  not  pre- 
ventive of  the  attack.  Families  not  quitting  the  house,  living  in  the 
greatest  seclusion,  even  the  bedridden,  do  not  always,  or  even  as  a  rule, 
escape.  Yet  it  has  frequently  been  observed  that  those  whose  occupations 
are  carried  on  in  the  open  air  are  attacked  earliest  and  in  greatest  num- 
bers. On  the  other  hand,  in  rare  instances,  persons  isolated  from  the 
community  with  strictness — in  prisons,  cloisters,  hospitals — have  remained 
free  from  the  disease  prevailing  around  them.  It  therefore  appears  proba- 
ble that,  under  certain  favorable  circumstances  not  as  yet  perfectly  under- 
stood, the  avoidance  of  the  open  air  and  of  the  direct  influences  cf  the 
weather  may  confer  some  degree  of  immunity  from  the  attack,  and  it  is 
desirable  that  the  class  of  persons  most  liable  to  the  graver  consequences 
of  the  disease  should  avail  themselves  of  even  the  most  uncertain  pre- 
cautions. 


874  .  INFLUENZA. 

The  treatment  of  influenza  is  expectant  and  supporting.  Not  only  is 
the  epidemic  self-limiting,  tending  to  exhaust  the  susceptibility  of  a  com- 
munity, in  most  instances,  in  the  space  of  a  few  weeks,  but  the  attack  is 
also  of  definite  duration,  and  the  perturbations  set  up  by  the  action  of 
the  influenza-poison  upon  the  individual  subside  spontaneously  in  three 
or  four,  or  at  most  ten  or  twelve,  days.  The  susceptibility  of  the  indi- 
vidual is  also,  for  the  time  being,  exhausted,  for  second  attacks  in  the 
same  epidemic  are  not  very  common.  In  cases  where  the  duration  of  the 
attack  is  prolonged  beyond  the  period  indicated,  it  is  kept  up  by  compli- 
cations, and  we  have  to  do  not  so  much  with  the  pathological  processes  of 
influenza  as  with  secondary  diseases  that  the  influenza  has  excited  either 
by  the  intensity  of  its  action  or  by  reason  of  some  peculiarity  of  the  sub- 
ject of  the  attack. 

By  far  the  greatest  number  of  cases  are  light  and  unattended  by  dan- 
ger. The  treatment  is  therefore,  for  the  most  part,  an  extremely  simple 
one.  These  lighter  cases  seldom  require  medical  measures.  The  patients 
are  uncomfortable  and  anxious,  easily  fatigued,  and  unfitted  for  busi- 
ness. It  is  best  that  they  keep  the  house,  and,  if  willing,  the  bed  or  sofa, 
for  the  space  of  two  or  three  days.  The  diet  should  be  restricted  to  a 
few  simple  and  easily-digested  dishes.  Meat  should  be  avoided.  The 
common  custom  of  taking  hot  beef-tea  is  an  extremely  bad  one ;  it  often 
increases  the  headache  and  languor.  Moderate  quantities  of  cold  drinks 
may  be  taken.  The  fruit-syrups,  lemonade,  raspberry  vinegar,  a  weak 
solution  of  citrate  of  potash  or  of  cream  of  tartar,  and  barley-water 
with  lemon,  are  useful.  Very  weak  wine-whey  is  often  liked.  The 
effervescing  mineral  waters  or  Apollinaris  are  preferred  by  many  per- 
sons. The  best  of  such  drinks  is  a  mixture  of  equal  parts  of  Seltzer- 
water  and  milk,  iced.  If  the  stomach  be  irritable,  koumiss  will  be  found 
an  excellent  beverage  and  food.  In  the  mild  cases  stimulants  are  not 
necessary.  Sound  claret,  with  or  without  Seltzer-water,  is  not  contrain- 
dicated.  In  all  cases  the  amount  of  fluid  taken  should  be  moderate. 

Quinine  in  moderate  doses  should  be  taken  from  the  onset.  The  head- 
pains  are  not  increased  by  it.  Dover's  powder,  if  well  borne,  should  be 
administered  at  night.  Some  form  of  opiate  may  be  required,  even  in 
mild  cases,  to  counteract  wakefuluess.  A  compressed  pill,  containing 
extract  of  opium  0.030  gramme  (gr.  J),  camphor  0.15  (gr.  ij),  and  ammo- 
nium carbonate  0.15  (gr.  ij),  will  be  found  useful  when  Dover's  powder  can- 
not be  employed.  During  convalescence  iron  and  barks  are  often  requisite. 

The  coryza,  tonsillitis,  laryngitis,  bronchitis  are  to  be  treated  according 
to  general  principles,  if  they  require  treatment  at  all.  In  most  mild  cases 
the  catarrhal  symptoms  call  for  no  special  measures  of  treatment. 

Free  inunctions  of  fatty  substances  about  the  brow  and  over  the  bridge 
of  the  nose  are  of  use  as  regards  the  coryza.  For  this  purpose  animal 
fats,  washed  lard,  simple  cerate,  cold  cream,  and  the  like  are  to  be  pre- 
ferred to  cosmoline  and  vaseline. 

Morphine  dissolved  in  cherry-laurel  water,  one  part  in  fifty  or  sixty,  is 
useful  for  the  relief  of  the  head-pains  associated  with  the  coryza.  A  few 
drops  may  be  snuffed  up  from  time  to  time.  These  pains  are  mitigated 
to  some  degree  by  wearing  a  flannel  cap  or  wrapping  the  head  in  a  silk 
handkerchief.  Warm  applications  sometimes  give  comfort,  while  cold 
almost  invariably  add  to  the  distress. 


TREATMENT.  875 

Distress  in  the  upper  air-passages  and  the  tickling  cough  call  for  steam 
inhalations,  and  the  air  of  the  apartment  may  be  rendered  moist  by  the 
evaporation  of  water  kept  boiling  in  a  broad,  shallow  vessel.  Gargles  of 
potassium  chlorate,  or  potassium  chlorate  with  sumac,  exert  a  soothing 
influence  upon  the  congested  tonsils. 

Severe  cases  call  for  more  energetic  measures  of  treatment.  The  most 
prominent  indications  are  the  control  of  the  fever ;  the  diminution  of  the 
hyperaemic  fluxion  to  the  mucous  tracts ;  measures  of  support ;  the  miti- 
gation of  pain  and  the  induction  of  sleep ;  and,  finally,  the  prevention  of 
the  pulmonary  congestion,  to  which  the  depression  leads  by  enfeeblement 
of  the  circulation.  The  last  indication  is  especially  urgent  in  infants,  the 
very  old,  and  those  previously  debilitated  from  any  cause. 

Inflammatory  complications  require  special  treatment  or  modifications 
of  treatment. 

The  febrile  movement  is  not,  as  a  rule,  high ;  grave  nervous  symptoms 
and  serious  catarrh  may  be  associated  with  moderate  fever. 

An  anti-febrile  regimen  is  to  be  observed.  The  moderate  duration  of 
this  fever,  as  compared  with  enteric  fever,  renders  it  less  important  that 
large  amounts  of  fever-food  should  be  given,  while  the  tendency  to 
depression  makes  it  of  the  utmost  importance  that  the  administration  of 
food  be  systematic  and  carefully  looked  after  by  the  medical  attendant. 
The  disinclination  to  take  food  is  so  great  that  it  is  often  with  difficulty 
that  a  sufficient  quantity  can  be  given  in  the  early  days  of  the  attack,  and 
it  is  to  be  doubted  whether  benefit  follows  anything  in  excess  of  the  most 
moderate  amount.  It  is  necessary  to  observe  regular  hours,  as  in  the 
management  of  all  the  low  fevers.  As  soon  as  convalescence  begins  the 
patient  should  be  urged  to  eat ;  the  quantity  of  food  taken  at  one  time  is 
to  be  augmented,  and  the  intervals  between  the  meals  may  be  longer. 

A  favorable  action  upon  the  excretory  function  of  the  skin  and  kidneys 
will  result  from  the  moderate  drinking  of  water  or  of  the  beverages 
already  spoken  of.  At  least  enough  fluid  should  be  taken  to  relieve 
thirst. 

Diaphoretics  have  been  much  used,  upon  the  theory  that  by  determina- 
tion to  the  skin  they  correspondingly  diminish  the  tendency  to  hypersemia 
of  the  affected  mucous  tracts.  Dover's  powder,  solution  of  the  acetate  of 
ammonia,  and  other  mild  diaphoretics  are  to  be  selected.  Jaborandi 
should  be  employed  with  caution.  The  wet  pack  and  other  hydrothera- 
peutic  measures  have  been  employed  to  act  upon  the  skin  and  to  effect  a 
direct  reduction  of  temperature  in  influenza.  For  old  and  feeble  persons 
warm  packs  are  employed.  A  profuse  sweating  at  the  onset  of  the  attack 
is  said  to  occasionally  cut  it  short.  Early  diaphoresis  often  brings  about 
a  rapid  and  lasting  amelioration  of  the  symptoms.  It  is  to  be  borne  in 
mind  that  the  fever  is  rarely  excessive,  and  that  sweating  is  not  infre- 
quently a  troublesome  symptom.  In  some  epidemics  it  has  been  a  very 
troublesome  one. 

General  bloodletting  is  not  to  be  resorted  to  in  influenza.  Its  danger 
was  apparent  to  some  of  the  early  writers.  As  has  been  pointed  out,  the 
high  mortality  of  some  of  the  older  epidemics  is  to  be  explained  by  the 
venesections  practised  at  the  beginning,  and  even  during  the  course,  of  the 
attack.  It  has  no  favorable  effect  upon  the  catarrhal  processes,  and  but 
little  upon  the  subjective  symptoms.  The  fever  is  not  relieved  by  it ;  the 


876  INFLUENZA. 

nervous  depression  is  increased  and  the  risk  of  lung-congestion  is  aug- 
mented. Bleeding  is  not  likely  to  be  practised  in  epidemic  catarrhal  fever 
while  the  present  views  of  its  place  in  therapeutics  continue  to  influence 
practice.  Cautious  local  bloodletting  for  the  relief  of  local  inflammatory 
trouble  is  spoken  of  in  most  of  the  modern  books.  The  occasions  for  its 
employment  are  so  rare  in  the  treatment  of  this  disease  that  even  this 
statement  should  be  henceforth  omitted.  In  influenza,  as  it  is  known  to 
medical  men  of  the  present  from  the  descriptions  of  the  old  and  personal 
experience  of  the  few  recent  and  milder  epidemics,  bloodletting,  either 
general  or  local,  is  clearly  uncalled  for. 

Emetics  hold  a  high  historical  place.  It  was  of  old  customary  to  begin 
the  treatment  with  a  vomit.  As  late  as  the  epidemic  of  1837,  Lombard 
of  Geneva  believed  that  they  shortened  the  attack  and  lessened  the 
intensity  of  the  symptoms  when  administered  at  the  beginning.  In  cases 
attended  by  early  gastric  disturbance  and  nausea  they  are  said  to  be  espe- 
cially of  use.  They  sometimes  set  up  great  irritability  of  the  stomach, 
with  vomiting  that  it  is  difficult  to  control.  On  the  whole,  the  cases  in 
which  an  emetic  would  do  good  are  extremely  rare. 

Purgatives  were  formerly  regarded  as  important  in  the  treatment.  This 
view  no  longer  prevails.  In  case  of  constipation  gentle  purgation,  ex 
indicatione  symptomatica,  is  a  necessary  part  of  the  proper  management 
of  the  case.  For  this  purpose  the  laxative  mineral  waters,  as  Frieder- 
ichshalle,  Hunyadi,  Pullna,  are  excellent.  Castor  oil  may  be  given,  and 
calomel  is  in  some  cases,  and  particularly  in  childhood,  of  great  service. 
Simple  enemata  of  warm  water  or  soap  and  water  will  often  suffice.  The 
tendency  in  some  cases  to  exhausting  and  troublesome  diarrhoea,  and  the 
fact  that  diarrhoea  occurs  spontaneously  some  time  in  the  course  of  most 
cases,  should  inspire  caution  in  the  use  of  purgatives.  Repeated  purga- 
tion during  the  progress  of  the  attack  is  not  only  useless — it  is  also  posi- 
tively injurious. 

In  the  severe  cases  quinine  is  to  be  given  early  and  in  full  doses.  It 
exerts  at  the  same  time  a  powerful  influence  upon  the  temperature,  upon 
the  tendency  to  local  hypersemias,  and  upon  the  nervous  symptoms,  and 
in  particular  the  headache.  Rawlins,1  as  early  as  1833,  found  that  excel- 
lent results  followed  its  administration,  the  effect  being  the  better  the 
earlier  it  was  given.  It  has  even  been  lauded  as  a  specific  for  influenza. 

The  mineral  acids  may  be  given  with  a  view  to  realizing  their  tonic 
effects. 

For  the  most  part,  the  foregoing  measures,  directed  against  the  fever, 
will  exert  a  favorable  influence  upon  the  catarrhal  processes.  Expect- 
orants are  of  advantage ;  ipecac  is  useful.  The  preparations  of  antimony 
are  inadmissible  by  reason  of  their  tendency  to  depress.  Ammonium 
chloride  is  indicated  in  the  earlier  stages  of  the  bronchitis.  Among  recent 
drugs,  yerba  santa  (Eryodiction  glutinosum)  and  the  oil  of  eucalyptus  are 
of  use  in  mitigating  the  symptoms  in  epidemic  catarrh,  as  they  do  in  cer- 
tain forms  of  simple  sporadic  catarrh. 

The  peculiar  dry,  racking  cough  so  often  present  in  the  early  days  of 
the  attack  should  be  relieved.     It  is  not  useful  in  removing  bronchial 
accumulations,  being,  as  has  been  shown,  in  most  instances  out  of  pro- 
portion to  the  lesions  of  the  bronchial  mucous  membrane ;  on  the  other 
1  London  Medical  Gazette,  May,  1833. 


TREATMENT.  877 

hand,  it  tends  to  increase  the  hypersemia  of  the  upper  air-passages  by  the 
mechanical  violence  of  the  cough-paroxysms.  Further,  it  is  distressing 
and  exhausting,  and  contributes  to  the  muscular  and  nervous  prostration. 
Benefit  will  be  derived  from  keeping  the  air  of  the  apartment  moist,  and 
from  the  occasional  inhalation  of  the  steam  from  hot  water,  either  used 
alone  or  poured  upon  the  compound  tincture  of  benzoin,  a  pint  to  the 
teaspoonful,  or  upon  paregoric,  a  pint  to  the  tablespoonful,  in  a  proper 
vessel  or  inhaler. 

No  drugs  are  more  potent  to  this  end  than  opium  and  its  derivatives, 
and  in  particular  morphia  and  codeia.  The  hypodermic  use  of  the  mor- 
phia salts,  judiciously  resorted  to,  constitutes  our  most  valuable  thera- 
peutic resource  in  fulfilling  the  threefold  indication  of  relieving  cough, 
alleviating  both  the  head-pain  and  the  pains  in  the  extremities,  and  in 
procuring  sleep.  The  old-time  dread  of  opium  in  influenza  was  not  well 
founded.  The  administration  of  this  drug  in  moderate  doses  is  attended 
with  advantages  that  far  outweigh  any  danger  of  increasing  the  tightness 
across  the  chest  and  retarding  expectoration.  It  is  necessary  to  observe 
the  same  caution  in  giving  it  to  infants  and  aged  persons  in  influenza 
that  is  necessary  under  other  circumstances.  The  influence  of  carbolic 
acid  in  restraining  cough  makes  it  a  useful  addition  to  soothing  draughts 
in  this  disease. 

The  substernal  and  other  chest-pains  may  be  combated  with  sinapisms, 
turpentine  stupes,  repeated  inunctions  of  fatty  substances  containing 
extract  of  belladonna,  and  the  like.  Pleurodynic  stitches  call  for  simi- 
lar measures ;  a  long  strip  of  machine-spread  belladonna  plaster,  about 
five  centimetres  (two  inches)  in  width,  applied  very  firmly  to  the  side 
of  the  chest  from  the  spine  in  a  direction  downward  and  forward  parallel 
with  the  ribs,  and  reaching  to  the  median  line  in  front,  affords  great 
relief  to  the  lateral  chest-pains. 

The  control  of  the  debility  must  be  regarded  as  the  most  important 
indication  in  old  and  feeble  persons.  Wine,  spirits,  milk-punch,  ammo- 
nia, spirits  of  chloroform,  are  to  be  used,  not  in  accordance  with  fixed 
rules,  but  as  occasion  may  require.  In  many  cases  wine  or  whiskey  will 
be  indicated  from  the  beginning,  the  quantity  being  determined  rather  by 
the  effect  upon  the  circulation  and  the  general  condition  of  the  case  than 
by  rule.  Women  and  others  unaccustomed  to  the  use  of  alcoholic  drinks 
often  take  wine  and  brandy  in  considerable  quantities,  with  striking 
benefit  and  without  flushing  or  other  evidences  of  its  disagreeing. 

Chloral  is  inadmissible  as  a  hypnotic  by  reason  of  its  depressing  effect 
upon  the  heart.  Paraldehyde  may  be  used,  or  the  bromides  in  connec- 
tion with  opium  if  the  latter  alone  is  not  well  borne. 

Diarrhoea  must  be  managed  in  accordance  with  general  principles.  If 
slight,  it  does  not  require  special  treatment.  It  is  apt  to  occur  at  one 
period  or  another  in  the  course  of  most  cases,  and  not  infrequently  marks 
the  beginning  of  convalescence.  Colic  may  be  treated  with  warrn  fomen- 
•tations  and  carminatives ;  if  it  be  due  to  constipation,  mild  laxatives  are 
to  be  combined  with  them.  .  . 

Severe  cases  of  influenza  demand  the  careful  attention  of  the  physician, 
who  must  be  on  the  alert  to  detect  the  inflammatory  lung  complications 
which  so  often  lead  up  to  the  fatal  issue  as  early  as  possible.  Their 
treatment  must  be  regulated  by  the  circumstances  of  the  case,  the  nature 


878  INFLUENZA. 

of  the  particular  complication,  the  age  of  the  patient,  and  so  on,  in  accord- 
ance with  general  therapeutical  indications. 

Finally,  all  measures,  of  whatever  kind,  that  tend  to  depress  the  gen- 
eral nervous  system  or  the  functional  activity  of  the  respiration,  and 
especially  the  heart-power,  are  to  be  sedulously  avoided  in  the  manage- 
ment of  influenza.  During  the  convalescence  unfavorable  influences  of 
the  weather  are  to  be  guarded  against.  It  is  important  to  warn  the 
patient  that  a  severe  attack  of  influenza  renders  him  liable  for  some  time 
afterward  to  pulmonary  disorders.  The  sequels,  and  in  particular  those 
implicating  the  respiratory  tract,  are  to  be  appropriately  treated.  After 
severe  cases  a  course  of  tonics  is  commonly  of  advantage,  and  a  change 
of  climate  often  necessary  to  re-establish  the  health. 

As  bearing  on  what  is  stated  in  the  foregoing  pages  on  the  causation 
of  influenza,  reference  may  be  made  to  the  investigations  of  Seifert,1  who 
claims  to  have  found  in  the  mucus  expectorated  by  patients  with  influ- 
enza numbers  of  a  peculiar  micrococcus.  It  is  evident,  however,  that 
no  conclusions  can  be  based  upon  these  observations  until  the  results  have 
been  subjected  to  careful  examination  in  other  epidemics. 

1  Volhmann's  klinische  Vortrage,  No.  240,  June  20,  1884. 


DENGUE. 

BY  H.  D.  SCHMIDT,  M.  D. 


SYNONYMS. — Break-bone  fever,  Dandy  fever. 

HISTORY. — The  history  of  this  disease  dates  only  from  the  second  half 
of  the  last  century,  though  it  appears  very  probable  that  previous  to  this 
time  dengue  existed  in  the  tropical  regions  of  Africa  and  Asia,  whence  it 
was  carried  to  Europe  and  America. 

In  Spain  the  disease  has  been  known  since  1764,  when,  up  to  1768,  it 
prevailed  in  Cadiz  and  Seville  under  the  name  of  la  piadosa  or  la  panto- 
rnina.1  In  1780  it  appeared  in  the  form  of  an  epidemic  in  Philadelphia, 
where  it  was  first  noticed  and  described  by  Rush  under  the  name  of 
bilious  remitting  fever,  commonly  called  break-bone  fever  on  account  of 
the  violent  pains  attending  it.  Next  it  prevailed  in  Calcutta  in  1824, 
and  two  years  afterward  it  made  its  first  appearance  on  the  southern  coast 
of  the  United  States,  in  Charleston  and  Savannah,  where  it  prevailed  to 
1827.  Toward  the  close  of  1827  another  dengue  epidemic  broke  out  in 
the  West  Indies,  whence  the  disease  proceeded  to  the  American  continent, 
reaching  New  Orleans  in  the  spring,  and  visiting  Charleston  and  Savan- 
nah in  the  summer  and  autumn  of  1828.2  In  1844  it  showed  itself  in 
Mobile,  and  in  1848  in  Natchez,  whilst  in  1850  it  reappeared  along  the 
Southern  seacoast,  particularly  in  Charleston,  from  which  it  proceeded 
even  to  inland  towns,  such  as  Augusta,  Ga.3  In  1865  dengue  appeared 
in  Teneriffe  and  other  Canary  Islands,  whilst  at  the  same  time  and  through 
the  years  1866  and  1867  it  prevailed  in  Andalusia  and  in  some  other 
Spanish  provinces.4 

One  of  the  most  extensive  epidemics  of  dengue  prevailed  from  July, 

1870,  to  January,  1871,  in  Zanzibar,5  on  the  East  Coast  of  Africa,  whence 
it  extended  to  Aden  in  Arabia  and  Port  Said  in  Egypt.     In  December, 

1871,  the  disease  appeared  simultaneously  at  Bombay  and  Calcutta,6  to 
which  place  it  had  been  carried  by  transport-ships  from  Aden.     Proceed- 
ing from  Bombay  in  a  northern  direction  along  the  railroad,  it  spread 

1  R.  H.  Poggio,  La  calentura  roja  observada  in  sus  aparidones  epidemicas  de  los  anos  1865 
y  1807,  Madrid  (reported  in  Virchow  und  Hirsch's  Jahresbericht  filr  das  Jahr  1871,  vol.  ii. 
p.  200).  *  G.  B.  Wood,  Practice  of  Medicine,  4th  ed.,  vol.  i.  p.  444. 

3  S.  H.  Dickson,  Elements  of  Medicine,  2d.  ed.,  p.  747. 

4  E.  H.  Poggio,  Virchow  und  Hirsch's  Jahresbericht  fiir  das  Jahr  1871,  vol.  ii.  p.  200. 

5  J.  Christie,  "Eemarks  on  Kidniga  Pepo,  a  peculiar  form  of  exanthematous  disease 
epidemic  in  Zanzibar,  East  Coast  of  Africa,  from  July,  1870,  to  January,  1871,"  Brit.  Med. 
Journal,  July  1,  1872,  p.  577  (reported  in  Virchow  und  Hirsch's  Jahresbericht  fur  das  Jahr 

1872,  vol.  ii.  p.  203). 

6  Virchow  und  Hirsch's  Jahresbericht  fur  das  Jahr  1873,  vol.  ii.  p.  208. 

879 


880  DENGUE. 

over  the  central  regions  of  the  North-western  Provinces,  the  Rajputaua 
states,  Cashmir,  and  the  Punjaub.  From  Calcutta  it  passed  over  Assam 
and  Bhotau  to  Thibet,  and  thence  downward  into  Burniah  and  to  all  the 
large  cities  along  the  coast ;  while  it  also  extended  along  the  coast  of 
Malabar  over  Visigapatam  to  Madras  and  Poiidichery,  finally  arriving  at 
Mysore.  Thus  the  disease  had  actually  spread  over  the  whole  Peninsula 
from  Cape  Tutikorin  to  the  foot  of  the  Himalayas,  attacking  equally  all 
races  or  nationalities  without  regard  to  age,  occupation,  or  position.  Forty 
years  previously,  however,  an  epidemic  of  dengue  had  prevailed  in  Bur- 
mah.  In  1873  it  appeared  on  the  island  of  Mauritius,  to  which  it  had 
been  carried  from  India  by  an  emigrant  ship.  In  the  same  year  a  con- 
siderable number  of  cases  of  dengue  were  observed  in  New  Orleans.  In 
1877  it  appeared  again  in  Egypt,  where  it  prevailed  in  Ismailia. 

Finally,  in  1880,  dengue,  in  the  form  of  a  very  extensive  epidemic, 
prevailed  once  more  along  the  Southern  coast,  visiting  equally  Charleston, 
Savannah,  and  New  Orleans.  A  number  of  valuable  observations  con- 
cerning the  nature  and  symptoms  of  the  disease  were  made  during  this 
epidemic  by  Drs.  D.  C.  Holliday  of  New  Orleans,  J.  G.  Thomas  of 
Savannah,  and  F.  T.  Porcher  and  J.  Forrest  of  Charleston.1  At  the  same 
time  it  prevailed  at  Alexandria2  (Egypt)  to  such  an  extent  as  to  affect 
nearly  the  whole  population. 

Dengue  has  been  known  under  various  popular  names  which  it  received 
from  the  people  of  the  particular  localities  where  it  appeared  in  epidemic 
form.  Even  the  designation,  dengue,  itself,  by  which  the  disease  is  at 
present  generally  known  to  the  medical  profession  of  the  leading  civilized 
nations,  is  of  popular  origin,3  for  it  is  supposed  to  be  a  Spanish  corruption 
of  the  word  dandy,  the  name  of  dandy-fever  having  been  jocosely  con- 
ferred on  the  disease  by  the  negroes  of  St.  Thomas  from  the  stiff  carriage 
of  those  affected  with  it.  At  Zanzibar  it  received  the  popular  name  of 
kiduiga  pepo,  signifying  spasmodic  pains. 

DEFINITION. — Dengue  is  a  peculiar  febrile  disease,  generally  appear- 
ing epidemically  in  tropical  or  semi-tropical  regions,  and  characterized  by 
a  single  paroxysm  with  or  without  remissions,  severe  pains,  and  stiffness 
in  the  joints  and  muscles,  a  peculiar  exanthematous  eruption,  and  almost 
never  terminating  fatally. 

SYMPTOMS,  COURSE,  AND  DURATION/ — Dengue  never  commences  with 
a  decided  chill,  though  in  many  cases  the  attack  of  the  disease  is  pre- 
ceded by  a  feeling  of  general  uneasiness  and  depression,  vertigo,  and 
headache,  or  even  by  a  slight  chilliness — a  condition  which  may  last  from 
a  few  to  twelve  or  even  eighteen  hours.  In  the  majority  of  cases,  how- 
ever, the  disease  appears  suddenly,  very  frequently  at  night,  and  an- 
nounces itself  at  once  by  pains  and  a  feeling  of  stiffness  in  the  muscles, 
joints,  back,  and  loins ;  in  severe  cases  the  pain  may  even  extend  to  the 

1  The  papers  of  Drs.  Holliday,  Thomas,  and  Porcher  were  read  before  the  American 
Public  Health  Association  at  its  annual  meeting,  December,  1880,  and  published  in  the 
Proceeding*  of  the  Association.     Dr.  Forrest's  paper  was  published   in  the  American 
Journal  of  Med.  Science,  April,  1881. 

2  A.  Vernoni,  "  Le  Dengue  a  Alexandrie  d'Egypte  en  1880,"  Gaz.  hebd.  de  med.  et  de 
chir.,  41,  42  (reported  in  Virckow  und  Hirscli's  Jakresbericht  far  das  Jahr  1880,  vol.  ii.  p.  5). 

8  G.  B.  Wood,  Practice  of  Medicine,  4th  edit.,  vol.  i.  p.  444. 

*  Judging  from  the  various  accounts  rendered  by  a  considerable  number  of  observers,  it 
appears  that  the  clinical  symptoms  of  dengue  had  been  the  same  in  all  the  different  local- 
ities on  the  globe  where  it  has  hitherto  prevailed  epidemically. 


SYMPTOMS,   COURSE,  AND   DURATION.  881 

bones.1  The  larger  and  smaller  joints  are  equally  affected,  either  simul- 
taneously or  successively,  and  frequently  swollen,  those  of  the  hands  and 
feet  generally  before  the  others.  The  pain  in  the  joints  is  increased  by 
motion,  and  is  therefore  justly  regarded  by  most  authors  as  rheumatic  in 
nature.  The  same  may  be  said  of  the  muscles.  Sheriff  even  observed 
redness  of  the  skin  covering  the  joints.  According  to  the  degree  of 
severity  of  the  case  these  pains  may  be  more  or  less  intense.  In  some 
cases  hyperresthesia  of  the  skin  of  the  palms  of  the  hands  and  of  the  soles 
of  the  i'eet  has  been  observed. 

Simultaneously  with  the  affection  of  the  joints  and  muscles  the  fevei 
commences ;  its  duration  is  from  four  to  five  days  on  the  average,  with 
one  or,  in  exceptional  cases,  even  more  remissions.  The  temperature  of 
the  body  during  the  first  and  second  days  of  the  fever  rises  to  102,  103, 
or  even  to  105°  F ;  it  then  declines,  to  return  to  the  normal  standard  on 
the  fifth  day.  According  to  the  measurements  made  by  the  late  Dr. 
D'Aquin 2  of  New  Orleans,  the  temperature  curves  of  dengue  showed  a 
continuous  and  steady  rise  until  the  highest  point  was  reached  on  the  first, 
second,  or  third  day  of  the  attack ;  then  comes  a  short  stadium  of  a  few 
hours,  and  then  a  remission,  soon  to  be  followed  by  another  rise  of  tem- 
perature, which,  however,  never  reaches  the  maximum  point  of  the  first. 
The  pulse  rises  with  the  temperature  of  the  body,  generally  to  from  80  to 
120  beats  a  minute,  and  subsequently  declines  with  the  temperature. 
Delirium  is  very  rarely  observed  in  adults,  but  frequently  in  children, 
though  without  aggravation  of  the  other  symptoms.  The  face  is  gener- 
ally flushed,  the  eyelids  swollen,  and  the  eyes  injected  and  watery.  The 
tongue  in  the  beginning  of  the  disease  is  covered  with  a  Avhite  fur;  its 
edges  are  red  and  its  body  swollen.  As  the  disease  advances  the  coating 
increases  in  thickness  and  assumes  a  dirty  yellow  color.  The  appetite  is 
lost,  without  excessive  thirst.  In  many  cases  there  is  slight  irritability 
of  the  stomach,  accompanied  sometimes  with  nausea,  though  vomiting 
rarely  takes  place.  The  condition  of  the  bowels  is  variable.  The  urine 
is  small  in-  quantity,  and  highly  colored  in  some  cases,  whilst  in  others  it 
has  been  reported  to  be  pale  and  copious,  and  rich  in  phosphates  in  the 
beginning  of  the  disease ;  it  seldom  shows  any  sediments  and  very  rarely 
contains  albumen.  The  disease  generally  reaches  its  acme  on  the  third  or 
fourth  day,  when  the  fever  commences  to  subside,  and  an  amelioration  of 
the  other  symptoms  takes  place,  so  that-  the  patient  feels  greatly  relieved. 
This,  however,  is  only  of  short  duration,  for  not  many  hours  afterward 
the  fever  rises  again,  while  the  other  symptoms  also  increase  in  severity. 
At  this  time  an  exanthematous  eruption  appears  upon  the  upper  part  of 
the  body,  the  face,  neck,  breast,  and  shoulders,  which  in  the  course  of  two 
days  extends  over  the  whole  body.  Simultaneously  with  the  appearance 
of  the  eruption  the  lymphatic  glands  of  the  back  of  the  head  and  those 
of  the  neck,  axillre,  and  groins  commence  to  swell ;  in  severe  cases  the 
mucous  membranes  of  the  nose,  mouth,  and  pharynx  also  become  con- 
gested. The  eruption,  which  is  attended  with  much  heat,  itching,  or 
even  pain,  is  not  uniform  in  character ;  for  while  in  some  cases  it  may 

1  M.  Sheriff,  "History  of  the  Epidemic  of  Dengue  in  Madras  in  1872,"  Med.  Times  and 
Gazette,  Nov.  15,  p.  543*(reported  in  Virchow  und  Hirsch's  JahresbericM  far  das.Tahr  1S73). 

2  D.  C.  Holliday,  "  Dengtie  or  Dandy  Fever,"  read  before  the  Amer.  Ptibl.  Health 
Assoc.  at  New  Orleans,  December,  1880. 

VOL.  I.— 56 


882  DENGUE. 

represent  a  simple  rash  or  erythema,  it  resembles  in  others  the  erup- 
tions of  scarlatina,  rubeola,  lichen,  or  urticaria.  Frequently  it  is  very 
light  and  evanescent,  showing  itself  only  for  a  few  hours,  and  perhaps 
in  the  majority  of  cases  it  does  not  appear  at  all.  In  the  severer  cases 
it  generally  remains  two  days,  when  it  commences  to  fade  and  dis- 
appear with  desquamation,  while  at  the  same  time  the  fever  subsides  and 
disappears  entirely,  though  the  stiffness  and  soreness  in  the  joints  and 
muscles,  together  with  the  inflammatory  condition  of  the  superficial  lym- 
phatic glands,  may  persist  for  many  weeks.  In  exceptional  cases  the 
eruption,  after  an  intermission  of  a  few  days,  reappears,  generally  with 
greater  intensity  and  with  an  aggravation  of  the  other  symptoms.  In 
others,  again,  it  has  been  observed  to  remain  a  whole  week. 

Hemorrhages  from  the  nose  and  gums  arc  also  occasionally  observed. 
Holliday  even  observed  the  occurrence  of  black  vomit  in  the  cases  of 
two  female  children,  aged  respectively  six  and  twelve,  in  the  same  family, 
who  had  suffered  from  yellow  fever  in  1878;  they  both  recovered  from 
the  attack  of  dengue,  though  they  were  extremely  ill  and  much  prostrated. 
In  female  patients  an  attack  of  dengue  not  uufrequently  causes  the  reap- 
pearance of  the  menstrual  flow,  while  the  paiiis  attending  the  disease 
equally  predispose  to  premature  labor  in  pregnant  women. 

In  severe  cases  of  dengue  the  prostration  following  upon  the  subsidence 
of  the  fever  is  very  great,  for  the  patient  is  affected  with  a  general  weak- 
ness both  of  body  and  mind,  indicating  a  great  loss  of  nervous  energy. 
In  some  cases  observed  by  Slaughter  the  memory  for  names  and  words, 
as  well  as  the  ability  for  correctly  writing  even  short  sentences,  was 
lost  for  one  or  two  weeks  after  the  commencement  of  convalescence. 
In  children  also  cases  are  reported  in  which  the  mind  remained  affected 
for  a  short  time  after  the  attack.  The  convalescence  in  dengue,  therefore, 
is  comparatively  slow,  particularly  as  the  pains  in  the  muscles  and  joints, 
as  already  mentioned,  pass  away  only  gradually. 

The  duration  of  the  disease,  including  the  stage  of  convalescence,  of 
course  depends  upon  the  degree  of  intensity  of  the  attack,  and  accordingly 
varies  in  different  cases.  In  a  great  number  of  cases  dengue  manifests 
itself  only  in  its  milder  form.  The  average  duration  of  the  disease  is 
from  three  to  six  days. 

PATHOLOGY.— The  pathological  changes  taking  place  in  the  different 
organs  during  the  course  of  dengue  are  unknown,  on  account  of  the 
almost  constantly  favorable  termination  of  the  disease.  From  the  peculiar 
features  of  some  of  the  clinical  symptoms  accompanying  the  disease,  how- 
ever, we  may  speculate  to  a  certain  extent  upon  the  nature  of  the  patho- 
logical processes  to  which  they  are  due.  The  sudden  appearance  of  the 
characteristic  pains  in  the  muscles  and  joints,  but  particularly  those  in  the 
head,  neck,  and  loins,  accompanied  by  a  comparatively  high  fever,  evi- 
dently point  to  the  presence  of  an  infectious  poison  in  the  system,  though 
the  question  whether  the  noxious  influence  of  this  poison  primarily  affects 
the  blood  or  the  nervous  system  will  be  difficult  to  answer.  But,  judging 
from  the  early  appearance  of  the  pains,  as  well  as  from  the  physical  and 
mental  depression  of  the  patient,  we  may  presume  that  the  nervous  sys- 
tem is  involved  from  the  very  beginning  of  the  disease,  and  that  the  pains 
depend  upon  a  hypcraemic  condition  of  the  affected  parts,  probably  caused 
by  a  vaso-motor  paralysis.  The  great  resemblance  of  the  painful  affec- 


ETIOLOGY.  883 

tion  of  the  muscles  and  joints  in  dengue  to  that  of  acute  articular 
rheumatism  kads  to  the  supposition  that  the  pathological  condition  in 
these  joints  is  the  same  in  both  diseases ;  this  view  appears  to  be  held  by 
the  majority  of  medical  observers.  In  dengue,  as  in  rheumatism,  the 
pain  due  to  the  pressure  of  the  hypersemic  and  swollen  tissues  upon  the 
irritated  sensory  nervous  filaments  is  increased  by  motion — a  phenomenon 
generally  absent  in  neuralgia.  The  persistent  headache,  restlessness,  and 
want  of  sleep,  as  well  as  the  delirium  and  loss  of  memory  observed  in  the 
severer  cases,  furthermore  indicate  a  hypenemic  condition  not  only  of  the 
pia  mater,  but  even  of  the  brain-substance. 

It  is  to  be  regretted  that  the  literature  of  dengue  within  our  reach 
shows  no  record  of  a  quantitative  analysis  of  the  urine,  from  which  we 
might  have  learned  the  quantity  of  urea  secreted  during  the  different 
stages  of  the  disease,  and  which  might  have  enabled  us  to  form  some  idea 
of  the  extent  of  the  destruction  of  the  albuminous  substances  during  the 
febrile  stage,  though,  judging  from  the  high  grade  of  fever  observed  in 
the  severer  cases,  we  may  well  presume  that  the  interchanges  of  matter  are 
considerably  augmented  during  this  stage ;  while,  on  the  other  hand,  the 
great  nervous  prostration  of  the  patient  directly  after  the  subsidence  of 
the  fever,  as  well  as  the  tardy  convalescence,  sufficiently  shows  that  a  large 
part  of  this  waste  is  derived  from  the  nervous  tissues.  The  exanthema- 
tous  eruption,  representing  a  hyperaBmia,  or  even  an  inflammation,  of  the 
skin,  furthermore  contributes  to  depress  the  nervous  system  by  the  pain 
and  itching  which  it  causes.  This  eruption,  together  with  the  inflamma- 
tion and  swelling  of  the  superficial  lymphatic  glands,  we  are  inclined  to 
associate  with  the  final  elimination  of  the  infectious  poison  from  the 
organism. 

Very  little  also  is  definitely  known  about  the  condition  of  the  remaining 
organs,  such  as  the  kidneys,  liver,  and  alimentary  canal.  The  examina- 
tions of  the  urine  in  dengue  recorded  in  literature  are  very  few  in 
number,  aud  appear  too  unreliable  for  drawing  any  definite  conclusions 
from  them  with  regard  to  the  condition  of  the  kidneys.  As  albuminuria 
is  met  with  in  other  infectious  diseases,  it  is  not  impossible  that  it  has 
also  occurred  in  severe  cases  of  dengue ;  though  from  the  favorable 
termination  of  the  disease  it  appears  quite  improbable  that  organic 
changes  take  place  in  these  organs.  In  the  same  way  may  the  liver  be 
functionally  deranged,  or,  judging  from  the  destruction  of  matter  during 
the  febrile  stage,  a  slight  fatty  infiltration  of  the  organ  may  even  occur — 
conditions  which  are  apt  to  pass  away  with  the  exciting  cause.  The 
gastric  irritability,  whenever  present,  may  be  of  nervous  origin,  though 
the  vomiting,  and"  particularly  that  of  black  hemorrhagic  matters,  observed 
in  exceptional  cases,  evidently  depends  upon  a  hypersemia  of  the  stomach. 

ETIOLOGY. — There  is  nothing  positively  known  of  the  origin  of 
dengue,  but  in  perusing  the  accounts  given  by  a  number  of  medical 
observers  from  the  different  localities  of  the  globe  where  it  prevailed,  we 
may  presume  that  it  existed  in  some  parts  of  Asia  and  Africa  long  before 
it  appeared  in  Europe  and  America.  Perhaps  the  earliest  record  of 
den<nie  is  the  one  dating  from  Cadiz  and  Seville,  and  concerning  the  epi- 


884  DENGUE. 

remembered  that  fifty  years  before  the  disease  had  prevailed  in  this  place. 
The  Arabians  living  at  this  island  also  had  known  the  disease  in  their 
own  country,  while  the  inhabitants  hailing  from  the  East  Indies  had 
never  seen  it.  From  the  accounts  of  other  writers  we  may  presume  that 
dengue  has  been  known  in  Arabia  for  many  generations.  But,  leaving 
aside  its  origin,  it  is  authentically  known  that  wherever  dengue  has 
appeared  it  has  almost  always  been  in  the  form  of  an  epidemic,  spreading 
from  place  to  place  and  from  family  to  family,  without  respect  to  race 
or  nationality,  to  age,  occupation  or  position,  until  every  one  suscepti- 
ble to  the  disease  was  aifected.  Slaughter  reports  from  India  that  even 
domestic  animals,  especially  dogs  and  cats,  were  not  exempt,  as  they 
appeared  to  suffer  from  rheumatoid  affections  of  the  joints. 

Although  toward  the  end  of  the  last  century  dengue  once  prevailed  epi- 
demically in  the  temperate  zone,  at  Philadelphia,  it  must  nevertheless  be 
considered  as  a  disease  especially  at  home  in  the  tropical  and  semi-tropical 
regions,  where  it  prefers  to  haunt  low  lands,  particularly  along  the  sea- 
coast,  leaving  almost  untouched  more  elevated  places.  Though  nothing 
definite  is  known  about  its  special  cause,  its  history  and  symptoms  evi- 
dently show  that  it  is  not  only  infectious,  but  also  highly  contagious,  in 
its  nature,  and  in  consequence  must  be  caused  by  the  entrance  of  a  spe- 
cific poison  into  the  system.  This  view  is  held  by  the  great  majority  of 
physicians  residing  in  the  various  localities  of  the  globe  where  the  disease 
has  prevailed.  But,  contagious  as  it  may  be,  it  greatly  distinguishes  itself 
from  other  contagious  diseases  by  almost  never  proving  fatal.  As  dengue 
generally  prevails  in  the  summer  season  and  disappears  with  the  approach 
of  cold  and  rainy  weather,  its  cause  is  apparently  subject  to  the  influence 
of  certain  meteorological  conditions. 

DIAGNOSIS. — When  dengue  appears  epidemically,  it  is  distinguished 
from  other  diseases  without  difficulty.  The  only  disease  with  which  it 
might  bo  confounded  when  appearing  in  a  sporadic  form  is  acute  articular 
rheumatism.  But  even  from  this  affection  it  may  be  distinguished  in  its 
earlier  stage  by  the  pains  not  being  limited  to  tlie  joints,  as  is  generally 
the  case  in  articular  rheumatism,  but  being  also  present  in  the  head, 
back,  and  loins.  Dengue  is,  moreover,  characterized  by  a  general 
physical  and  mental  nervous  depression,  while  in  rheumatism  the  mind 
almost  always  remains  clear.  In  the  latter  stage  the  peculiar  eruption 
and  painful  swelling  of  the  superficial  lymphatic  glands  in  dengue  decides 
the  question. 

It  has  frequently  been  stated  that  dengue  resembles  yellow  fever,  and 
some  physicians  have  even  regarded  it  as  a  mild  form  of  this  disease.  In 
examining  attentively,  however,  the  temperature  of  the  patient  during 
the  febrile  stage,  it  will  be  found  that  while  it  steadily  rises  in  yellow 
fever,  it  is  remittent  in  dengue.  There  is,  furthermore,  a  difference 
observed  in  the  state  of  the  pulse,  which  in  yellow  fever  generally  falls 
on  the  third  day,  while  the  temperature  continues  to  rise ;  in  dengue,  on 
the  contrary,  the  pulse  rises  with  the  temperature.  In  the  condition  of 
the  stomach  also  dengue  considerably  differs  from  yellow  fever,  for  while 
in  the  latter  disease  this  organ  is  almost  always  irritable,  and  vomiting 
is  very  frequently  present,  it  is  but  rarely  affected  in  dengue.  The  urine 
in  yellow  fever  very  frequently  contains  albumen  as  soon  as  the  third 
day ;  in  dengue,  almost  never,  so  far  as  the  analyses  recorded  enable  us 


PROGNOSIS.— TREATMENT.  885 

to  judge.  Finally,  the  absence  of  jaundice  and  the  appearance  of  the  erup- 
tion on  the  fourth  or  fifth  day  remove  all  doubt  about  the  nature  of  the 
disease.  There  are  a  number  of  other  points  by  which  dengue  may  be  dis- 
tinguished from  yellow  fever,  which  we,  however,  forbear  to  enumerate, 
for  the  reason  that  those  already  mentioned  wall  suffice  for  a  correct  dif- 
ferential diagnosis. 

PROGNOSIS. — Dengue,  as  has  been  stated  before,  scarcely  ever  termi- 
nates fatally  unless  it  is  complicated  by  some  iutercurrent  disease.  The 
prognosis,  therefore,  is  highly  favorable. 

TREATMENT. — Nearly  all  authors  recommend  a  symptomatic  treatment 
in  dengue,  beginning  with  a  mild  cathartic,  mercurial  or  not,  and  followed 
by  a  mild  diaphoretic.  To  relieve  pain  and  procure  sleep  opium — either 
uucombined  or  in  the  form  of  Dover's  powder — belladonna,  camphor, 
assafoetida,  valerian,  etc.  have  been  recommended  by  different  physicians ; 
liniments  containing  camphor  or  chloroform  have  also  been  used  with 
advantage  for  the  same  purpose.  Foot-baths  have  been  recommended  to 
relieve  the  headache.  To  relieve  the  stiffness  of  the  muscles  and  the 
articular  pains  after  the  subsidence  of  the  fever  iodide  of  potassium 
appears  to  be  a  favorite  remedy  in  the  East.  Colchicum  combined  with 
aconite  is  also  recommended  for  this  purpose,  as  well  as  artificial  sulphur 
baths  and  massage.  The  nervous  depression  during  convalescence  is  to 
be  combated  with  tonics  and  with  regulation  of  the  diet.  Quinia  appears 
to  be  generally  discarded  as  a  remedy  in  dengue. 


RABIES  AND  HYDROPHOBIA. 

BY  JAMES   LAW,  F.KC.V.S. 


SYNONYMS. — Canine  Madness,  Rabidus  Canis,  Canis  Rabiosa.  Greek, 
Lyssa,  Lytta,  Lyssa  Canina,  Cynolyssa,  Hydrophobia,  Pantephobia, 
JErophobia,  Phobodipsia,  Erethisiuus  Hydrophobia,  Clouos  Hydropho- 
bia, Dyscataposis.  French,  Tetanus  Rabien,  La  Rage,  Toxicose  Rabique. 
German,  Wuth,  Hundswuth,  Tolhvuth,  Wuthkraukheit,  Hundtollheit. 
Italian,  Rabbia,  Arabiata.  Spanish,  Rabia,  Rabiosa.  Swedish,  Hunds- 
juka.  Roumanian,  Turbarea. 

DEFINITION. — Canine  madness  is  an  acute  infectious  disease,  supposed 
to  arise  spontaneously  in  the  genus  Cauis  (dog,  wolf,  fox,  etc.)  and  Felis 
(cat,  etc.),  but  transmissible  by  inoculation  to  the  other  Mammalia  and  to 
birds.  It  is  characterized  by  a  long  period  of  incubation,  by  exaggerated 
reflex  excitability,  by  disorder  of  the  intellectual,  emotional,  and  other 
nervous  functions,  by  change  of  habits,  by  extreme  irritability  of  temper, 
by  optical  and  other  delusions,  by  spasms  of  the  muscles  of  the  eyeballs 
and  throat,  by  paralysis,  and  by  more  or  less  fever.  The  disease  runs  a 
short  and  almost  without  exception  fatal  course. 

HISTORY. — Plutarch  claims  that  hydrophobia  was  first  recognized  by 
the  Asclepiadre,  and  Homer's  allusions  to  the  malign  dog-star  and  to 
Hector's  acting  like  a  raging  dog  have  been  quoted  as  implying  a  know- 
ledge of  rabies.  We  find  no  certain  reference  to  the  affection,  however, 
until  we  come  to  Democritus  and  Aristotle,  in  the  fourth  century  B.  c. 
The  latter  clearly  describes  the  disease  and  uses  the  name  lytta,  but,  sin- 
gularly enough,  claims  for  man  an  exemption  from  the  general  suscepti- 
bility to  the  infection  by  inoculation.1  From  that  date  to  this  the  suc- 
cessive outbreaks,  sufficiently  noteworthy  to  secure  a  place  in  history,  are 
so  numerous  and  widespread  as  to  show  a  continuous  prevalence  of  the 
malady  in  the  Old  World,  and,  since  the  early  part  of  the  eighteenth  cen- 
tury, in  the  New. 

GEOGRAPHICAL,  DISTRIBUTION. — Rabies  is  more  prevalent  in  tem- 
perate regions  than  in  the  tropics  and  Arctic  Circle,  but  this  is  common  to 
all  animal  plagues  propagated  solely  or  mainly  by  contagion,  and  is  mani- 
festly due  chiefly  to  the  density  of  population,  the  activity  of  commerce, 
and  the  free  movement  of  men  and  animals  in  the  temperate  zone.  That 
a  hot  or  cold  climate  is  incompatible  with  rabies  is  disproved  by  its  preva- 
lence under  the  tropics  in  Southern  China,  India,  Abyssinia,  the  West 
Indies,  Peru,  Chili,  and  Brazil,  and  in  the  Arctic  Circle  in  Northern 
Greenland,  Lapland,  Siberia,  and  Kamtchatka.  On  the  other  hand,  many 

1  Hisloria  Animalium,  lib.  viii.  cap.  22. 
886 


ETIOLOGY.  887 

islands  and  secluded  regions  in  the  temperate  zones  maintain  a  continued 
immunity  or  have  been  invaded  only  recently  by  the  introduction  of 
infected  clogs.  We  may  instance  the  Hebrides,  Australia,  Tasmania,  New 
Zealand,  South  Africa,  West  Africa,  the  Azores,  St.  Helena,  and,  until  the 
last  half  century,  La  Plata,  Malta,  and  Hong-Kong.  The  disease  is  well 
known  throughput  North  Africa,  Arabia,  Syria,  Turkey,  and  Asia  gener- 
ally, in  Ceylon  and  other  of  the  East  Indian  islands.  It  is  also  notorious 
that  even  when  unusually  prevalent  its  progress  is  often  abruptly  arrested 
by  a  considerable  river,  and  Schrader  and  Virchow  both  notice  that 
though  it  ravaged  both  banks  of  a  river,  yet  the  islands  in  the  river 
escaped,  as  was  notorious  of  the  islands  in  the  Elbe  during  the  great 
Hamburg  epizootic  in  1852-53.  While,  therefore,  rabies  prevails  most 
extensively  in  the  more  civilized  countries  and  in  large  cities,  yet  we  can 
point  to  no  geographical  area  in  which  ,the  contagion  has  failed  to  spread 
among  those  bitten  by  rabid  animals,  nor  to  any  locality  in  which  the 
disease  has  been  shown  to  arise  spontaneously  from  unwholesome  condi- 
tions of  climate,  soil,  or  general  environment. 

ETIOLOGY. — We  know  of  but  one  efficient  cause  of  rabies — namely, 
infection.  Yet  as  many  conditions  are  believed  to  favor  its  extension,  or 
even  to  determine  its  spontaneous  eruption,  it  is  necessary  to  speak  of 
them  shortly. 

As  shown  above,  climate  cannot  be  charged  with  the  generation  nor 
diffusion  of  rabies.  Many  countries  formerly  thought  exempt  are  now 
known  to  suffer.  The  following  may  be  named  :  The  East  and  West 
Indies,  Syria,  Egypt,  Cyprus,  Siberia,  the  lands  north  of  the  Baltic,  and 
South  America.  Others  manifestly  maintain  their  exernptiou  only 
because  the  morbid  germ  has  not  yet  been  introduced. 

Certain  seasons  undeniably  show  a  far  wider  extension  of  the  disease 
than  others,  but  such  epizootics  are  not  limited  to  a  particular  season  or 
year,  and,  unless  cut  short  by  human  intervention,  cover  a  succession  of 
years  of  the  most  varied  climatic  character,  spare  inaccessible  or  secluded 
islands  in  the  very  centre  of  the  outbreak,  and  the  cycles  of  prevalence 
will  succeed  each  other,  in  place,  of  occurring  simultaneously,  in  closely 
adjacent  countries  subject  to  the  same  climatic  vicissitudes,  but  separated 
by  narrow  seas.  Even  a  broad  river  destitute  of  bridges  usually  abruptly 
arrests  an  epizootic,  and  protects  the  laud  beyond  lying  under  precisely 
the  same  general  influences.  In  this  connection  may  be  quoted  the  recent 
great  epizootic  of  1856-72  in  England,  which  succeeded,  but  did  not 
accompany,  that  of  1851-56  in  Germany.  Prof.  Roll  reports  the  extra- 
ordinary prevalence  of  rabies  at  Vienna  in  1814,  1815,  1830,  1838, 
1842,  and  1862 — years  remarkable  for  diversity  rather  than  uniformity 
of  climatic  characters. 

Popular  opinion  refers  rabies  to  the  extreme  heats  of  summer,  and  each 
year  dogs  are  muzzled  or  otherwise  confined  by  order  of  municipal  author- 
ities during  the  dog  days,  though  left  at  liberty  throughout  the  rest  of 
the  year.  In  1780,  Audry  observed  that  the  coldest  and  hottest  months 
furnished  the  least  number  of  cases,  and  later  Hurtrel  D'Arboval  claimed 
that  in  France  dogs  suffered  most  in  May  and  September,  and  wolves  in 
March  and  April.  Bouley  claims  that  the  majority  of  dogs  suffer  in 
March,  April,  and  May.  The  following  statistics  are  interesting  in  this 
connection  : 


888  RABIES  AND  HYDROPHOBIA. 

Cases  of  Rabies  in 
"\VIXTER.  SPRING.  SUMMER.  AUTUMN. 

Dec.,  Jan.,  Feb.       March,  April,  May.       June,  July,  Aug.       Sept.,  Oct.,  Nov. 

Dogs 755  857  788  696  (Bouley). 

Men 17  25  42  13  (Boiulin). 

The  increase  of  cases  of  rabies  caiiina  in  the  spring  and  summer 
mouths,  as  shown  by  the  above  statistics  (7-15  per  cent.),  cannot  reason- 
ably be  attributed  to  the  influence  of  the  weather,  since  even  the  strongest 
advocates  for  spontaneity  would  at  once  decline  to  claim  any  such  ratio 
of  spontaneous  developments.  The  increase  must  therefore  be  mainly, 
if  not  altogether,  due  to  the  increased  number  of  inoculations;  and  these 
latter  are  provided  for  in  the  jealousies  and  quarrels  in  the  troops  of 
males  that  follow  each  rutting  bitch  in  spring,  the  principal  period  of 
oestrum  in  the  canine  female.  The  infection  spread  in  this  way  in 
early  spring  tends  to  remain  more  prevalent  throughout  the  hot  summer 
months. 

With  regard  to  the  greatly  enhanced  mortality  in  man  during  the 
summer  mouths,  as  shown  in  Boudin's  statistics  for  France,  in  the 
absence  of  any  genuine  hydrophobia  in  man  apart  from  inoculation 
from  a  rabid  animal,  it  may  be  attributed  to  three  principal  causes : 
1st.  The  bites  sustained  from  rabid  dogs  in  spring  and  early  summer, 
when  the  disease  is  most  widely  spread  among  these  animals,  will  give 
rise  to  hydrophobia  weeks  or  months  later.  2d.  In  the  warm  season 
the  body  is  more  thinly  clad  and  the  hands  and  other  portions  are  more 
frequently  left  bare,  so  that  the  teeth  are  less  likely  to  be  cleansed  of  the 
virulent  saliva  by  passing  through  the  clothes  before  entering  the  skin. 
3d.  The  languor,  fever,  and  nervousness  attendant  on  extreme  heat  tend 
not  only  to  hasten  the  activity  of  any  disease-germs  actually  present  in 
the  system,  but  also  strongly  favor  the  increase  of  that  nervous  fear 
which  so  often  generates  a  fatal  pseudo-hydrophobia  (lyssophobia)  in 
persons  that  have  been  bitten  by  dogs. 

Hunger,  thirst,  and  spoiled  food  are  invoked  as  causes  of  rabies,  yet  in 
the  East,  where  the  dogs  are  the  scavengers  of  the  cities  and  often  suffer 
severely  from  hunger  and  thirst,  eat  the  most  offensive  carrion,  and 
drink  the  foulest  water,  the  disease  has  a  very  restricted  prevalence, 
while  in  South  Africa  and  Australia  the  outcast  and  sheep-dogs,  often 
the  victims  of  starvation  and  thirst,  entirely  escape.  Bourgelat,  Dupuy- 
tren,  Majendie,  Breschet,  and  others  have  cruelly  destroyed  dogs  by  pri- 
vation of  food  and  water  and  by  exposure  under  a  broiling  sun,  but  no 
rabies,  nor  anything  resembling  it,  was  produced.  Dogs  perspire  little 
and  suffer  severely  from  heat,  but  there  is  no  evidence  that  this  can 
develop  canine  madness.  It  is  claimed  that  Rossi  of  Turin  developed 
rabies  in  cats  by  withholding  food  and  drink,  but,  as  he  furnishes  no 
inoculation-tests  confirmatory  of  its  virulence,  the  claim  cannot  be 
endorsed.  Experiments  with  an  exclusive  diet  of  salt  meat,  putrid 
meat,  and  water  only  have  failed  to  produce  rabies. 

The  large  preponderance  of  male  dogs  attacked  with  rabies  has  been 
constantly  remarked  by  writers.  Of  1990  rabid  dogs  reported  by  differ- 
ent authors,  1746  were  males  and  244  females — a  ratio  of  more  than  7 
to  1.  This  excess  of  males  attacked  is  much  higher  than  the  ratio  of 
males  in  the  dogs  of  the  districts  drawn  upon.  Thus,  Bourrel  found  a 


ETIOLOGY.  889 

ratio  of  6  rabid  males  to  1  rabid  female,  while  in  his  patients  generally 
the  proportion  was  4  to  1.  Leblanc  found  that  14  per  cent,  of  the  male 
dogs  went  mad,  while  but  1  per  cent,  of  the  females  suffered.  That  sex 
is  no  protection  against  inoculated  virus  is  shown  by  the  frequent  inocula- 
tion of  castrated  dogs  of  both  sexes.  The  excess  of  male  subjects  may 
be  attributed  mainly  to  the  frequency  with  which  these  bite  each  other 
when  following  a  female  in  heat,  and  the  respect  of  all  alike  for  the 
latter  sex.  Even  in  the  rabid  dog  the  sexual  instinct  rises  above  the 
propensity  to  bite  in  the  early  stages  of  the  malady. 

Toffoli  claims  that  he  has  caused  spontaneous  rabies  by  shutting  up  seve- 
ral dogs  in  a  loose  box  with  a  bitch  in  heat  and  allowing  them  to  fight  for 
the  prize.  Weber  and  Leblanc  have  noticed  similar  occurrences.  But 
Greve  and  Menecier  have  repeated  the  experiments  with  a  contrary 
result ;  so  that  it  remains  probable  that  when  successful  the  victims  had 
already  been  inoculated  before  they  were  shut  up.  Moreover,  the  seclu- 
sion of  male  canine  animals  for  a  lifetime  in  menagerie  cages,  often 
adjoining  those  of  their  corresponding  females,  has  never  been  known 
to  induce  rabies. 

The  bite  of  the  violently  enraged  dog,  and  the  bites  mutually  given 
when  following  a  rutting  bitch,  are  popularly  supposed  to  cause  rabies ; 
but  if  this  were  the  case,  the  disease  must  have  been  universally  preva- 
lent. The  idea  that  the  bite  of  a  dog  will  cause  hydrophobia  should  that 
dog  at  any  subsequent  period  go  mad  is  a  similar  delusion.  Men  doubtless 
occasionally  develop  lyssophobia  under  such  an  influence,  but  animals  do 
not  contract  genuine  rabies. 

Dogs  are  alleged  to  have  gone  mad  from  violent  suffering  after  an 
operation,  and  cats  from  being  scalded  or  robbed  of  their  kittens,  but  all 
such  causes  are  continually  operating  without  such  effect,  and  when  in  a 
solitary  case  rabies  develops,  it  can  only  be  looked  on  as  a  coincidence. 

Much  popular  prejudice  exists  against  certain  breeds,  and  the  Pome- 
ranian has  been  virtually  ostracised  on  account  of  its  supposed  liability 
to  rabies;  but  statistics  show  that  the  liability  to  contract  the  affection 
bears  a  relation  to  the  exposure  rather  than  the  special  breed.  Eckel, 
Pillwax,  and  Hertwig  found  that  dogs  kept  as  house-  or  Avatch-dogs,  and 
most  pampered  and  confined,  are  the  most  liable,  while  St.  Cyr  and 
Peuch  found  the  greatest  number  of  cases  among  those  runnuiug  at  large 
and  allowed  the  freest  exercise. 

There  is  a  popular  belief  that  the  bite  of  the  skunk  (Mephitis  mephitica) 
is  always  rabi  fie.  Rev.  H.  C.  Hovey  describes  a  number  of  cases  of  infection 
from  this  animal,1  and  John  G.  Janeway  has  reported  other  instances.2  Both 
claim  that  the  disease  is  spontaneous  in  the  skunk,  and  Mr.  Hovey  holds,  on 
very  insufficient  grounds,  that  the  affection  is  a  distinct  variety  of  rabies 
(rabies  mephitica).  The  facts  seem  to  warrant  only  the  conclusion  that 
skunks  in  certain  districts  of  Michigan  and  Kansas  have  had  rabies  com- 
municated to  them,  and  follow  the  rabid  impulse  to  bite  other  animals  and 
men.  The  Mephitime  abound  in  the  Eastern  States,  but  we  never  hear 
of  them  stealing  up  and  biting  men  or  dogs,  nor  of  the  latter  contracting 
rabies  from  skunk-bite.  Eastern  dogs  frequently  kill  skunks  and  sustain 
bites,  but  do  not  thereby  contract  rabies.  Even  in  Kansas  this  evil 

1  Amer.  Jour,  of  Science  and  Art,  May,  1874. 

2  ATew  York  Medico]  Record,  March  13,  1875. 


890  EABIES  AND  HYDROPHOBIA. 

influence  of  the  skunk-bite  was  unknown  until  1870,  showing  that  it  is 
not  inherent  in  the  climate  nor  soil,  but  has  been  presumably  imported. 
The  spontaneity  of  the  affection  is  assumed,  not  proved. 

In  the  above  epitome  of  alleged  causes  we  find  nothing  proving  the 
spontaneous  evolution  of  rabies.  The  prevalence  of  the  affection  in 
wolves,  foxes,  jackals,  cats,  skunks,  etc.  proves  nothing  for  spontaneity, 
more  than  its  existence  in  the  dog."  In  all  these  species  of  animals  the 
malady  develops  the  dread  propensity  to  bite,  and  thus  in  all  alike  pro-' 
vision  is  made  for  the  perpetuation  and  propagation  of  the  malady. 
Unless  a  previous  attack  by  a  rabid  animal  has  been  observed,  owners 
usually  insist  that  their  dogs  have  contracted  the  malady  spontaneously, 
yet  a  rigid  scrutiny  will  almost  always  reveal  a  strong  probability,  at  least, 
of  inoculation.  The  rabid  dog  wanders  far  from  home,  and  sometimes 
accomplishes  wonderful  feats  of  leaping  to  reach  his  victim,  so  that  his 
presence  in  a  district  is  not  even  suspected,  and  animals  thought  to  be 
safely  secluded  inside  high  walls  suffer  from  his  fangs.  He  is  more 
inclined  to  bite  and  rush  on  than  to  stay  and  devour,  and  thus  small 
animals,  like  the  skunk,  when  bitten  may  survive  to  propagate  the  disease 
in  places  to  which  a  dog  could  not  possibly  find  access.  Much  circum- 
stantial evidence  makes  strongly  against  the  theory  of  spontaneity.  Thus, 
the  immunity  of  the  islands  of  the  Elbe  in  the  very  midst  of  a  severe 
and  protracted  epizo5tic,  the  continued  immunity  of  the  Hebrides  and 
of  Malta,  each  famed  for  its  indigenous  race  of  dogs,  for  long  centuries, 
during  which  the  malady  prevailed  at  frequent  intervals  on  the  adjacent 
mainlands,  and  the  continued  exemption  of  South  Africa  and  of  the 
Australasian  and  other  islands,  in  the  face  of  the  counter-fact  that  the 
affection  persisted  after  importation  in  the  West  Indies  and  South 
America,  speak  strongly  for  the  doctrine  that  the  introduction  of  a  pre- 
existing germ  is  an  essential  condition  of  the  evolution  of  the  disease. 
The  following  statistics  of  cases  which  entered  the  Berlin  Veterinary 
College  furnish  further  corroborative  evidence.  There  entered  the  college, 

In  9  years,  1845-53,  inclusive,  278  rabid  dogs. 
"  1854  4     " 

"  1855  1     "      dog. 

"  1856  1     "        " 

"  5  years,  1857-61,  inclusive,      0    "        " 

The  average  for  each  of  the  first  nine  years  was  a  fraction  less  than  31. 
In  the  two  last  of  the  nine  the  cases  rose  to  68  and  82,  and  this  led  early 
in  1854  to  an  order  for  the  muzzling  of  all  dogs,  which  was  rigidly 
enforced  by  the  police.  The  disease  was  promptly  suppressed,  the  two 
cases  in  the  two  succeeding  years  being  probably  due  to  infected  kennels 
or  to  importation  from  without.  The  results  in  Eldena  (Fuertenberg) 
and  Holland  (Van  Capelle)  are  equally  conclusive.  The  inefficiency  of 
some  orders  for  the  muzzling  of  dogs  makes  nothing  against  these  facts. 
A  law  on  the  statute-book  is  not  always  a  law  in  force,  as  I  saw  in 
Alfort  and  Lyons  in  18G3;  the  dogs  wore  their  muzzles  only  in  honor 
of  the  periodic  visits  of  the  commi««ionuaire  of  police,  and  rabies  pre- 
vailed. 

Tlie  great  majority  of  competent  observers  of  to-day  deny,  or  at  least 
strongly  doubt,  the  occurrence  of  the  disease  apart  from  inoculation. 
Without  assuming  to  decide  the  question  for  all  times  and  places,  it  may 


ETIOLOGY.  891 

be  safely  asserted  that  there  is  no  sufficient  proof  of  such  an  occurrence 
in  any  recent  time.1 

The  contagion  of  rabies  is  usually  resident  in  the  saliva,  but  is  by  no 
means  confined  to  that  product.  Paul  Bert  found  the  bronchial  mucus 
virulent  in  dogs  in  which  the  saliva  was  non-virulent.  The  flesh  has 
conveyed  the  disease  when  eaten,  though  probably  only  because  of  sores 
or  abrasions  on  the  alimentary  tract.  Smith  records  the  death  of  negroes 
in  Peru  from  eating  rabid  cows ; 2  Schenkius,  that  of  persons  who  ate  of 
a  rabid  pig ;  aud  Gohier  and  Lafosse  have  infected  dogs  by  feeding  the 
flesh  of  rabid  dogs  and  ruminants ;  Rossi  and  Hertwig  have  separately 
induced  rabies  by  inoculating  sound  animals  with  portions  of  nerves  from 
raoid  ones.  No  absolute  proof  can  be  adduced  that  the  disease  has  been 
conveyed  through  consumption  of  the  milk.  Cases  quoted  to  show  its 
virulence  are  open  to  the  objection  that  the  dam  probably  licked  the 
offspring.  A  similar  uncertainty  attaches  to  the  spermatic  fluid.  Women 
are  alleged  to  have  acquired  hydrophobia  by  coitus,  but  no  such  case  can 
be  adduced  among  animals,  though  rabid  males  have  often  had  connection 
with  healthy  females.  The  .alleged  cases  in  women  were  therefore 
probably  the  result  of  an  excited  imagination  or  caused  by  virus  intro- 
duced through  some  other  channel.  The  breath  and  perspiration  seem 
incapable  of  becoming  media  for  the  transmission  of  the  disease.  The 
blood  was  supposed  to  be  non-virulent  by  Breschet,  Majeudie,  Dupuytren, 
Elaine,  Youatt,  etc.,  but  has  been  shown  by  Eckel  and  Lafosse  to  be 
rabific.  Eckel  successfully  inoculated  the  blood  of  a  rabid  he-goat  on  a 
sheep  and  that  of  a  rabid  man  on  a  dog.  Lafosse  accomplished  the  same 
in  one  of  three  attempts  by  inoculation  from  dog  to  dog.  The  blood  is 
probably  only  virulent  in  the  advanced  stages  of  the  disease,  and  its 
virulence  implies  the  virulence  of  all  vascular  tissues. 

The  saliva  of  rabid  Herbivora  and  Omnivora,  long  held  to  be  harm- 
less, is  now  known  to  be  virulent.  Berudt  has  successfully  inoculated  it 
from  an  ox  to  four  sheep ;  Eckel  from  a  goat  to  a  sheep ;  Rey  from  sheep 
to  sheep ;  Lessona  from  an  ox  to  two  horses  and  a  sheep ;  Tombaro  from 
a  heifer  to  a  sheep,  a  horse,  and  two  dogs ;  Youatt  from  horse  and  ox 
respectively  to  dogs  ;  Ashburner  from  an  ox  to  fowls ;  King  from  a  cow 
to  fowls ;  and  Majendie,  Breschet,  Eckel,  Hertwig,  and  Renault  from 
man  to  dog ;  and  Earle  from  man  to  rabbits.  Besides  these  are  a  series 
of  accidental  cases,  as  from  horse  to  man  (Youatt),  from  a  sheep  to  its 
shepherd  (Tardieu),  and  from  man  to  man  (Aureliauus,  Euaux,  Chaussier). 

Experiments  by  Hertwig  and  Eckel  seem  to  show  that  saliva  loses  its 
virulence  on  the  supervention  of  cadaveric  rigidity  or  putrefaction  in  the 
dead  body.  Haubner  even  believed  dried  saliva  to  be  innocuous.  Yet 
Count  Salm  successfully  inoculated  the  dried  saliva  of  a  rabid  dog,  and 
Schenkius  reports  a  case  of  hydrophobia  produced  by  a  scratch  of  a 
hunting-knife  that  had  been  used  to  kill  a  mad  dog  some  years  before. 
A  veterinary  student  at  Copenhagen  cut  his  finger  while  dissecting 

1  Mr.  SAze,  a  former  student,  informed  me  that  boys  in  Japan  produce  what  is  believed 
to  be  canine  rabies  by  administering  to  dogs  a  fungus  (bukgryo)  found  growing  on  a  con- 
iferous tree.  The  dogs  do  not  all  seem  to  die,  but  are  usually  killed  by  way  of_ precau- 
tion. The  symptoms  are  those  of  delirium,  with  a  propensity  to  bite,  and  the  disease  is 
assumed  to  be  communicable,  though  no  facts  are  given  to  show  that  it  is  so.  This 
popular  fancy  has  all  the  air  of  a  popular  fallacy,  but  as  the  counterfeit  attests  the 
genuine,  it  sliows  the  familiarity  of  the  Japanese  with  true  rabies.  2  Peru  as  it  Is. 


892  RABIES  AND  HYDROPHOBIA. 

the  body  of  a  rabid  dog  twelve  hours  after  death,  and  died  of  hydro- 
phobia six  weeks  later.  These  cases  in  man  may,  it  is  true,  have  resulted 
from  fear,  but  the  same  cannot  be  said  of  the  infection  of  hound  after 
hound  placed  in  empty  infected  kennels,  as  recorded  by  Blaine,  Youatt, 
and  others.  In  the  face  of  this  it  would  require  very  strong  negative 
testimony,  indeed,  to  prove  that  the  virus  of  rabies  is  devitalized  in 
drying — a  process  which  prolongs  the  vitality  of  other  virulent  matters. 

Up  to  the  present  time  the  germ  of  rabies  has  not  been  demonstrated. 
That  it  is  a  particulate  living  organism  may  be  reasonably  deduced  from 
its  power  of  indefinite  increase — a  quality  possessed  by  no  mere  chemical 
nor  mechanical  agent,  also  from  the  saliva  proving  non-virulent  after  fil- 
tration through  plaster,  while  the  solid  residue  left  on  the  filter  was  viru- 
lent (Bert).  But,  although  bacteria  have  been  found  in  the  saliva,  those 
demonstrated  up  to  the  present  are  manifestly  ordinary  aerial  bacteria, 
such  as  in  Pasteur's  experiments  produced  septicaemia  rather  than  rabies. 
It  still  remains,  therefore,  for  some  future  observer  to  discover  that  germ 
of  which  we  cannot  doubt  the  existence. 

The  point  of  election  of  this  germ  appears  to  be  mainly  the  nervous 
tissue.  Pasteur  found  the  brain-matter  of  rabid  animals  invariably 
infectious,  and  has  preserved  the  moist  brain  in  an  infecting  condition  for 
three  weeks  at  a  temperature  of  12°  C.  He  found  that  by  direct  inocula- 
tion in  the  brain-substance  the  period  of  incubation  was  abridged,  rabies 
often  showing  itself  in  six,  eight,  or  ten  days.  In  the  face  of  Rossi's 
successful  inoculation  of  nerves  and  Pasteur's  results  with  brain-matter  it 
is  difficult  to  account  for  the  unsuccessful  inoculation  of  nerve-tissue  in 
six  successive  experiments  by  Hertwig.  It  seems  to  show  that  though 
the  virus  is  concentrated  in  the  brain,  and  especially  in  the  medulla  and 
pons,  yet  it  does  not  equally  permeate  the  entire  nervous  system.  This 
election  of  the  poison  for  the  nervous  tissue  led  IJr.  Douboue  in  1851  to 
advance  the  theory  that  it  is  propagated  from  the  seat  of  inoculation  to  the 
brain  through  the  medium  of  the  nerves — a  position  now  assumed  by  Pas- 
teur. This,  we  fear,  is  not  well  founded.  The  poison,  advancing  for  a  month 
or  more  along  the  lines  of  the  nerves,  would  probably  derange  and  abolish 
their  functions,  as  it  does  so  speedily  and  effectually  that  of  the  nerve- 
centres  after  it  has  gained  a  seat  in  them,  whereas,  in  reality,  the  local 
paralysis  only  appears  in  the  last  stages  and  after  the  symptoms  of  cere- 
bral disorder  are  well  established.  Futhermore,  a  common  premonitory 
symptom  of  rabies  is  congestion,  swelling,  and  irritation  of  the  inoculation 
wound,  showing  a  sudden  extraordinary  activity  at  that  point  as  a  herald, 
if  not  a  condition,  of  the  general  infection,  whereas  under  a  S!OAV  propa- 
gation along  the  nerves  from  the  first  this  irritation  would  probably  have 
been  greatest  in  the  wound  at  the  outset,  and  would  have  thereafter  kept 
pace  with  the  progress  of  the  virus  along  the  nerves.  Again,  the  blood 
is  not  always  infecting.  Blaine,  Youatt,  and  others  of  the  older  observers 
had  no  fear  of  the  blood.  Hertwig  obtained  rabies  in  two  cases  only  out 
of  eleven  inoculations  with  the  blood  of  rabid  subjects.  The  blood  in 
this,  as  in  some  other  diseases  (variola  equina,  v.  ovina,  lung  plague  of 
cattle),  proves  to  a  certain  extent  inimical  and  destructive  to  the  poison. 
Galtier  inoculated  nine  sheep  and  one  goat  by  intravenous  injection  of  the 
saliva  of  mad  dogs,  in  no  case  with  fatal  results  nor  indeed  with  any 
manifestation  of  rabies,  but  with  the  effect  of  fortifying  the  system  so, 


ETIOLOGY.  893 

that  subsequent  inoculation  into  the  tissues  of  the  saliva  of  rabid  animals 
was  harmless.  Test  inoculations  made  in  the  tissues  of  other  animals 
with  the  same  virus  used  in  his  intravenous  injections,  and  his  subsequent 
inoculations  of  the  animals  so  treated,  invariably  determined  rabies. 
Pasteur  repeated  these  intravenous  injections  in  dogs  with  the  result  of 
rapidly  inducing  rabies  iu  a  fair  proportion  of  cases.  One  of  his  cases 
produced  in  this  way  recovered,  and  thenceforward  resisted  all  further 
inoculation  with  the  virus.  Others  that  did  not  perish  from  intravenous 
injection  afterward  died  of  rabies  after  inoculation  in  the  brain.  Unfortu- 
nately, neither  G aider  nor  Pasteur  have  reported  how  much  virulent 
saliva  was  injected  in  any  one  case,  so  that  we  have  no  data  as  to  whe- 
ther the  difference  was  due  to  the  varying  quantity  of  the  virus  intro- 
duced in  the  various  cases.  Lussana,  an  Italian  physician,  had  already  in 
1878  experimented  on  two  dogs  by  injecting  into  their  veins  the  blood  of 
a  physician  who  died  of  hydrophobia.  The  blood  Avas  drawn  by  leeches 
and  cupping-glasses,  and  five  grammes  were  injected  into  each  dog.  One 
died  on  the  twenty-fourth  day,  presenting  the  symptoms  and  post-mortem 
appearances  of  rabies.  The  second  at  the  end  of  one  hundred  and  forty 
days  developed  symptoms  of  rabies  which  lasted  a  month,  when  the  ani- 
mal was  sacrificed,  and  nothing  special  found  at  the  autopsy.  The  data 
do  not  warrant  a  very  positive  conclusion,  yet  they  seem  to  imply  that 
the  receptivity  on  the  part  of  the  dog  is  greater  than  that  of  the  small 
ruminants.  They  suggest,  further,  a  greater  relative  potency  in  the  battle 
for  life  of  the  blood-globules  of  the  small  ruminants  with  this  unknown 
rabific  germ.  This  antagonism  between  the  blood  of  the  ruminant  and  the 
germ  of  rabies  finds  a  parallel  in  the  case  of  other  disease-poisons  in  their 
relations  to  the  nuclei  of  the  tissues.  Thus  animals  may  prove  refractory 
to  a  small  dose  of  the  poison  of  anthrax,  yet  Chauveau  has  shown  that  this 
virus  will  overcome  all  native  or  acquired  insusceptibility  when  adminis- 
tered in  excess.  The  same  is  true  of  the  poison  of  chicken  cholera,  which 
Salmon  dilutes  until  it  is  non-fatal,  though  still  affecting  the  system  and 
conferring  an  immunity  from  its  attacks  in  the  future.  So  with  the  lymph 
of  variola  ovina,  which  Peuch  diluted  to  -fa  and  injected  with  the  effect 
of  producing  slight  fever  and  immunity  without  vesiculation. 

This  view  would  imply  that  in  ordinary  cases  (inoculation  with  a  mod- 
erate amount  of  the  poison)  the  virus  is  for  a  time  localized  in  the  vicinity 
of  the  wound ;  and.  this  is  further  supported  by  the  fact  that  thorough 
excision  and  cauterization  of  the  wound  some  time  after  it  has  been 
received  is  still  often  protective.  It  is  weakened  by  the  fact  that  bites  of 
dogs  in  the  stage  of  incubation  sometimes  produce  rabies,  but  it  must  be 
borne  in  mind  that  there  is  still  a  period  between  the  passage  of  the  liv- 
ing germ  to  the  salivary  glands  and  brain  and  the  growth  of  the  germ 
in  the  nerve-centres,  so  as  to  produce  pathognomonic  symptoms,  during 
which  both  blood  and  saliva  must  be  virulent. 

The  ratio  of  successful  inoculations  to  the  bites  is  very  varied.  Thus, 
out  of  555  dogs  reported  to  have  been  bitten  by  rabid  dogs,  188  con- 
tracted rabies  ;  out  of  183  experimentally  exposed  till  bitten  or  inoculated, 
91  became  mad ;  out  of  73  cattle  bitten,  45  became  rabid ;  out  of  121  sheep 
bitten,  51  succumbed;  and  of  890  persons  bitten,  428  took  hydrophobia 
(48  per  cent.).  Of  440  bitten  by  rabid  wolves,  291,  or  66  per  cent.,  took 
the  disease.  Such  statistics  are,  however,  far  from  satisfactory.  Of  dogs 


894  RABIES  AND  HYDROPHOBIA. 

reported  mad,  some  have  only  suffered  from  epilepsy,  convulsions,  or  colic, 
while  of  those  bitten  by  the  really  mad  dog,  some  have  sustained  simple 
bruises  without  any  real  abrasion ;  in  other  cases  the  teeth  have  been 
wiped  clean  by  passing  through  thick  wool,  hair,  or  clothing,  or  even  the 
flesh  of  other  animals  just  bitten  ;  in  other  cases  the  bite  has  been  inflicted 
at  a  time  when  the  virulence  of  the  saliva  was  at  its  minimum,  or  in  a 
subject  which  was  naturally  insusceptible.  The  protective  effect  of  cloth- 
ing was  well  illustrated  in  a  case  which  came  under  my  notice  in  London. 
Six  animals  bitten  by  a  rabid  dog  all  contracted  mbies,  whilst  a  man  bitten 
a  few  hours  before  through  the  coat-sleeve,  and  who  did  not  have  the 
wound  cauterized  for  a  full  hour  after  the  bite,  escaped.  Bouley  found 
that  in  32  persons  bitten  in  the  face,  29  died  of  rabies  (90  per  cent.) ;  of 
73  bitten  on  the  hands,  46  died  (63  per  cent.) ;  of  28  bitten  on  the  arms, 
8  died  (28  per  cent.) ;  of  24  bitten  on  the  lower  limbs,  7  died  (29  per 
cent.);  of  19  bitten  on  the  body  (usually  multiple  wounds),  12  died  (63 
per  cent.).  The  high  mortaltty  from  the  bites  of  rabid  wolves  and 
skunks  is  mainly  due  to  this  habit  of  attacking  the  face  and  hands.  As 
illustrative  of  insusceptibility  may  be  quoted  the  poodle  of  Hertwig, 
which  was  inoculated  nine  times  with  unquestionably  rabic  virus  without 
effect;  also  the  pointer  of  Rey,  which  was  seventeen  times  bitten  by  rabid 
dogs  without  harm  ;  also  the  acquired  immunity  of  Galtier's  sheep  and 
rabbits,  above  referred  to. 

INCUBATION. — In  the  dog  this  varies  from  6  days  (Pasteur)  to  240 
days  (Bellinger).  In  the  majority  of  cases  it  ends  in  from  20  to  50  days. 
Pasteur,  by  inoculating  into  the  brain  substance  direct,  reduced  the  incu- 
bation from  20  days  to  6  days.  In  the  horse  the  limits  of  reported  cases 
are  from  15  days  to  92  days.  In  the  ox  incubation  varies  from  20  to 
30  days ;  in  sheep,  from  20  to  74  days ;  and  in  swine,  from  20  to  49 
days  in  recorded  cases. 

In  man  incubation  is  believed  to  be  often  much  more  prolonged.  In 
6  per  cent,  of  all  cases  it  is  from  3  to  18  days ;  in  60  per  cent.,  from  18 
to  64  days ;  and  in  34  per  cent,  it  exceeds  64  days  (Hamilton,  Thamhayn). 
Quite  frequently  symptoms  of  hydrophobia  appear  from  three  to  six 
mouths  after  the  bite ;  in  a  few  the  period  is  prolonged  to  one  or  two 
years,  and  in  rare  instances  to  seven  (Schule),  and  even  twelve  years 
(Chabert).  But  all  such  cases  of  prolonged  incubation  in  man  are  at  the 
least  extremely  doubtful.  Man  often  contracts  a  pseudo-hydrophobia  as 
the  result  of  fear,  and  is  curable  by  moral  suasion -alone ;  and  as  no  such 
protracted  incubations  are  noticed  in  the  lower  animals,  and  as  no  one  of 
these  abnormally  deferred  attacks  in  man  has  been  verified  by  successful 
inoculation  on  animals,  it  is  prudent  to  reserve  a  full  assent  until  they  are 
supported  by  better  testimony.  A  specimen  of  such  cases  is  that  recorded 
by  Chirac,  in  which  a  cadet  bitten  at  Montpellier  afterward  spent  ten 
years  in  Holland,  and  then,  returning  and  hearing  that  his  fellow-cadet 
bitten  by  the  same  dog  had  died  of  hydrophobia,  he  also  manifested  the 
disease  and  died.  Another  is  the  case  of  a  man  who,  after  having  been 
bitten,  spent  two  years  in  prison,  and  then  developed  hydrophobia  and 
died.  A  mind  naturally  erratic  and  rendered  weaker  and  more  suscepti- 
ble by  prolonged  confinement  would  prey  upon  itself  and  exaggerate  the 
danger  when  the  subject  had  been  forcibly  presented.  In  all  such  cases 
the  attending  physician  should  feel  bound  in  the  interests  of  humanity  to 


SYMPTOMATOLOGY.  895 

inoculate  a  dog  or  other  animal  and  ascertain  whether  or  not  the  disease 
is  virulent.  The  value  of  such  results  in  dealing  with  future  cases  of 
the  same  kind  cannot  be  overestimated. 

The  period  of  incubation  appears  to  be  relatively  shorter  in  the  young 
(average  45  days)  than  the  old  (average  70  days),  and  is  believed  to  be 
shortened  by  constitutional  excitement  from  violent  passion,  fever,  the 
heat  of  the  weather,  or  electrical  disturbances. 

During  incubation  no  sign  of  the  disease  can  be  detected  ;  it  is  even 
said  that  the  wounds  heal  with  unusual  rapidity  ;  but  it  is  certain  that 
toward  the  end  of  the  latency  the  cicatrix,  alike  in  man  and  animals, 
tends^to  become  sensitive,  itchy,  congested,  and  even  the  seat  of  papular 
eruptions.  The  vesicles  (lyssi)  which,  according  to  Xanthos,  Marochetti, 
and  Magistel,  appear  near  the  opening  of  the  sublingnal  glands  within  a 
few  days  (6  to  20)  after  inoculation,  have  not  been  found  by  any  recent 
observer. 

SYMPTOMATOLOGY. — Three  forms  of  rabies  in  the  dog  are  recogniml — 
the  furious,  the  paralytic,  and  the  lethargic.  The  prodromata  are,  how- 
ever, the  same  in  all,  so  that  these  may  be  conveniently  considered  before 
the  different  types  are  noticed. 

The  premonitory  symptoms  are  by  far  the  most  important,  as  if  these 
are  recognized  the  dog  may  be  safely  secluded  or  destroyed  before  there 
is  any  disposition  to  bite.  Any  sudden  change  in  a  dog's  habits  or 
instincts  is  ground  for  suspicion.  Boulcy  well  says  that  a  sick  dog  is 
always  to  be  suspected.  In  some  cases  there  is  unusual  dulness  and  apathy, 
in  others  great  restlessnes,  watchfulness,  and  nervousness.  A  morbid 
appetite,  in  house-dogs  a  tendency  to  pick  up  and  swallow  straws,  thread, 
paper,  pins,  and  other  objects,  or  to  devour  their  own  dung  and  urine,  is 
highly  characteristic.  A  desire  to  lick  cold  smooth  objects,  as  a  stone,  a 
boot,  a  piece  of  metal,  or  the  nose  of  another  dog,  is  often  seen.  Smell- 
ing and  licking  the  anus  or  generative  organs  of  another  dog  and  the 
exhibition  of  sexual  desire  are  frequent  manifestations.  An  increased 
fondness  for  the  owner,  shown  by  fawning  and  licking,  is  occasionally 
seen,  though  more  commonly  there  is  a  change  from  a  formerly  amiable 
temper  to  a  morose,  sullen,  retiring,  and  resentful  disposition.  If  a 
naturally  quiet  dog  flies  into  a  violent  passion  at  the  sight  of  another  dog 
or  a  cat,  and  attempts  to  bite  it,  he  should  be  carefully  watched.  If  a 
social  dog  seeks  seclusion  and  darkness,  or  if  while  crouching  and  shrink- 
ing from  a  blow  (hypercesthesia)  lie  yet  bears  it  without  howl  or  whine, 
he  is  to  be  strongly  suspected.  Barking  without  object,  constant  moving, 
searching,  and  scraping,  a  disposition  to  tear  wood,  clothing,  etc.  to  pieces, 
and,  above  all,  an  absence  from  home  for  a  day  or  tAvo,  should  beget 
grave  apprehensions.  The  rabid  bark  or  howl  which  is  often  heard  early 
in  the  disease  is  hoarse,  low,  and  muffled,  partaking  of  the  nature  of  both 
bark  and  howl,  the  first  running  into  the  second,  and  consists  of  one  loud 
howl  followed  by  three  or  four  others  progressively  diminished  in  force 
and  uttered  without  closing  the  mouth.  Some  rub  the. chaps  with  the 
forepaws  as  if  to  dislodge  an  offending  body  from  the  mouth ;  others 
reject  bloody  matter  by  vomiting ;  and  others  turn  the  head  and  eyes  as 
if  following  imaginary  objects,  and  snap  at  them.  Finally,  a  tendency  to 
bite,  rub,  or  gnaw  the  wound  is  significant,  and  usually  draws  attention 
to  the  fact  that  the  wound,  long  healed,  is  still  red,  sensitive,  and  swollen, 


896  RABIES  AND  HYDROPHOBIA. 

or  even  papular.  The  conjunctiva  are  usually  congested,  there  is  an 
increased  nasal  defluxion,  and  the  skin  of  the  forehead  and  over  the  eyes 
is  drawn  into  wrinkles.  This  stage  lasts  from  a  half  to  two  or  three 
days. 

Following  one  or  more  of  the  above  symptoms,  paroxysms  of  wicked 
fury  come  on,  alternating  still  with  periods  of  quiet,  in  which  prodro- 
mata  only  are  observed.  The  red  congested  eyes  assume  a  fixed  stare, 
often  squint  or  roll  as  if  following  an  imaginary  object,  at  which  the  dog 
presently  snaps.  A  paroxysm  is  ilshered  in  by  increasing  uneasiness, 
frequent  change  of  position,  and  a  desire  to  escape,  shown  in  rushing  at 
the  door,  tugging  at  the  chain,  or  gnawing  the  post  and  walls  of  the 
kennel.  The  tendency  to  bite  and  gnaw  is  further  shown  by  seizing  the 
straw  or  tearing  to  pieces  wooden  and  other  articles  within  reach,  or  even 
by  the  victim  lacerating  its  own  body. 

The  rabid  howl  becomes  more  frequent,  and  the  rage  and  disposition  to 
bite  strange  animals  and  persons  merge  into  a  mischievous  desire  to 
worry  all  that  come  in  the  way,  the  respect  for  former  companions  and 
friends  being  steadily  lost  as  the  paroxysm  increases  in  violence.  Yet 
for  a  considerable  time  the  voice  of  a  loved  master  recalls  the  suffering 
animal  to  some  degree  of  self-control.  If  free  to  escape  during  such 
paroxysms,  the  dog  expends  his  excitement  in  wandering,  making  long 
journeys  of  five,  ten,  or  twenty  miles,  and  flying  at  every  animal  or  man  he 
meets,  especially  if  they  increase  his  excitement  by  any  noise  or  outcry.  If 
the  victim  escapes  destruction  during  one  of  these  wanderings,  he  returns 
during  a  lucid  interval  exceedingly  dangerous,  for,  though  he  may  recog- 
nize or  even  fawn  upon  his  friends,  yet  the  demon  of  mischief  is  even 
more  potent  within  him,  and  may  be  roused  to  sudden  violence  by  any 
noise  or  excitement.  The  intervals  of  quiet  are  attended  by  a  prostra- 
tion proportionate  to  the  violence  of  the  previous  paroxysm,  and  the 
animal  usually  seeks  seclusion  and  darkness,  where  he  may  lie  dull  and 
torpid,  but  he  may  be  roused  at  any  time  to  a  renewed  paroxysm  by  any 
noise,  disturbance,  the  presentation  of  a  stick,  or,  above  all,  by  the 
approach  of  another  animal.  During  the  paroxysm  the  animal  is  mani- 
festly the  subject  of  acute  delirium,  has  hallucinations,  snatches  and  bites 
at  unreal  objects,  turns  on  his  best  friends,  even  his  master,  seizes  and 
holds  on  to  a  stick  or  iron  bar  until  the  teeth  are  detached  and  the  gums 
lacerated,  bites  his  own  body,  even  amputating  tail,  testicles,  or  toes  with 
his  teeth ;  a  bitch  deserts  her  puppies  or  worries  them,  and  all  follow  the 
unconquerable  impulse  to  wander  and  to  wound  living  beings.  The 
victim  will  sometimes  manifest  incredible  strength  in  breaking  his  chain 
and  scaling  high  walls.  Twitchings  of  the  muscles  of  the  face,  and  even 
general  convulsions,  are  sometimes  seen.  Food  is  usually  rejected,  or  if 
swallowed  is  soon  vomited.  In  the  course  of  two  or  three  days  the 
furious  stage  merges  into  the  paralytic  one,  first  shown  by  paresis  of  the 
hind  extremities  and  a  swaying  motion  in  walking,  then  by  paralysis  of 
the  lower  jaw,  which  hangs  pendent  and  allows  the  escape  of  a  viscid 
saliva.  The  palsy  gradually  extends  over  the  whole  body — a  sure  pre- 
cursor of  approaching  death,  which  is  rarely  delayed  beyond  eight  days, 
and  never  more  than  ten,  from  the  onset.  In  this  last  stage  the  animal 
has  become  extrenlely  emaciated,  with  dry  withered  hair,  hollow  flanks, 
and  small  weak  pulse;  he  may  at  first  rise  on  his  fore  limbs  when  dis- 


POPULAR  FALLACIES.  897 

turbed,  and  even  attempt  to  snap,  but  there  is  now  little  danger  of  a  bite. 
Convulsions  may  alternate  with  the  paralysis.  The  result  is  mvarably 
fatal. 

The  peculiarity  of  dumb  or  paralytic  rabies  in  dogs  is  that  the  last  or 
paralytic  stage  supervenes  at  once  on  the  prodromata,  without  any  inter- 
vening period  of  acute  delirium  and  fury.  The  animal  is  throughout 
dull,  quiet,  and  depressed,  and  shows  little  tendency  to  bite,  to  wander, 
or  to  restless  movement.  The  excitement  of  the  sexual  passion  is  the 
same  as  in  the  furious  forms,  and  the  howl  is  still  emitted,  though  much 
more  rarely.  Soon  the  lower  jaw  drops  from  paralysis,  allowing  the 
saliva  to  drivel  from  the  mouth,  and  the  animal  can  only  succeed  in 
closing  it  momentarily  under  the  greatest  provocation  to  bite.  Paralysis 
of  the  hind  limbs  and  of  the  whole  body  speedily  follows,  and  death 
ensues  in  from  two  to  three  days.  As  soon  as  the  jaw  is  paralyzed  the 
subject  is  unable  to  drink,  eat,  bite,  or  bark,  and  emaciation  advances 
with  extraordinary  rapidity. 

The  lethargic  or  tranquil  form  of  rabies  in  dogs  is  manifested 
neither  by  furious  madness  nor  by  palsy  of  the  jaws,  but  the  nervous 
prostration  is  shown  in  a  profound  lethargy  and  apathy.  The  patient 
curls  himself  up,  and  will  not  be  roused1  by  his  master's  voice,  by  any 
noise,  disturbance,  or  even  punishment;  he  makes  no  response  to  the 
caresses  of  his  friends,  and  pays  no  attention  to  the  food  or  drink  they 
bring  him,  but  remains  in  his  place,  growing  daily  more  emaciated  and 
lethargic,  until  relieved  by  death  toward  the  tenth  or  fifteenth  day  of  the 
illness. 

Besides  the  three  typical  forms  there  are  intermediate  varieties,  which 
are  classed  with  one  or  other  according  as  the  symptoms  of  that  type 
seem  to  predominate.  The  same  virus,  inoculated,  will  produce  different 
types  in  separate  individuals,  the  result  seeming  to  depend  more  on  the 
susceptibility  of  the  subject  than  any  special  quality  in  the  poison.  With 
many  notable  exceptions  it  may  be  stated  that,  on  the  whole,  furious  rabies 
predominates  in  hounds,  bull-dogs,  and  other  less  domesticated  or  naturally 
vicious  and  courageous  breeds,  while  the  paralytic  and  tranquil  types 
attack  especially  house  and  pet  dogs. 

POPULAR  FALLACIES. — It  is  a  dangerous  delusion  to  suppose  thai, 
mad  dogs  have  a  dread  of  water  and  polished  surfaces,  that  they  will  not 
eat  or  drink,  that  they  froth  abundantly  from  the  mouth,  and  that  they 
run  with  the  tail  drooping  between  the  hind  limbs.  There  is  no  hydro- 
phobia in  the  dog  or  other  domestic  animal.  The  rabid  dog  drinks 
freely  in  the  early  stages  of  the  disease,  lapping  even  his  own  urine; 
later,  he  still  laps,  and  even  plunges  his  nose  in  water,  though  often 
unable  to  swallow ;  and  in  his  wanderings  he  swims  rivers  without  the 
slightest  reluctance.  The  appetite  is  not  entirely  lost,  though  greatly 
impaired  and  usually  depraved,  all  sorts  of  unsuitable,  noxious,  and  dis- 
gusting objects  being  picked  up  and  swallowed  with  avidity.  Frothing 
from  the  mouth  is  exceptional  in  rabies,  and  the  flow  of  saliva  is  rarely- 
seen  unless  when  the  jaw  is  paralyzed  and  pendent.  Carrying  the  tail 
between  the  legs  is  a  symptom  of  all  diseases  attended  by  abdominal  pain, 
and  is  by  no  means  constant  in  rabies.  During  the  paroxysms  the  tail  is 
usually  carried  erect. 

Foxes,  jackals,  and  badgers  attacked  by  rabies  lose  their  natural  sny- 

VOL.  I.— 57 


888  RABIES  AND  HYDROPHOBIA. 

Cases  of  Rabies  in 
WINTER.  SPRING.  SUMMER.  AUTUMN. 

Dec.,  Jan.,  Feb.       March,  April,  May.       June,  July,  Aug.       Sept.,  Oct.,  Nov. 

Dogs 755  857  788  696  (Bouley). 

Men 17  25  42  13  (Bomlin). 

The  increase  of  cases  of  rabies  canina  in  the  spring  and  summer 
mouths,  as  shown  by  the  above  statistics  (7—15  per  cent.),  cannot  reason- 
ably be  attributed  to  the  influence  of  the  weather,  since  even  the  strongest 
advocates  for  spontaneity  would  at  once  decline  to  claim  any  such  ratio 
of  spontaneous  developments.  The  increase  must  therefore  be  mainly, 
if  not  altogether,  due  to  the  increased  number  of  inoculations;  and  these 
latter  are  provided  for  in  the  jealousies  and  quarrels  in  the  troops  of 
males  that  follow  each  rutting  bitch  in  spring,  the  principal  period  of 
oestrum  in  the  canine  female.  The  infection  spread  in  this  way  in 
early  spring  tends  to  remain  more  prevalent  throughout  the  hot  summer 
months. 

With  regard  to  the  greatly  enhanced  mortality  in  man  during  the 
summer  months,  as  shown  in  Boudin's  statistics  for  France,  in  the 
absence  of  any  genuine  hydrophobia  in  man  apart  from  inoculation 
from  a  rabid  animal,  it  may  be  attributed  to  three  principal  causes : 
1st.  The  bites  sustained  from  rabid  dogs  in  spring  and  early  summer, 
when  the  disease  is  most  widely  spread  among  these  animals,  will  give 
rise  to  hydrophobia  weeks  or  months  later.  2d.  In  the  warm  season 
the  body  is  more  thinly  clad  and  the  hands  and  other  portions  are  more 
frequently  left  bare,  so  that  the  teeth  are  less  likely  to  be  cleansed  of  the 
virulent  saliva  by  passing  through  the  clothes  before  entering  the  skin. 
3d.  The  languor,  fever,  and  nervousness  attendant  on  extreme  heat  tend 
not  only  to  hasten  the  activity  of  any  disease-germs  actually  present  in 
the  system,  but  also  strongly  favor  the  increase  of  that  nervous  fear 
which  so  often  generates  a  fatal  pseudo-hydrophobia  (lyssophobia)  in 
persons  that  have  been  bitten  by  dogs. 

Hunger,  thirst,  and  spoiled  food  are  invoked  as  causes  of  rabies,  yet  in 
the  East,  where  the  dogs  are  the  scavengers  of  the  cities  and  often  suffer 
severely  from  hunger  and  thirst,  eat  the  most  offensive  carrion,  and 
drink  the  foulest  water,  the  disease  has  a  very  restricted  prevalence, 
while  in  South  Africa  and  Australia  the  outcast  and  sheep-dogs,  often 
the  victims  of  starvation  and  thirst,  entirely  escape.  Bourgelat,  Dupuy- 
tren,  Majendie,  Breschet,  and  others  have  cruelly  destroyed  dogs  by  pri- 
vation of  food  and  water  and  by  exposure  under  a  broiling  sun,  but  no 
rabies,  nor  anything  resembling  it,  was  produced.  Dogs  perspire  little 
and  suffer  severely  from  heat,  but  there  is  no  evidence  that  this  can 
develop  canine  madness.  It  is  claimed  that  Rossi  of  Turin  developed 
rabies  in  cats  by  withholding  food  and  drink,  but,  as  he  furnishes  no 
inoculation-tests  confirmatory  of  its  virulence,  the  claim  cannot  be 
endorsed.  Experiments  with  an  exclusive  diet  of  salt  meat,  putrid 
meat,  and  water  only  have  failed  to  produce  rabies. 

The  large  preponderance  of  male  dogs  attacked  with  rabies  has  been 
constantly  remarked  by  writers.  Of  1900  rabid  dogs  reported  by  differ- 
ent authors,  1746  were  males  and  244  females — a  ratio  of  more  than  7 
to  1.  This  excess  of  males  attacked  is  much  higher  than  the  ratio  of 
males  in  the  dogs  of  the  districts  drawn  upon.  Thus,  Bourrel  found  a 


ETIOLOGY.  889 

ratio  of  6  rabid  males  to  1  rabid  female,  while  in  his  patients  generally 
the  proportion  was  4  to  1.  Leblauc  found  that  14  per  cent,  of  the  male 
dogs  went  mad,  Avhile  but  1  per  cent,  of  the  females  suffered.  That  sex 
is  no  protection  against  inoculated  virus  is  shown  by  the  frequent  inocula- 
tion of  castrated  dogs  of  both  sexes.  The  excess  of  male  subjects  may 
be  attributed  mainly  to  the  frequency  with  which  these  bite  each  other 
when  following  a  female  in  heat,  and  the  respect  of  all  alike  for  the 
latter  sex.  Even  in  the  rabid  dog  the  sexual  instinct  rises  above  the 
propensity  to  bite  in  the  early  stages  of  the  malady. 

Toffoli  claims  that  he  has  caused  spontaneous  rubies  by  shutting  up  seve- 
ral dogs  in  a  loose  box  with  a  bitch  in  heat  and  allowing  them  to  fight  for 
the  prize.  Weber  and  Leblanc  have  noticed  similar  occurrences.  But 
Greve  and  Meuecier  have  repeated  the  experiments  with  a  contrary 
result;  so  that  it  remains  probable  that  when  successful  the  victims  had 
already  been  inoculated  before  they  were  shut  up.  Moreover,  the  seclu- 
sion of  male  canine  animals  for  a  lifetime  in  menagerie  cages,  often 
adjoining  those  of  their  corresponding  females,  has  never  been  known 
to  induce  rabies. 

The  bite  of  the  violently  enraged  dog,  and  the  bites  mutually  given 
when  following  a  rutting  bitch,  are  popularly  supposed  to  cause  rabies  ; 
but  if  this  were  the  case,  the  disease  must  have  been  universally  preva- 
lent. The  idea  that  the  bite  of  a  dog  will  cause  hydrophobia  should  that 
dog  at  any  subsequent  period  go  mad  is  a  similar  delusion.  Men  doubtless 
occasionally  develop  lyssophobia  under  such  an  influence,  but  animals  do 
not  contract  genuine  rabies. 

Dogs  are  alleged  to  have  gone  mad  from  violent  suffering  after  an 
operation,  and  cats  from  being  scalded  or  robbed  of  their  kittens,  but  all 
such  causes  are  continually  operating  without  such  effect,  and  when  in  a 
solitary  case  rabies  develops,  it  can  only  be  looked  on  as  a  coincidence. 

Much  popular  prejudice  exists  against  certain  breeds,  and  the  Pome- 
ranian has  been  virtually  ostracised  on  account  of  its  supposed  liability 
to  rabies ;  but  statistics  show  that  the  liability  to  contract  the  affection 
bears  a  relation  to  the  exposure  rather  than  the  special  breed.  Eckel, 
Pillwax,  and  Hertwig  found  that  dogs  kept  as  house-  or  watch-dogs,  and 
most  pampered  and  confined,  are  the  most  liable,  while  St.  Cyr  and 
Peuch  found  the  greatest  number  of  cases  among  those  runnuiug  at  large 
and  allowed  the  freest  exercise. 

There  is  a  popular  belief  that  the  bite  of  the  skunk  (Mephitis  mephitica) 
is  always  rabi  fie.  Rev.  H.  C.  Hovey  describes  a  number  of  cases  of  infection 
from  this  animal,1  and  John  G.  Janeway  has  reported  other  instances.2  Both 
claim  that  the  disease  is  spontaneous  in  the  skunk,  and  Mr.  Hovey  holds,  on 
very  insufficient  grounds,  that  the  affection  is  a  distinct  variety  of  rabies 
(rabies  mephitica).  The  facts  seem  to  warrant  only  the  conclusion  that 
skunks  in  certain  districts  of  Michigan  and  Kansas  have  had  rabies  com- 
municated to  them,  and  follow  the  rabid  impulse  to  bite  other  animals  and 
men.  The  Mephitinse  abound  in  the  Eastern  States,  but  we  never  hear 
of  them  stealing  up  and  biting  men  or  dogs,  nor  of  the  latter  contracting 
rabies  from  skunk-bite.  Eastern  dogs  frequently  kill  skunks  and  sustain 
bites,  but  do  not  thereby  contract  rabies.  Even  in  Kansas  this  evil 

1  Amer.  Jour,  of  Science  and  Art,  May,  1874. 

2  New  York  Medical  Record,  March  13,  1875. 


900  RABIES  AND  HYDROPHOBIA. 

current  of  air,  the  approach  of  a  candle,  or  even  the  ordinary  tones  of 
conversation,  produce  extreme  agitation  and  may  precipitate  a  violent 
convulsive  paroxysm.  The  duration  of  the  paroxysms  and  of  the  inter- 
vals varies  much,  but  in  general  terms  the  former  increase  rapidly  in 
number  and  severity,  while  the  latter  are  correspondingly  shortened. 
Restraint  serves  to  aggravate  the  paroxysm,  while,  according  to  Hunter, 
the  earlier  and  lighter  ones  may  be  relieved  by  running.  The  intense 
excitement  sometimes  becomes  manifest  in  the  persistent  talking,  and  it 
is  noticeable  that  the  patient  is  free  from  mental  delusions.  As  it  is 
impossible  to  swallow,  the  patient  spits  out  the  now  viscid  saliva  on  all 
sides — a  feature,  like  the  fear  of  water,  peculiar  to  man.  As  the  disease 
advances  the  paroxysms  are  marked  by  the  most  perfect  hallucinations 
and  delirium,  which  impel  the  victim  to  acts  of  insane  violence  toward 
every  one  and  every  thing  about  him.  In  these  fits  he  will  use  every 
available  means  of  offence,  even  to  the  snapping  of  the  jaws,  though  on 
the  subsidence  of  the  fit  he  will  often  express  the  greatest  regret  and 
warn  his  victims  to  be  on  their  guard  when  he  finds  another  paroxysm 
coming  on.  In  some  few  instances  the  delusions  continue  even  during 
the  remissions,  and  the  patient  remains  possessed  of  a  sense  of  suspicion 
and  horror  of  all  about  him,  and  yet  the  fear  of  being  left  alone  is 
usually  greater  still.  The  convulsions  may  become  tetanic  (as  opistho- 
tonos).  They  are  habitually  more  severe  in  men  than  in  women  and 
children.  During  a  convulsion  the  victim  will  at  times  become  black  in 
the  face,  and  may  die  from  suffocation,  apoplexy,  or  nervous  exhaustion. 

Should  he  survive  this  danger  the  final  paralytic  stage  sets  in.  The 
spasms  gradually  become  weaker,  reflex  irritability  is  lessened,  and  a 
period  of  quiet,  and  even  comparative  composure,  may  ensue,  during 
which  the  former  sights  and  sounds  fail  to  produce  a  paroxysm,  and 
some  patients  even  recover  the  power  of  deglutition ;  but  muscular  weak- 
ness and  prostration  become  more  extreme,  the  lower  jaw  may  even  drop, 
and  the  viscid  saliva  drivel  from  the  lips ;  finally,  stupor  supervenes,  and 
the  patient  dies  in  a  state  of  profound  coma  or  complete  exhaustion.  This 
last  stage  lasts  from  one  to  eighteen  hours. 

Cases  are  met  with  in  the  human  subject,  as  in  the  dog,  in  which  the 
paroxysmal  stage  is  omitted  in  greater  part  or  entirely.  The  patient  com- 
plains only  of  oppressed  breathing,  and  sighs  deeply  when  lie  attempts  to 
swallow,  and  paroxysms,  if  they  occur  at  all,  are  very  mild.  Decroix 
indeed  claims  that  if  a  person  suffering  from  hydrophobia  is  kept  in  a 
dark  room  and  perfectly  quiet,  no  paroxysms  appear.  The  malady  is,  how- 
ever, none  the  less  fatal. 

DIAGNOSIS. — The  diagnosis  of  rabies  and  Hydrophobia  is  not  usually 
difficult  if  the  disease  has  progressed  to  its  paroxysmal  stage.  The  most 
pathognomonic  features  are  the  fact  of  a  bite  by  a  rabid  animal  and  the 
evidence  of  lesions  and  an  extraordinary  irritability  of  the  medulla  oblon- 
gata,  inducing  severe  reflex  spasms  of  the  muscles  of  deglutition  and 
respiration  under  the  influence  of  any  peripheral  irritation.  The  clonic 
nature  of  the  spasms  and  the  entire  absence  of  trismus  serve  to  distin- 
guish it  from  tetanus.  From  pharyngeal  anthrax  and  diphtheria  attended 
with  spasm  it  is  diagnosed  by  the  extreme  exaltation  of  the  special  senses 
and  the  absence  of  any  marked  febrile  reaction ;  from  acute  mania  by  the 
difficulty  of  breathing  and  deglutition,  the  more  rapid  heart-beats  during 


DIAGNOSIS.  90] 

a  paroxysm,  and  by  the  marked  hypersesthesia  and  exalted  reflex  sus- 
ceptibility, as  well  as  by  the  perfectly  lucid  intermissions ;  and  from  epi- 
lepsy, in  that  the  latter  is  not  associated  with  the  same  hypersesthesia,  that 
the  paroxysm  is  not  developed  by  noise,  movement,  attempts  to  swallow, 
sight  of  water,  etc.,  that  the  spasms  are  more  universal,  and  that  they  do 
not  recur  often,  nor  can  they  be  roused  by  the  causes  immediately  produ- 
cing those  of  hydrophobia.  Hysterical  cases  can  usually  be  recognized  by 
the  imperfection  of  the  symptoms  ;  the  subject,  not  knowing  all  the  mani- 
festations of  hydrophobia,  naturally  fails  to  produce  them. 

The  most  difficult  to  distinguish  from  the  genuine  disease  are  those 
cases  in  which  hydrophobia  occurs  as  a  disease  of  the  imagination,  the 
result  of  fear — the  lyssophobia  or  hydrophobie  uon-rabique  of  the  writers. 
In  these  there  is  always  the  history  of  a  bite ;  the  cicatrix  even  may  have 
become  the  seat  of  congestive  redness,  itching,  or  neuralgic  pains,  and 
these,  acting  on  a  susceptible  brain,  develop  a  disease  which  is  hardly  dis- 
tinguishable from  true  hydrophobia,  and  which  is  quite  as  fatal  if  left  to 
run  its  course.  These  cases  have  usually  less  reflex  susceptibility  than 
genuine  hydrophobia;  the  attack  mostly  occurs  shortly  after  some  conversa- 
tion on  the  subject,  and  especially  about  the  effects  of  the  bites  on  others ; 
and  the  victim  is  seen  to  have  a  nervous  organization,  and  may  even  be 
known  to  have  been  subject  to  hysteria  or  other  nervous  disorder.  At 
the  same  time,  the  concentration  of  the  mind  on  this  subject  sometimes 
produces  even  structural  changes  in  the  medulla,  and  the  reflex  susceptibility 
in  co-ordination  with  the  other  symptoms  may  be  almost  perfect.  In  a  case 
reported  a  few  years  ago  by  Hammond  the  symptoms  appeared  perfectly 
characteristic,  and  at  the  necropsy  circumscribed  points  of  congestion  were 
found  near  the  roots  of  the  vagus;  yet  the  dog  that  bit  this  man  was  said 
to  be  alive  and  well,  and  in  the  absence  of  any  successful  inoculation  from 
biter  or  bitten  the  case  must  be  presumed  to  have  been  lyssophobia. 

Many  cases  with  a  more  favorable  issue  are  recorded.  Bellenger  had 
a  patient  who  had  been  bitten  by  his  cat,  and  manifested  violent  par- 
oxysms of  hydrophobia,  but  was  instantly  cured  by  the  sight  of  the  ani- 
mal in  good  health.  Bouardel  records  that  a  man  was  bitten  by  his  dog, 
which  afterward  disappeared.  He  was  seized  with  severe  hydrophobia, 
which  continued  for  two  days,  when  the  lost  dog  was  found  and  presented 
to  him,  and  the  symptoms  disappeared.  Trousseau  speaks  of  a  magis- 
trate whose  hand  had  been  licked  by  his  hound,  which  immediately  after 
attacked  a  flock  of  sheep,  so  that  many  of  them  died  of  rabies.  The 
master  then  manifested  hydrophobia,  but  as  death  was  deferred  beyond  the 
usual  time,  he  concluded  it  was  not  genuine  and  recovered.  Prof.  Dick 
was  called  to  visit  a  man  who  had  been  bitten  by  a  favorite  dog  while 
suffering  from  distemper,  had  manifested  severe  hydrophobie  symptoms, 
and  had  been  given  up  by  the  attending  physicians.  He  succeeded  in 
convincing  the  subject  that  as  the  dog  had  had  distemper,  and  as  no  two 
great  diseases  could  coexist  in  the  same  system,  it  could  not  have  had 
rabies.  In  spite  of  the  false  premises,  this  reasoning  had  the  desired 
effect  and  the  patient  recovered.  A  few  years  ago  a  boy  twelve  years  old 
in  Ithaca,  N.  Y.,  was  bitten  by  a  dog  supposed  to  be  rabid,  and  in  due 
time  manifested  hydrophobia,  which  advanced  rapidly  until  he  was  having 
a  violent  paroxysm  every  half  hour,  and  it  was  pronounced  impossible  for 
him  to  survive  another  day.  At  this  time  I  saw  him,  observed  tint  he 


902  RABIES  AND  HYDROPHOBIA. 

had  a  nervous  organization,  and  was  somewhat  lacking  in  the  hyper- 
sesthesia  of  rabies,  learned  that  he  had  recently  been  gorging  himself  with 
Christmas  delicacies,  and  was  now  very  costive ;  and,  as  there  was  no  sat- 
isfactory history  of  the  dog,  I  at  once  suspected  lyssophobia.  The  friends 
and  strangers  who  had  come  to  condole  with  the  parents  and  feast  on  the 
horror  were  excluded,  and  the  boy's  attention  fully  engaged  in  amusing 
pictures  and  conversation ;  the  paroxysms  were  omitted,  and  in  two  hours 
the  patient,  overcome  by  weariness,  went  to  sleep.  Next  morning  he  was 
still  kept  secluded  and  quiet,  and  two  enthusiastic  students  took  up  the 
role  of  keeping  his  attention  constantly  engaged  on  whatever  would  interest 
him.  The  prima  vise  was  relieved  by  medicine,  and  under  a  course  of 
tonics  the  boy  quickly  recruited,  and  at  the  end  of  a  week  went  back  to 
school. 

In  doubtful  cases  the  test  by  inoculation  may  be  tried.  Inoculation 
with  the  saliva  of  a  man  suffering  from  hydrophobia  is  manifestly  use- 
less, since  he  must  die  before  we  can  hope  for  the  development  of  the 
disease.  But  in  the  case  of  a  dog  having  bitten  one  or  more  people  the 
inoculation  of  the  virus  on  the  brain  of  one  or  two  other  dogs  would 
ensure  the  development  of  the  affection  in  the  course  of  one  or  two 
weeks,  provided  the  first  was  rabid.  The  non-success  of  this  operation 
when  practised  on  two  dogs  Avould  provide  the  best  possible  medicine  for 
the  diseased  mind  of  the  person  bitten. 

PATHOLOGICAL  AXATOMY. — Post-mortem  lesions  are  rather  remark- 
able for  their  inconstancy  than  for  their  specific  characters.  Hardly  a 
single  lesion  can  be  specified  which  may  not  be  absent  in  particular  cases, 
yet  some  are  so  characteristic  that,  when  taken. along  with  the  symptoms 
during  life,  they  very  materially  assist  in  diagnosing  the  disease.  Of  the 
pathological  appearances  common  to  man,  dog,  and  other  animals  the 
following  may  be  named :  The  body  is  greatly  emaciated;  the  rigor  mortis 
is  normal  or  nearly  so;  decomposition  usually  sets  in  early;  a  white  skin 
is  livid,  cyauotic,  or  petechial;  the  cicatrix  is  often  hardly  noticeable  even 
after  the  animal  has  been  shaved ;  the  superficial  veins,  especially  those  of 
the  neck  and  head,  are  filled  with  black  inspissated  blood;  the  external 
mucous  membranes  are  of  a  dark  livid  hue,  those  of  the  mouth  and  nose 
being  covered  by  a  tenacious  mucous  or  muco-purulent  secretion  (in  dogs 
they  are  usually  covered  with  earth  or  dust) ;  the  fauces,  pharynx,  and 
tonsils  are  usually  of  a  dark  livid  hue,  and  sometimes  swollen ;  in  other 
cases  the  dark  red  hue  and  manifest  swelling  that  obtained  during  life 
disappear  after  death;  similar  lesions  are  found  in  the  larynx,  and  I 
have  seen  extensive  erosions ;  the  bronchial  mucous  membrane  is  red- 
dened and  coated  with  a  muco-purulent  secretion  (and  in  dogs  with  earth 
and  foreign  bodies) ;  the  lungs  are  usually  congested,  often  to  the  extent 
of  showing  death  by  asphyxia ;  the  heart  and  large  blood-vessels  are 
filled  with  a  black  thick,  venous  blood,  and  the  muscles,  charged  with  the 
same  blood,  have  a  dark  reddish-brown  hue ;  the  stomach  is  usually 
congested,  sometimes  to  a  port-wine  hue,  and  is  the  seat  of  blood-extrav- 
a^ations  and  even  erosions ;  this  congestion  is  often  present,  though  to  a 
less  degree,  in  the  intestines;  the  mesenteric  glands  and  those  in  the 
vicinity  of  the  pharynx  are  not  unfrequently  enlarged  and  congested;  a 
very  constant  feature  is  the  entire  absence  of  proper  food  in  the  stomach 
and  of  chyme  in  the  small  intestine ;  the  liver  is  usually  hypernemic, 


PROPHYLAXIS.  903 

exuding  on  pressure  the  characteristic  dark  blood,  and  it  may  be  the  seat 
of  some  granular  degeneration,  but  it  usually  retains  its  normal  consist- 
ency ;  the  spleen  is  normal ;  the  kidneys  are  hypersemic  and  leaden  or 
bluish  gray,  and  slightly  cloudy  on  the  surface  (in  dogs  fatty  degenera- 
tion of  the  inner  cortical  layer  is  common  even  in  health) ;  the  urinary 
bladder  is  usually  empty  or  contains  a  little  turbid,  yellowish,  slightly 
albuminous  urine,  while  the  mucous  membrane  is  often  covered  with 
dark  reddish-brown  petechial  spots ;  the  brain  is  usually  hypertemic,  and, 
together  with  its  membranes,  slightly  cedematous,  yet  the  lesions  are  not, 
constant  either  in  kind  or  degree ;  the  medulla  oblongata  usually  shows  a 
similar  condition,  and  even  minute  points  of 'acute  congestion,  but  neither 
these  nor  the  hypersemia  and  oedema  of  the  spinal  cord  can  be  found  in 
every  case. 

Some  conditions  are  especially  pathognomonic  in  the  dog.  In  nearly 
all  cases  of  furious  rabies  the  stomach  is  gorged  with  foreign  bodies,  such 
as  hay,  straw,  wood,  coal,  leather,  portions  of  textile  fabrics,  faeces,  earth, 
sand,  stones,  pieces  of  iron,  lead,  etc.,  and  the  same  materials  are  usually 
found  in  the  small  intestine,  while  the  large  intestines  are  empty.  Por- 
tions of  these  foreign  bodies  are  often  found  in  the  bronchia  as  well, 
giving  rise  to  circumscribed  lobular  pneumonia.  The  significance  of  such 
matters  Avhen  found  in  large  amount  in  the  stomach  of  a  dog  which  has 
been  given  to  biting  or  other  symptom  of  rabies  is  very  great,  and  if  the 
stomach  contains  none  of  the  natural  food  of  the  animal  and  the  duo- 
denum no  chyme,  it  may  be  held  pathognomonic  of  rabies.  Jf,  however, 
the  materials  are  small  in  quantity  and  mingled  with  natural  food,  and 
if  the  duodenum  contains  chyme,  the  dog  was  probably  not  rabid.  Dogs 
frequently  chew  and  swallow  fresh  leaves  of  grass,  and  those  in  detention 
gnaw  and  swallow  pieces  of  wood,  cloth,  horn,  etc.;  but  these  are  used 
either  as  an  emetic  or  a  teething-ring,  and  virtually  imply  that  digestion 
is  not  entirely  abolished.  Their  presence,  therefore,  along  with  food  does 
not  indicate  rabies. 

PROPHYLAXIS. — In  view  of  the  almost  or  quite  constantly  fatal  issue 
of  rabies  in  man 'and  animals,  the  main  attention  should  be  given  to  the 
question  of  prevention.  As  the  disease  is  perhaps  never  in  our  time 
developed  except  as  the  result  of  contagion,  we  have  the  most  perfect 
guarantee  that  by  suitably  devised  measures  it  may  be  absolutely  sup- 
pressed and  excluded  from  any  country.  Even  if  we  allow  that  a  rare  case 
is  at  long  intervals  developed  spontaneously,  it  is  none  the  less  certain 
that  the  disease  can  be  practically  abolished,  as  nothing  can  be  easier  than 
to  nip  the  disease  in  the  bud  in  the  locality  where  it  first  shows  itself. 
Thus  in  Australia,  Tasmania,  and  New  Zealand  rabies  has  not  yet 
appeared,  though  prevailing  in  the  same  latitude  and  climate  in  both  hemi- 
spheres. It  reached  Mauritius  in  1813,  and  has  prevailed  uninterruptedly 
since,  while  in  Bourbon,  immediately  adjacent  and  almost  identical  in 
geology,  climate,  flora,  and  fauna,  it  is  still  unknown.  The  same  truth  is 
told  in  the  entire  extinction  of  rabies  in  Berlin  by  the  universal  muzzling 
of  dogs,  as  recorded  above.  The  immunity  lasted  for  nine  years,  during 
which  muzzling  was  enforced.  A  more  recent  example  of  the  same  kind 
is  found  in  Holland.  In  1875  universal  muzzling  was  made  obligatory 
in  all  communes  where  rabid  animals  had  been  and  in  adjoining  com- 
munes. From  1877  on  the  disease  was  unknown  save  on  the  borders  of 


904  RABIES  AND  HYDROPHOBIA. 

Belgium  and  Prussia  and  in  a  very  few  dogs  recently  imported.  Nearly 
all  cases  of  hydrophobia  in  man  and  animals  being  due  to  bites  by  rabid 
members  of  the  canine  fraternity,  a  fundamental  condition  of  all  success 
in  prevention  is  the  prohibition  of  its  diffusion  by  dogs.  For  this  reason 
the  following  measures  are  requisite  :  1st.  All  dogs  should  be  registered 
and  heavily  taxed.  The  number  of  useless  dogs  kept  in  every  com- 
munity affords  the  greatest  opportunity  for  the  speedy  diffusion  of  the 
rabid  germ  whenever  that  has  been  introduced.  Whatever  tends  to 
reduce  this  number  directly  tends  to  the  restriction  and  extinction  of 
rabies.  2d.  Every  dog  should  be  made  to  wear  a  collar  with  plate  bear- 
ing the  name  and  residence  of  his  owner.  All  stray  dogs  without  such 
badge  should  be  summarily  shot  by  the  police.  This  will  secure  the  pay- 
ment of  the  taxes  and  the  destruction  of  superfluous  and  dangerous  dogs. 
3d.  In  all  cities  and  counties  where  rabies  has  existed  within  a  year,  and 
in  the  counties  adjoining  them,  every  dog  should  be  muzzled  except  when, 
securely  shut  up  or  tied.  All  dogs  found  at  large  without  a  muzzle 
should  be  promptly  shot  by  the  police.  The  objection  to  muzzles  is  satis- 
factorily met  by  the  use  of  the  wire  muzzle,  which  impedes  neither  breath- 
ing nor  drinking.  4th.  Dogs  and  cats  suspected  or  known  to  have  been 
bitten  by  rabid  animals  should  be  at  once  destroyed,  or  if  considered  suffi- 
ciently valuable  may  be  confined  in  a  secure  cage  for  six  months  under 
veterinary  supervision.  5th.  Dogs  which  have  bitten  and  are  supposed 
to  be  rabid  should  be  similarly  caged  and  placed  under  veterinary  super- 
vision. If  rabid,  the  symptoms  will  be  fully  developed  in  a  few  days, 
whereas  if  destroyed  at  once  the  bitten  party  is  liable  to  develop  lysso- 
phobia.  6th.  Dogs  imported  from  countries  where  hydrophobia  is  known 
to  exist  should  be  subjected  to  a  period  of  quarantine  of  six  months. 
7th.  Foxes,  wolves,  badgers,  martens,  skunks,  must  be  indiscriminately 
destroyed  in  localities  where  they  have  become  infected  with  rabies.  8th. 
The  disinfection  or  burning  of  the  kennels  where  rabid  dogs  have  been  is 
a  natural  corollary  of  the  above. 

Other  measures  less  thorough  and  efficient  are  often  advocated  and 
resorted  to,  but  should  be  discarded  whenever  it  is  possible  to  practise  a 
method  of  absolute  extermination.  Among  these  may  be  named  the 
flattening  of  the  teeth,  and  especially  of  the  canines,  with  a  file,  as  advo- 
cated by  Bourrel,  and  later  by  Fleming.  While  this  is  a  measure  of  pro- 
tection, it  does  not  remove  the  desire  to  bite,  nor  the  power  of  wounding 
the  skin  when  that  is  delicate  or  tender.  Another  method  is  to  hang  a 
block  of  wood  from  the  neck,  so  that  it  may  impede  the  movements  of 
the  forelegs  and  prevent  a  rush  and  sudden  attack.  The  futility  of  such 
a  resort  need  hardly  be  remarked  upon.  The  emasculation  of  dogs  is 
another  preventive  measure  advocated.  The  single  advantage  of  this  is 
that  it  does  away  with  the  host  of  suitors  that  follow  a  rutting  bitch,  and 
the  mutual  worrying  and  biting  that  ensue.  But  it  is  not  yet  proved  that 
the  disease  is  produced  by  privation  of  the  generative  act,  while  if  it 
were  it  is  still  certain  that  cases  of  spontaneous  rabies  are  extremely  rare; 
that  the  rabid  dog  bites  the  castrated  one  as  readily  as  the  perfect  male ; 
that  the  emasculated  one  contracts  rabies  as  readily  as  others  when  bitten, 
and  that  he  communicates  it  no  less  persistently.  Galtier's  method  of 
intravenous  injection  of  the  rabic  saliva,  which  seems  to  have  proved 
effectual  in  sheep  and  rabbits,  utterly  failed  in  the  hands  of  Lussaua  and 


TREATMENT  OF  SITES.  905 

Pasteur  in  dogs.  Besides  this  objection,  that  it  is  useless  for  the  animal 
which  is  beyond  all  comparison  the  main  propagator  of  rabies,  it  has  the 
serious  disadvantages  that  its  practice  would  necessitate  the  maintenance 
of  a  constant  succession  of  cases  of  rabies,  that  great  danger  attends  this 
production  and  handling  of  the  virus,  and  the  expense  and  risk  of  a 
general  application  of  the  measure  must  absolutely  forbid  it. 

More  recently  Pasteur  has  found  that  the  virus  when  transmitted 
through  several  monkeys  in  succession  becomes  so  weak  as  to  be  harm- 
less to  the  animal  inoculated,  and  yet  protects  the  animal  against  the 
more  virulent  poison.  This  fact  he  utilizes  by  inoculating  this  mitigated 
ape-virus  on  the  brain  of  the  animal  just  bitten,  so  as  to  render  that 
refractory  to  the  disease  when  the  poison  from  the  bitten  wound  shall 
reach  it  by  its  ordinary  slow  channel.  At  the  time  of  writing,  the  method 
is  being  attempted  on  a  man  bitten  by  a  mad  dog. 

Another  precautionary  measure  which  is  always  in  place  is  the  diffusion 
among  dog-owners  of  correct  information  as  to  the  premonitory  symptoms 
of  rabies,  and  the  necessity  for  careful  seclusion  when  any  such  symptoms 
are  manifested. 

TREATMENT  OF  BITES. — The  treatment  of  bites  by  animals  supposed 
to  be  rabid  consists  mainly  in  seeking  the  elimination  of  the  poison  or  its 
destruction  by  caustic.  The  first  object  should  be  to  prevent  absorption 
of  the  poison.  If  the  bite  has  been  on  a  limb,  a  tourniquet  should  be 
instantly  placed  above  it.  A  stout  cord  or  handkerchief  is  always  at 
hand,  and  may  be  tied  around  the  limb  and  twisted  with  a  piece  of  wood 
until  circulation  is  arrested.  Sucking  the  wound  is  usually  effective  in 
withdrawing  the  poison,  and  can  convey  no  additional  danger  to  the  per- 
son bitten.  If  the  patient  cannot  reach  the  wound  with  his  own  mouth, 
another  may  volunteer  to  suck  it,  though  in  these  days  of  diseased  teeth 
and  gums  the  act  is  pregnant  of  danger.  This  may  be  largely  obviated 
by  alternately  sucking  and  rinsing  the  mouth  with  a  solution  of  carbolic 
acid,  or,  better,  by  applying  such  a  solution  to  the  wound  before  Bucking, 
or  finally  by  sucking  through  a  tube.  Cupping  over  the  wound  is  highly 
commendable,  though  less  effective  than  sucking.  When  cupping  can  be 
combined  with  wringing  of  the  wound,  there  is  an  approximation  to  suck- 
ing. Cupping  is  especially  valuable  in  wounds  of  the  trunk,  where  a 
tourniquet  cannot  be  applied.  Intermittent  squeezing  and  wringing  of 
the  part  and  steeping  in  warm  water  is  an  excellent  resort  when ^  no ^ better 
measure  can  be  had.  Cutting  the  wound  open  to  its  depth,  while  it  may 
in  certain  cases  be  necessary  to  allow  of  the  thorough  application  of  a 
caustic,  is  objectionable  as  multiplying  the  points  of  infection  and  absorp- 
tion. Drinking  of  liquids  to  excess  temporarily  retards  absorption  by  over- 
filling the  vascular  system.  Ammoniacal,  alcoholic,  and  other  stimulants 
are  resorted  to  for  the  same  purpose,  being  held^  to  cause  plenitude,  not 
only  by  quantity,  but  by  rarefying  the  animal  fluids. 

No  such  measures  should,  however,  be  allowed  to  delay  for  an  instant 
the  use  of  caustics.  This  is  the  one  effectual  means  of  destroying  the 
poison,  and  the  choice  of  caustic  is  of  less  consequence  than  its  thorough 
application.  The  hot  iron  in  the  form  of  a  skewer,  nail,  poker,  or  other 
available  instrument,  at  a  white  heat,  may  be  brought  in  contact  with  all 
parts  of  the  wound  to  its  utmost  recesses. 

Of  chemical  caustics,  solid  sticks  of  nitrate  of  silver,  chloride  of  zmc, 


906  RABIES  AND  HYDROPHOBIA. 

and  potassa,  or  the  crystals  of  cupric  or  ferric  sulphate,  are  to  be  preferred  to 
the  liquid  forms  (mineral  acids,  butter  of  autimouy,  etc.),  because  of  the 
greater  thoroughness  with  which  they  can  be  brought  into  contact  with  all 
parts  of  the  wound.  Lastly,  the  galvano-cautery  may  be  used  if  within 
reach.  If  the  liquid  caustics  are  employed,  they  may  be  introduced  into 
the  depth  of  the  wound  by  means  of  a  pipette,  a  piece  of  porous  wood,  or 
a  pledget  of  tow.  For  a  great  number  of  small  wounds  a  bath  of  corro- 
sive sublimate  has  been  recommended. 

In  some  cases  the  amputation  of  a  badly-lacerated  member  or  one  with 
a  compound  fracture  offers  the  only  measure  of  protection. 

But  although  nothing  should  be  allowed  to  delay  cauterization,  yet  the 
impossibility  of  an  immediate  application  should  not  be  accepted  as  a  rea- 
son for  its  neglect  at  a  later  date.  On  the  presumption  that  the  virus  is 
localized  in  the  seat  of  inoculation  until  it  has  increased  largely  and  is 
poured  into  the  blood  in  sufficient  quantity  to  subjugate  the  blood-globules 
to  its  influence,  it  is  logical  to  excise  the  cicatrix  and  cauterize  the  wound, 
though  days  or  even  weeks  have  elapsed. 

If  it  should  be  shown  by  further  experiment  that  Galtier's  intravenous 
injection  of  virulent  saliva  is  harmless  and  protective  to  sheep,  rabbits, 
and  it  may  be  other  Herbivora,  it  would  be  logical  to  employ  this  in  these 
animals  just  after  they  have  been  bitten,  as  there  will  be  ample  time  to 
establish  the  systemic  influence  of  the  intravenous  injection  before  the 
poison  shall  have  accomplished  its  recrudescence  in  the  cicatrix.  The 
constantly  fatal  result  of  rabid  bites  in  these  animals  would  at  least  war- 
rant such  an  attempt,  the  main  precaution  being  that  the  liquid  shall  be 
most  carefully  preserved  from  contact  with  any  of  the  tissues,  including 
even  the  coats  of  the  injected  vein. 

In  addition  to  the  local  treatment  of  the  sore,  certain  general  medica- 
tion has  usually  been  resorted  to,  though  its  real  value  may  well  be  ques- 
tioned. Thus,  the  elimination  of  the  poison  has  been  sought  by  profuse 
perspiration  induced  by  warm,  Turkish,  and  Roman  baths,  and  by  the 
use  of  medicinal  agents,  sudorifics,  sialogogues  (mercury),  laxatives,  and 
diuretics  (cantharides).  The  neutralization  of  the  poison  has  been 
attempted  by  ammonia,  the  sulphites  and  hyposulphites,  chlorine,  etc. 
Besides  these  are  used  nerve-sedatives  and  tonics,  such  as  venesection, 
belladonna,  prussic  acid,  tartar  emetic,  sulphates  of  copper  and  zinc, 
arsenic,  strychnia,  etc. 

What  is  probably  of  greater  importance  is  a  sound  hygiene.  Stimu- 
lating food  eaten  to  excess  is  injurious  alike  to  man  and  beast,  and  by 
inducing  digestive  disorder  and  cerebral  congestion  will  tend  at  least  to 
precipitate  the  attack.  Costiveness  or  biliousness  from  sedentary  habits 
and  lack  of  exercise  in  the  outer  air  and  sunshine,  exposure  to  intense 
heat  or  cold  and  over-exertion,  are  all  to  be  guarded  against." 

Finally,  psychical  treatment  is  of  the  highest  importance.  Those  about 
the  person  who  has  been  bitten  should  preserve  a  calm,  equable,  and 
cheerful  demeanor  and  avoid  all  allusion  to  the  occurrence.  The  patient 
should  be  protected  against  all  sources  of  excitement,  and  should  not  be 
allowed  to  see  that  he  is  an  object  of  solicitude.  If  the  matter  is  referred 
to  incidentally,  he  should  be  impressed  with  a  conviction  of  the  efficacy 
of  the  treatment  adopted. 

THERAPEUTIC  TREATMENT. — Almost  every  agent  in  the  Pharmaco- 


THERAPEUTIC  TREATMENT.  907 

poeia  has  been  employed  as  a  remedy  for  hydrophobia,  but,  up  to  the 
present,  it  must  be  acknowledged,  with  no  'measure  of  success.  The 
agents  supposed  to  be  prophylactics  are  those  also  resorted  to  as  therapeu- 
tic remedies.  To  these  may  be  added  the  potent  nerve-sedatives  and  anti- 
spasinodics — chloroform,  chloral  hydrate,  ether,  bromides  of  potassium, 
sodium,  and  ammonium,  curare,  Calabar  bean,  and  the  sialogogue  diapho- 
retic pilocarpine. 

Chloroform  is  one  of  the  most  appropriate,  as  it  may  be  taken  by 
inhalation,  though  with  much  excitement  to  the  patient,  and  it  at  once 
relieves  the  oppressed  breathing  and  pharyugeal  and  other  spasms,  while 
it  acts  as  a  cerebral  sedative  and  anaesthetic ;  and  if  it  cannot  be  held  up 
as  a  curative  agent,  it  at  least  secures  euthanasia.  Chloral  given  as  au 
injection,  so  as  to  induce  its  soporific  action,  is  equally  soothing,  though 
nothing  more.  Curare  injected  hypodermically  overcomes  the  spasms, 
but  does  not  usually,  if  ever,  retard  death.  Three  cases  of  hydrophobia 
in  man  treated  in  this  way  recovered,  but  we  have  no  proof  that  even 
these  exceptional  cases  were  rabies.  Pilocarpiue  has  been  used  in  a 
number  of  cases,  but,  with  the  exceptional  case  of  a  young  man  reported 
by  Denis  Dumont,  all  terminated  fatally.  The  committee  of  the  Paris 
Academy  of  Medicine  reported  in  1874  that  in  three  experimental  cases 
"it  hastened  death  by  the  fits  it  brought  on."  Morphia  is  often  of  great 
value  in  calming  the  excitement  and  giving  rest  and  sleep  during  the 
intervals  of  the  paroxysms.  Daturia  and  atropia,  administered  hypo- 
dermically, are  somewhat  less  effectual.  Inhalation  of  oxygen  is  said  to 
arrest  the  convulsions  and  delirium,  but  not  to  retard  death.  Vaccine 
virus  and  the  venom  of  the  viper  have  each  been  tried,  but  with  no  good 
effect. 

Of  non-medicinal  therapeutic  measures  the  following  are  among  the 
most  promising :  Perfect  seclusion,  quiet,  and  darkness  serve  to  abate  the 
hypersesthesia,  the  painful  acuteness  of  the  senses,  and  the  convulsive  and 
delirious  paroxysms.  It  can  no  longer  be  doubted  that  a  very  few  cases 
of  genuine  rabies  recover,  but  those  that  do  so  have  almost  all  had  special 
advantages  in  the  way  of  quiet  and  seclusion,  and  few  have  had  the 
excitement  of  medicinal  treatment.  Eight  cases  of  the  recovery  of 
rabid  dogs  are  reported  by  Meuecier,  Decroix,  Laquerriere,  Rey,  Harold 
Leiuey,  and  Pasteur.  The  two  first  were  attested  by  successful  inocula- 
tion on  other  animals ;  Decroix's  second  case  was  caused  by  inoculation 
with  the  saliva  of  a  hydrophobous  man  ;  the  next  three  had  been  bitten 
by  dogs  undoubtedly  mad  ;  while  Pasteur's  was  inoculated  with  the 
brain-matter  of  a  rabid  cow.  All  in  due  time  presented  the  characteristic 
symptoms  of  rabies,  yet  all  recovered,  without  any  record  of  medicinal 
treatment.  Pasteur's  case,  when  again  inoculated,  resisted  the  disease. 
A  certain  number  of  recoveries  of  men  from  pronounced  hydrophobia 
under  medicine  and  without  it  are  on  record,  but  in  the  absence  of  suc- 
cessful inoculations  it  is  impossible  to  tell  how  many  were  cases  of  infect- 
ing rabies.  The  parallel  between  rabies  and  tetanus  in  the  intensity  of 
the  reflex  excitability  would  demand  darkness  and  quiet  as  a  sine  qua  non 
of  any  rational  treatment.  Faradization  has  produced  a  temporary  relief, 
but  no  permanent  improvement.  Warm  baths,  steam  baths,  and  hot-air 
baths  serve  to  abate  excitability  and  spasm,  and  have  been  lauded  as 
specific  in  hydrophobia,  but  have  proved  useless  in  the  lower  animals. 


908  RABIES  AND  HYDROPHOBIA. 

Intravenous  injection  of  warm  water  (two  pints)  in  a  hydrophobous 
man  reduced  the  pulse  from  150  to  86  and  restored  the  power  of  deglu- 
tition. Life  was  prolonged  for  nine  days,  but  in  great  agony,  from  the 
supervention  of  suppurative  arthritis  (Majendie).  In  another  case  the 
dread  of  water  disappeared,  but  death  ensued  in  fifty-four  hours.  In 
the  hands  of  Youatt  and  Mayo  it  proved  equally  unsuccessful  in  dogs. 
A  cold  bath  with  submersion  to  unconsciousness  is  an  old  remedy  now  aban- 
doned. Venesection  to  fainting,  with  or  without  mercury,  mitigated  the 
symptoms,  but  seemed  to  hasten  paralysis  and  death.  The  excision  and 
cauterization  of  the  cicatrix,  or  the  cutting  of  the  nerves  proceeding  from 
it,  has  been  useful  in  delaying,  or  even  absolutely  preventing,  the  par- 
oxysms. When,  therefore,  the  premonitory  symptoms  of  hydrophobia 
have  set  in,  and  when  an  aura  or  shooting  pain  is  felt  proceeding  from 
the  seat  of  the  wound  toward  the  heart,  one  or  other  of  these  measures 
may  serve  to  prevent  the  immediate  occurrence  of  reflex  convulsions. 
When  the  poison  has  actually  invaded  the  brain,  this  can  be  looked  on  as 
a  palliative  measure  only,  but  in  the  many  cases  of  lyssophobia  it  may 
put  an  instant  stop  to  the  affection. 


GLANDERS  (EQUINIA  GRAVIOR,  FARCY), 

BY  JAMES  LAW,  F.  R  C.  V.  S. 


^  SYNONYMS. — Greek,  fjid^.  Latin,  Malleus,  Equinia  Nasalis,  E.  Apos- 
timatos,  Farcinia.  French,  Morve,  Farcin.  German,  Rotz,  Lungenrotz, 
Hautrotz,  Wurm,  Hautwurm.  Italian,  Morva,  Moccis,  Cimurro.  Spanish, 
Cimorro,  Lamparones. 

DEFINITION. — An  infectious,  bacteridian  disease  occurring  in  the 
horse,  ass,  or  mule,  and  communicated  by  inoculation  to  various  other 
animals,  including  man.  It  is  usually  ushered  in  by  rigors,  followed  by 
articular  pains,  lameness,  and  the  formation  of  a  specific  deposit  in  the 
lymphatic  system  of  some  part  of  the  body,  with  a  tendency  to  destruc- 
tive degeneration  and  ulceration.  In  the  form  known  as  glanders  these 
deposits  and  ulcers  take  place  mainly  in  the  nasal  mucosa,  in  the  lungs, 
and  in  adjacent  glands,  while  in  that  known  as  farcy  the  deposits  occur 
in  the  cutaneous  and  subcutaneous  lymphatic  plexuses  and  the  dependent 
glands. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — Under  the  name,  of 
malis  Aristotle  describes  a  fatal  disease  of  asses,  supposed  to  have  been 
identical  with  the  malleus  humidus  of  Vegetius  Renatus  and  other  writers 
of  early  Christian  times,  and  with  the  cymoira  of  other  early  Roman 
writers.  This  malady  wras  characterized  by  swelling  of  the  submaxillary 
glands  and  discharge  from  nose  and  mouth.  From  the  fourteenth  cen- 
tury onward  glanders  is  reported  from  different  parts  of  Europe  at  fre- 
quent intervals;  thus  in  1320  in  England  (Rogers);  in  1640  in  Badajoz, 
brought  by  Portugese  horses  (Villalba);  in  1686  at  Treves  (Eggerdes); 
again  in  1776  in  Southern  France  (Lafosse);  in  1794  in  Bavaria  (Plank); 
in  1796  in  Franconia  (Laubender);  and  in  1798  in  Piedmont  (Toggia). 
At  the  beginning  of  the  present  century  this  aifection  was  very  widely 
prevalent  in  Great  Britain,  the  chronic  cases  being  habitually  worked  in 
stage-coaches,  but  of  recent  years,  when  it  has  been  made  criminal  to 
expose  or  use  a  glandered  horse,  the  malady  has  to  a  great  extent  disap- 
peared. To-day  glanders  is  almost  coexistent  with  the  distribution  of 
the  plomesticated  equine  family,  yet  its  prevalence  bears  a  direct  relation 
to  the  facilities  for  infection  (horse-traffic,  war,  preservation  of  the 
diseased,  confinement  in  close  stables,  ships,  etc.),  and  some  countries 
appear  to  be  entirely  free  from  the  affection.  Thus,  Krabbe  gives  the 
yearly  losses  per  100,000  horses  for  the  principal  countries  of  Europe 
and  Algiers  as  follows:  Norway,  6;  Denmark,  8.5;  England,  14;  Swe- 
den, 57 ;  Wurtenberg,  77 ;  Prussia,  78 ;  Saxony,  95 ;  Belgium,  138 ; 

009 


910  GLANDERS. 

France  (array),  1 1 30 ;  Algeria  (army),  1 548.  The  losses  in  Prussia 
more  than  doubled  after  the  Franco-German  War;  thus,  in  1869—70 
they  were  966,  and  in  1873—74,  2058.  In  Bavaria  they  rose  in  the  same 
period  from  173  to  390  (Hahn).  In  Lisbon,  Portugal,  glanders  was 
unknown  for  the  thirty  years  preceding  the  Peninsular  War,  whereas 
after  the  war  it  proved  a  veritable  scourge  (Saunier).  Charles  Percivall, 
during  an  eight  years'  residence  at  Meerut  and  Cawnpore,  Hindostan, 
saw  not  a  single  case  of  glanders,  and  so  late  as  1275,  Fleming  claims  an 
entire  immunity  for  India  ;  yet  in  1877  complaints  were  numerous  of  the 
very  general  prevalence  of  the  disease  in  Upper  India  especially,  while 
in  1879  the  campaign  in  Afghanistan  was  seriously  affected  by  its  ravages. 
Climate  appears  to  have  little  influence.  The  disease  is  virtually  unknown 
in  the  island  of  Born  holm  with  7000  horses,  and  in  the  Faroes  and  Ice- 
land with  35,000,  while  it  is  quite  frequent  in  Sweden.  It  is  unknown 
in  Australia,  but  is  very  prevalent  in  China,  South  Africa,  Abyssinia, 
and  Algiers,  and  but  little  known  in  Asia  Minor,  Arabia,  and  Egypt. 

In  the  United  States  as  in  Europe  the  disease  has  mainly  concentrated 
itself  in  the  large  cities  in  times  of  peace,  and  spread  widely  on  the 
advent  of  war.  It  is  alleged  that  it  first  entered  Mexico  in  1847  with 
the  American  cavalry,  though  with  the  horses  kept  in  the  open  air  it  failed 
to  gain  a  wide  extension.  The  horses  and  mules  drawn  into  the  Union 
armies  in  1861  brought  infection  with  them,  and  soon  the  disease  was 
most  prevalent  and  destructive,  not  only  in  the  ranks,  but  in  every  State 
in  which  the  armies  operated.  John  K.  Page  says  the  first  case  he  saw 
in  the  Confederate  army  was  a  captured  Federal  troop-horse  on  the  retreat 
from  Manassas,  and  that  the  breaking  down  of  the  Confederate  cavalry 
in  the  last  two  years  of  the  war  was  mainly  due  to  glanders.  At  the 
close  of  the  war  the  sale  of  army  horses  distributed  the  infection  widely 
through  all  the  States,  North  as  well  as  South.  Every  year  in  a  country 
district  in  Western  New  York  I  see  several  cases  of  glanders,  and  occa- 
sionally a  whole  stud  is  carried  off  through  an  infected  purchase.  In 
other  States  the  case  is  no  better.  In  Pennsylvania,  Ohio,  Illinois,  and 
Michigan  cases  are  constantly  seen  in  the  country  districts,  and  in  the 
three  last-named  States  five  human  victims  have  been  reported  within  a 
short  period.  In  Connecticut  the  same  is  true,  and  the  disease  made  one 
human  victim  in  Waterbury  in  1879.  In  the  large  cities  the  case  is  still 
worse.  Liautard  of  New  York  in  1878,  in  a  single  visit  to  one  car- 
stable,  condemned  8  horses,  in  another  stable  18,  and  in  a  third,  at  two 
visits,  45,  while  a  fourth  had  lost  no  fewer  than  200  horses  in  the  course 
of  one  year  from  glanders.  In  the  Troy  (X.  Y.)  car-stables  the  malady 
prevailed  from  1875— 77,  most  of  the  subjects  suffering  from  chronic  farcy, 
until  in  the  latter  year,  by  my  advice,  these  propagators  of  contagion 
were  destroyed.  In  Springfield,  Mass.,  in  1879,  the  disease  assumed  such 
alarming  proportions  that  it  was  vigorously  suppressed  by  a  city  ordi- 
nance enjoining  summary  slaughter.  These  are  but  indications  of  what 
is  happening  all  over  the  country,  entailing  losses  of  many  hundreds  of 
thousands  yearly  as  well  as  an  enormous  risk  to  humanity. 

The  following  table  gives  the  number  of  cases  occurring  in  the  equine 
family  in  two  of  the  principal  countries  of  Europe  in  the  last  few  years : 


ETIOLOGY. 


911 


Casea  of  Glanders  in  — 

Great  Britain. 

Germany. 

1878  

888 

2753 

1879  

1367 

1880  

2048 

1941 

1881  

1710 

1774 

1882  :  

1389 

1838 

As  both  countries  systematically  suppress  this  disease  through  their  veteri- 
nary sanitary  officials,  it  cannot  be  doubted  that  the  figures  for  America, 
if  obtainable,  would  be  relatively  higher. 

Glanders  prevails  especially  in  horses,  asses,  mules,  and  other  solipedes, 
and  is  communicated  by  inoculation  to  all  domestic  animals  except  the 
genus  Bovis.  In  the  sheep  and  goat  the  receptivity  is  considerable,  and 
the  disease  may  prove  fatal  in  fifteen  days  (Gerlach)  or  it  may  be  delayed 
for  seven  weeks  (Bollinger).  The  Carnivora  (dogs,  cats,  lions,  polar 
bears)  contract  the  affection  by  eating  diseased  flesh,  as  do  some  rodents 
(prairie-dogs,  rabbits,  guinea-pigs,  mice),  and,  by  administration,  solipedes. 
Swine  contract  the  disease  by  inoculation  (Gerlach,  Spinola),  though  in 
these  and  in  the  dog  the  constitutional  symptoms  are  usually  slight  and 
recovery  may  follow  the  local  affection. 

The  susceptibility  of  man  is  doubtless  less  than  that  of  the  solipedes, 
judging  from  the  few  cases  of  glanders  compared  with  the  frequent  expo- 
sures, yet  when  once  established  in  the  system  it  can  hardly  be  said  to  be 
less  malignant  or  fatal. 

ETIOLOGY. — The  one  known  cause  of  glanders  is  contagion,  and  the 
recent  experiments  of  Capitan  and  Charrin  in  France  and  of  Schiitz  and 
Lofler  in  Germany,  demonstrating  that  the  bacillus  of  the  glanderous 
deposits  is  the  one  essential  cause  of  the  disease,  effectually  dispose  of  any 
claim  of  its  spontaneous  origin.  Glanders  can  no  longer  be  considered 
spontaneous,  further  than  that  its  germ  is  now  proved  capable,  like  that 
of  anthrax,  of  survival  and  multiplication  out  of  the  animal  economy,  so 
that  infection  may  come  from  other  objects  than  a  sick  animal ;  and  it 
may  even  yet  appear  that  the  bacillus,  living  at  times  as  a  harmless  sap- 
rophyte out  of  the  animal  body,  may  acquire  deadly  properties  under 
certain  conditions  of  the  environment.  At  the  same  time,  the  most  exten- 
sive acquaintance  with  glanders  and  the  broadest  generalizations  ^froni 
known  facts  do  not  warrant  the  assumption  of  the  extension  of  the  disease 
by  the  growth  of  the  bacillus  out  of  the  living  body,  unless  it  be  on  the 
rarest  possible  occasions,  while  the  soundness  of  extensive  countries  (Aus- 
tralia, New  Zealand)  for  a  century  or  more  speaks  strongly  against  any 
frequent  development  from  a  harmless  saprophyte. 

To  the  same  effect  speak  the  experiences  of  the  English  army.  At  the 
beginning  of  the  century,  under  the  teaching  of  Coleman,  most  cases  were 
attributed  to  lack  of  stable  care,  and  extensive  experiments  were  made  in 
the  treatment  of  the  disease,  with  the  result  of  a  very  high  mortality 
from  this  cause.  Now,  when  contagion  is  looked  on  as  the  main  or  sole 
cause,  and  all  suspected  horses  in  the  army  are  promptly  destroyed,  the 
disease  is  only  seen  in  recently-purchased  animals  or  after  the  inevitable 
exposures  of  a  campaign.1  In  the  French  army  the  doctrine  of  the  non- 
1  Wilkinson,  Jour,  of  Roy.  Ayr.  Soc.,  No.  50. 


912  GLANDERS. 

contagiousness  of  chronic  glanders  led  to  a  greater  prevalence  of  this  dis- 
ease than  in  any  other  country  of  Europe.  Prior  to  1836  it  was  about 
90  per  1000  per  annum,  whereas  now,  under  the  doctrine  of  contagion 
and  a  corresponding  practice,  glanders  kills  but  2  per  1000  per  annum 
(Rossignol). 

But  while  the  essential  cause  of  glanders  is  the  specific  bacillus,  an 
individual  susceptibility  is  no  less  requisite  to  an  attack.  This  may  be 
innate  or  acquired.  As  we  have  seen,  it  varies  according  to  the  genus, 
being  greatest  in  the  solipede.  But  many  solipedes  show  a  strong  power 
of  resistance.  Of  138  horses  similarly  exposed  by  cohabitation  with 
glandered  horses,  but  29  (21  per  cent.)  suffered.  Of  28  inoculated  with 
glanders  virus,  but  9  (32  per  cent.)  succumbed  (Lamirault,  Bagge,  Tschern- 
ing).  The  accessory  causes  which  predispose  the  system  to  the  reception 
of  glanders  may  be  included  under  one  general  term — low  condition  and 
ill  health.  Three  of  these  causes,  however,  deserve  especial  mention  :  1st. 
Impure  and  rebreathed  air.  Prior  to  1836  the  yearly  losses  per  1000  of 
the  French  army  horses  were  from  180  to  197.  At  the  date  named  the 
ventilation  of  the  stables  was  greatly  improved,  and  the  mortality  fell  to 
68  per  1000  per  annum,  one-half  from  glanders.  Later  improvements 
have  reduced  the  34  cases  to  2.  During  the  Italian  War,  in  1859,  10,000 
of  these  horses  were  kept  for  nine  months  in  open  sheds,  with  but  one 
case  of  glanders.1  In  the  expedition  to  Quiberou  during  the  Napoleonic 
wars,  a  cavalry  contingent,  believed  to  be  healthy,  shipped  on  new  trans- 
ports, encountered  a  storm,  and  had  the  hatches  fastened  down,  so  that 
several  horses  were  suffocated.  Among  the  survivors,  landed  at  South- 
ampton and  placed  in  stables  hitherto  unchallenged,  many  soon  developed 
glanders  in  its  worst  form.  Similar  results  followed  the  English  expe- 
ditions to  Varna  in  1854,  and  that  to  Abyssinia  in  1867.  In  badly- 
ventilated  mines  and  stables,  especially  cellar  stables,  glanders,  once 
started,  is  always  most  virulent. 

2d.  Cold,  damp,  draughty  stables  greatly  favor  the  progress  of  glan- 
ders. Leblanc  reports  the  case  of  a  stud  of  240  horses  that  had  had  no 
glanders  for  eight  years,  but  which  lost  half  their  number  in  three 
months  after  removal  into  a  new  stable,  very  lofty,  but  dark  and  damp, 
and  subject  to  cold  draughts.  It  is  worthy  of  notice  that  they  had  also 
been  subjected  to  double  work,  and  were  consequently  emaciated,  but 
there  was  not  known  to  be  any  unusual  exposure  to  contagion.  In  a 
Boston  street-car  stable,  where  glanders  had  long  prevailed,  Thayer  cut 
it  short  by  destroying  the  infected  animals  and  by  improving  the  ventila- 
tion by  windows  hung  at  the  bottom  and  opening  inward,  so  that  the  air 
entered  in  an  upward  direction,  and  cold  draughts  on  the  horses  were 
avoided. 

3d.  Debility  from  ill-health,  low  feeding,  or  overwork. — The  nervous 
and  nutritive  debility  consequent  on  chronic  disease,  overwork,  and 
exhaustion  lessens  the  power  of  resistance  to  specific  poisons,  but  in  such 
circumstances  there  is  always  the  added  predisposition  of  an  excess  of 
waste  material  in  the  blood,  a  specially  abundant  food  for  the  diseuse- 
germ.  So  notorious  is  this  that  it  used  to  be  held  that  the  specific  poison 
of  glanders  was  generated  in  connection  with  the  excess  of  creatine,  crea- 
tinine,  and  lactic  acid  resulting  from  muscular  action.  Of  the  effect  of 
1  Larrey,  Hyg.  dea  Hop.  Mil.,  1862,  p.  63. 


ETIOLOGY.  913 

low  diet  we  have  a  striking  example,  furnished  by  Bouley,  of  a  stud  of 
120  horses,  60  of  which  were  attacked  within  a  year  after  they  had  been 
placed  on  a  food  insufficient  to  repair  the  body- waste,  and  from  which  the 
disease  disappeared  after  the  slaughter  of  the  infected  and  improvement 
of  the  ration.  So  long  as  glandered  horses  were  preserved  for  work,  the 
then  nearly  ubiquitous  germ  attacked  nearly  all  that  were  run  down  by 
chronic  diseases ;  hence  glanders  was  looked  upon  as  the  natural  winding 
up  of  exhausting  diseases  in  the  horse,  as  tuberculosis  was  thought  to  be 
in  the  human  subject.  Modern  discovery  shows  that  without  the  germ 
all  such  debilitating  causes  are  impotent,  but  it  can  never  disprove  the 
great  potency  of  these  in  laying  the  system  open  to  attack,  nor  the  value 
of  vigorous  health  and  sound  hygiene  in  fortifying  the  system  against  it. 

The  channel  of  infection  manifestly  varies  in  different  cases.  In 
direct  inoculations  the  morbid  process  develops  first  at  the  point  of  inser- 
tion, and  secondly  in  the  nearest  lymphatic  glands  and  internal  organs. 
When  contracted  in  the  ordinary  way,  the  lesions  are  usually  first  seen 
in  the  posterior  nasal  passages,  the  larynx  or  the  lungs,  or  in  the  super- 
ficial lymphatics,  especially  of  the  hind  limbs.  This  susceptibility  of 
the  deeper  portions  of  the  air-passages  seems  to  imply  that  the  bacillus, 
borne  on  the  air,  is  lodged  on  different  parts  of  the  respiratory  mucous 
membrane,  and  first  sets  up  the  morbid  process  in  the  thinnest  or  most 
susceptible  portion.  That  it  can  be  thus  borne  on  the  air  is  shown  by 
the  experiments  of  Viborg  and  Gerlach,  who  separately  collected  the 
participate  elements  from  the  exhalations  of  glandered  horses  and  suc- 
cessfully inoculated  them.  That  the  virus  is  not  usually  carried  far  on 
the  air  in  a  virulent  form  is  attested  by  the  many  instances  in  which 
horses  have  stood  for  months  in  the  same  stable  with  a  glandered  animal 
without  becoming  infected.  That  infection  may  also  take  place  through 
the  ingestion  of  infected  matters  is  undoubted,  as  glanderous  products 
mixed  with  food,  or  even  made  into  balls  and  enclosed  in  paper  and 
administered  to  horses  in  this  form,  have  produced  the  disease.  The 
virulence  is  said  to  be  lost  by  passing  through  the  digestive  canal  of 
man  (Decroix),  dog,  pig,  and  fowl  (Renault),  but  even  to  Carnivora  the 
infection  may  be  conveyed  in  the  food. 

While  the  virus  is  concentrated  in  the  material  of  the  special  glander- 
ous deposits  and  the  discharges  from  these,  yet  no  part  of  the  body  can 
be  considered  as  free  from  the  poison.  Viborg,  Colemau,  Hering,  and 
Chauveau  have  communicated  the  disease  by  transfusion  of  blood  from 
a  glandered  horse  to  a  healthy  one ;  hence  every  vascular  organ  must  be 
liable  to  infect.  The  secretions  of  the  diseased  body  ^  (tears,  saliva, 
mucus,  sweat,  urine,  and  milk)  have  each  been  successfully  inoculated,  and 
the  conveyance  of  the  disease  to  the  foetus  in  utero  and  to  the  female  by 
coition  imply  that  even  the  generative  secretions  are  virulent.  ^  Failures 
to  convey  the  disease  by  inoculation  with  the  blood  and  secretions  have 
often  occurred,  however,  and  they  must  be  held  as  less  virulent  than  the 
products  of  the  local  disease-processes. 

The  claims  that  inoculation  with  pus,  ichor,  and  other  irritants  have 
produced  glanders  must  be  entirely  discredited.  The  deposits  and  ulcers 
in  the  lungs  and  elsewhere  resulting  from  such  inoculations  have  been 
either  septicaemia,  mistaken  for  glanders  in  the  earlier  days  of  patholog- 
ical anatomy;  or  the  septic  and  other  inflammations  set  up  by  these  inoc- 


Voi,.  I.— 58 


914  GLANDERS. 

illations  have  merely  served  as  fertile  spots  for  the  planting  and  growth 
of  the  glanders  bacillus  accidentally  present,  and  which  to  a  healthy  sys- 
tem might  have  proved  harmless. 

In  1882,  Chauveau  had  demonstrated  the  particulate  nature  of  the 
glander  germ  by  his  unsuccessful  inoculations  with  the  liquids  filtered 
from  dilutions  of  pus  taken  from  a  pulmonary  glanderous  ulcer.  The 
filtrate  and  the  liquid  mixture  formed  by  mixing  the  pus  with  five  hun- 
dred times  its  own  weight  of  water  retained  their  virulence  undiminished. 
In  1868,  Christol  and  Kiener  discovered  in  glanderous  products  a  bacillus 
which  they  figured  as  made  up  of  a  chain  of  nearly  globular  elements 
apparently  enclosed  in  a  common  sheath.  In  1881-82,  Bouchard,  Cap- 
itan,  and  Charrin  cultivated  these  microphytes  in  a  neutralized  extract 
of  meat  through  five  successive  cultures,  using  in  each  case  a  milligramme 
of  the  previous  culture,  or  less  than  j-^Vu"  Part  °f  tne  culture-liquid. 
Counting  that  the  milligramme  of  pus  would  give  to  each  centigramme 
of  the  first  culture-liquid  1,000,000,000  bacilli,  it  follows  that  the  second 
culture  would,  on  the  principle  of  dilution,  contain  1,000,000,  the  third 
1000,  the  fourth  1,  while  for  the  fifth  it  was  as  999  to  1  that  it  would 
receive  nothing  unless  the  germ  were  multiplied  in  the  culture-liquid. 
Inoculation  of  a  cat  with  this  fifth  culture,  started  originally  from  a 
nasal  ulcer  of  a  glandered  horse,  led  to  a  fatal  result  in  twenty-five  days, 
with  suppurating  tumor  of  the  left  testicle  and  inguinal  glands.  The 
products  of  the  first  cat  were  inoculated  on  a  second,  those  of  the  last  on 
a  third,  those  of  the  third  on  a  guinea-pig,  and  those  of  the  guinea-pig 
on  an  ass,  producing  in  every  case  specific  lesions  of  glanders,  including 
miliary  nodules  and  abscesses,  and  death  respectively  on  the  following 
days:  16,  7,  31,  and  10. 

In  September,  1882,  and  the  two  succeeding  months,  a  similar  course  of 
experiments  was  conducted  by  Schiitz  and  Lofler  at  Berlin.  The  viru- 
lent matter  used  for  starting  the  culture  was  procured  from  a  pulmonary 
deposit  and  spleen  of  a  glaudered  horse ;  the  cultivation  was  continued 
through  eight  successive  culture-fluids.  One  horse  was  successfully  inoc- 
ulated with  the  product  of  the  eighth  culture,  and  a  second  with  both  the 
fifth  and  eighth.  The  first  died  on  the  fifty-eighth  day,  and  the  second, 
now  very  weak,  was  sacrificed  on  the  fifty-ninth.  Both  showed  the  most 
extensive  lesions  of  glanders  alike  in  the  skin,  the  lymphatic  glands,  the 
pituitary  and  laryngeal  mucous  membrane,  and  the  lungs.  To  demon- 
strate the  bacillus  they  take  a  thin  layer  of  the  infecting  liquid  on  a 
cover  glass,  dry  it,  stain  with  methyl  violet,  wash  with  dilute  acetic  acid, 
dehydrated  by  absolute  alcohol,  and  clear  by  oil  of  cedar.  Like  other 
pathogenic  microphytes  this  may  be  preserved  for  months  or  years  if 
thoroughly  dried,  but  in  the  moist  condition  it  is  easily  destroyed  by 
heat  (133°  F. ;  Viborg,  Hofacker,  Renault),  chlorine,  and  the  disinfectant 
chlorides  and  sulphites. 

SYMPTOMS. — Acute  nasal  glanders  in  horses  has  a  period  of  incuba- 
tion lasting  from  three  to  five  days  in  inoculated  cases.  Where  in  infected 
subjects  the  incubation  appears  to  have  extended  over  months  or  a  year, 
there  have  usually  (or  always)  been  deposits  in  internal  organs  Avhich 
passed  without  recognition  until  the  lesions  appeared  in  the  nose.  At 
the  outset  there  is  fever,  which  appears  before  any  local  lesions  are 
recognizable,  even  post-mortem  (Chauveau),  and  soon  with  languor, 


SYMPTOMS.  915 

and  loss  of  appetite,  there  is  a  serous  nasal  discharge,  often  from 
one  side  only.  By  the  sixth  day  this  has  become  yellowish,  the  margin 
of  the  nostril  is  often  swollen,  and  upon  the  pituitary  membrane  may  be 
detected  elevations  of  various  sizes  of  a  general  yellowish  tinge,  dotted 
with  minute  red  points  and  surrounded  by  a  bright-red  or  purple  and 
slightly  elevated  areola.  These  may  be  simple,  pea-like  nodules  or  more 
or  less  extensive  patches,  which  in  certain  cases  extend  over  nearly  the 
whole  pituitary  membrane.  At  the  same  time  the  submaxillary  lymph- 
atic glands  on  the  same  side  become  the  seat  of  a  hard  nodular  painless 
enlargement,  feeling  like  a  conglomerate  mass  of  peas,  and  often  show- 
ing a  tendency  to  become  more  closely  adherent  to  some  adjacent  part 
(bone,  skin,  base  of  tongue) ;  but  they  only  ulcerate  exceptionally.  Ex- 
tensive hot,  painful  engorgements  also  often  appear  on  other  parts  of  the 
body,  and  if  on  the  limbs  or  joints  cause  lameness.  Soon  the  swellings 
on  the  mucosa  become  eroded  and  are  gradually  destroyed,  forming  large 
unhealthy,  chancrous-looking  ulcers,  tending  to  become  confluent  and  to 
eat  deeply  through  the  mucosa  into  the  subjacent  tissues.  These  are 
mostly  reddish  gray  or  yellowish  gray,  with  raised  ragged  red  or  yellow- 
ish-red margins.  They  bleed  readily,  and  may  be  black  from  hemor- 
rhage, or  greenish  or  of  some  other  shade  from  decomposition.  The 
discharge  is  always  somewhat  glutinous  and  sticky,  but  it  may  vary  in 
color  from  simple  white  to  yellowish,  greenish,  brownish,  or  red,  accord- 
ing to  the  destruction  of  tissue,  the  septic  changes,  or  the  effusion  of 
blood. 

By  the  sixth  to  the  fifteenth  day  the  acme  has  been  reached.  The  alge 
of  the  nostrils  are  glued  together  by  the  drying  discharge,  and  this,  with 
the  general  swelling  of  the  nasal  passages,  renders  the  breathing  snuffling 
and  difficult.  The  lymphatics  on  the  side  of  the  face  are  usually  inflamed 
and  corded,  and  the  same  is  true  of  the  cutaneous  lymphatics  of  the  hind 
limbs  of  some  other  part  of  the  body  (farcy).  Death  usually  ensues  from 
suffocation,  preceded  by  the  most  painful  dyspnosa. 

Chronic  glanders  in  horses  often  sets  in  insidiously,  but  frequently  also 
it  first  shows  itself  by  constitutional  disturbance,  which  gradually  sub- 
sides as  the  local  lesions  are  formed.  Among  frequent  premonitory 
symptoms  may  be  mentioned  intermittent  or  continued  lameness,  oedema 
of  one  or  more  limbs,  infiltration  of  the  testicle,  cough,  and  bleeding  from 
the  nose.  The  general  health  may  appear  good,  and  if  in  good  hygienic 
condition  the  digestion  and  nutrition  may  be  sufficient,  the  body  plump, 
and  the  skin  shining  ;  but  there  is  usually  some  dulness  of  the  eye,  dry- 
ness  of  the  coat,  lack  of  endurance,  and  a  tendency  to  sweat  easily  and  to 
run  down  rapidly  under  hard  work  or  debilitating  conditions.  The 
discharge,  at  first  clear,  becomes  turbid,  grayish,  sticky,  and  purulent, 
tending  to  agglutinate  the  hairs  and  edges  of  the  aloe  nasi,  a;;d  is  expelled 
by  snorting  in  masses.  The  nasal  mucosa,  and  especially  over  the  septum, 
is  the  seat  of  the  peculiar  elevations,  ulcers,  and  firm  white,  condensed 
deposits  resembling  cicatrices,  usually  low  enough  down  to  be  seen  or  felt. 
The  submaxillary  lymphatic  glands  are  the  seat  of  the  nodular  enlarge- 
ment described  in  acute  glanders,  and,  as  in  that  affection,  there  may  be 
pulmonary  or  skin  deposits  shown  by  cough  or  osdema,  with  swelling  and 
cording  of  the  cutaneous  lymphatics  with  nodules  and  ulcers. 

These  cases  often  maintain  this  indolent  type  for  years,  spreading  the 


916  GLANDERS. 

infection  widely,  but  they  tend  sooner  or  later  to  develop  the  acute  type, 
especially  under  some  debilitating  conditions. 

When  the  mucous  membrane  of  the  larynx  and  bronchi  is  first  at- 
tacked the  nasal  lesions  may  be  delayed  for  a  time,  but  the  cough,  the 
variously  colored  tenacious  expectoration,  the  excessive  tenderness  of  the 
larynx,  and  the  nodular  enlargement  of  the  adjacent  lymphatic  glands, 
with  the  general  ill-condition,  suggest  that  which  is  later  confirmed  by 
the  specific  lesions  in  nose  and  skin. 

When  the  affection  is  confined  to  the  bronchia  and  pulmonary  paren- 
chyma, there  are  the  usual  signs  of  bronchitis,  disturbed  breathing,  with 
hard,  soft,  mucous,  or  dry  husky  cough,  and  blowing,  mucous  or  sibilant 
rale,  at  points  crepitation,  and  at  others  some  diminution  of  murmur 
and  resonance.  The  breath  is  mawkish  or  fetid,  and  expectoration  more 
or  less  sticky  and  charged  with  bacilli ;  but  all  these  symptoms  are  at 
times  equivocal,  and  inoculation  alone  can  attest  the  true  nature  of  the 
disease.  This  should  be  practised  by  preference  on  a  donkey  or  an  old 
horse  in  poor  condition  but  with  general  good  health.  Then  the  disease 
shows  itself  in  the  acute  form  in  six  days.  If  solipedes  are  not  available, 
rabbits  or  guinea-pigs  may  be  used  for  inoculation. 

In  acute  cutaneous  glanders  or  farcy,  premonitory  symptoms  resemble 
those  of  ordinary  acute  glanders,  which  indeed  is  usually  present  as  well, 
and  always  supervenes  before  farcy  terminates  in  death.  The  local  lesions 
consist  in  inflammation  of  the  lymphatic  vessels,  which  become  like  firm 
cords,  the  appearance  at  intervals  along  these  cords  of  rounded  glanderous 
nodules  varying  in  size  from  a  pea  to  a  hickory-nut,  and  with  a  marked 
tendency  to  ulceration  and  the  formation  of  hot,  painful  cedematous  swell- 
ings. The  swelling  of  the  lymphatics  appears  by  preference  in  the  lower 
part  of  a  hind  limb,  and  the  first  nodules  may  be  near  the  fetlock  or  tar- 
sus. The  ulcers  forming  about  the  sixth  day  have  a  yellowish-white 
appearance  with  red  points  and  raised  irregular  borders,  and  the  discharge 
is  grumous  and  viscous,  with  a  yellowish  or  reddish  tinge.  The  disease 
extends  toward  the  body,  the  upper  air-passages  become  involved,  and 
death  speedily  follows. 

Chronic  cutaneous  glanders,  chronic  farcy,  usually  begins  by  a  local 
swelling,  mostly  of  the  fetlock,  in  the  midst  of  which  a  careful  examina- 
tion detects  a  small  glanderous  nodule.  This  tardily  softens,  ulcerates, 
and  discharges  the  characteristic  ichor,  the  lymphatics  leading  up  from  it 
become  thick  and  rigid  (corded),  and  new  nodules  appear.  Though  very 
indolent,  these  finally  tend  to  ulcerate,  and  in  time  cedematous  swellings 
appear  in  the  vicinity  or  at  distant  parts  of  the  body,  with  nodules  at 
intervals.  This  will  go  on  for  months,  or  even  for  years,  and  recoveries 
occasionally  take  place,  while  in  other  cases,  and  especially  when  the  con- 
ditions of  life  are  bad,  acute  glanders  supervene. 

MORBID  ANATOMY. — The  lesions  consist  essentially  in  a  cellular 
growth  in  the  connective  tissue,  determined  by  the  presence  of  the 
specific  poison,  and  in  destructive  changes  in  the  elements  of  such 
growth — softening,  fatty  degeneration,  ulceratiou,  and  discharge.  In 
certain  cases  of  nasal  glanders  at  the  earliest  stage  there  is  merely  an 
increased  proliferation  of  the  mucous  corpuscles,  which  become  more 
granular  or  purulent.  Soon,  however,  the  fibro-vascular  layer  is  in- 
volved, the  affected  part  being  the  seat  of  dark  bluish  congestion,  and 


MORBID  ANATOMY.  917 

of  the  proliferation  of  small  rounded  lymphoid  cells,  comparable  to  those 
of  the  early  stage  of  tubercle,  and  enclosed  in  more  or  less  dense  fibrous 
areoloe.  The  common  nasal  nodule  or  patch  has  a  soft  velvety  surface, 
dirty  gray  or  grayish  yellow,  and  the  lymphoid  cells  are  so  circumscribed 
in  nests  that  when  soaked  in  water  the  cells  are  washed  out  and  the 
fibrous  reticulum  is  left  hollowed  out  like  a  honeycomb.  In  this  fibrous 
reticulum  are  many  spindle-shaped  and  a  few  rounded  cells.  Its  vas- 
cularity  is  easily  demonstrated  by  injection.  The  centre  of  each  nest 
is  the  palest  part  of  the  mass,  and  unless  stained  by  extravasation  it 
contrasts  with  the  reddish  areola.  These  islets  of  lymphoid  cells,  at 
first  isolated  and  each  the  size  of  a  pin's  head,  may  enlarge  and  become 
confluent,  forming  the  larger  nodules.  With  this  increase  the  centre  of 
each  becomes  turbid,  and  the  cells  are  found  to  have  become  granular 
and  fatty,  and  to  have  in  pail  broken  up  into  a  granular  debris.  This 
characterizes  the  period  of  ulceration,  and  erosions  and  ulcers  follow  in 
ratio  with  the  extent  of  the  neoplasm  and  the  rapidity  of  its  growth. 
If  the  growth  is  tardy,  the  ulcer,  with  irregular  eroded  and  everted 
edges,  may  remain  for  some  time  stationary  or  even  recede,  while  if  rapid, 
new  tubercles  form  around  the  margin  of  the  first,  and  by  the  disintegra- 
tion of  their  elements  the  ulcer  is  continuously  extended.  The  lesions 
are  especially  common  on  the  septum  nasi  and  turbinated  bones.  Similar 
lesions  may  be  found  in  the  nasal  sinuses  or  larynx. 

The  nodules  found  in  the  lungs  strongly  resemble  miliary  tubercles, 
but  are  usually  less  numerous.  As  in  the  nose,  they  have  a  punctiform, 
central,  grayish,  turbid  portion,  encircled  by  a  more  translucent  ring, 
surrounded  in  its  turn  by  a  vascular  area.  They  are  also  composed  of 
the  same  granular  rounded  cells,  though  they  may,  especially  in  the 
chronic  forms,  have  undergone  caseous,  fibrous,  or  calcareous  degenera- 
tion. The  acute  tubercles  are  often  surrounded  by  circumscribed  pneu- 
monia with  considerable  exudation.  They  are  distinguished  from  genu- 
ine tubercle  by  their  vascularity  and  by  the  absence  of  giant-cells. 

The  cutaneous  deposits  are  composed  of  the  same  histological  products 
imbedded  in  the  dermis  or  in  the  subcutaneous  connective  tissue,  and  extend- 
ing in  some  cases  deeply  between  the  muscles,  with  no  clear  line  of  demar- 
cation from  the  sound  tissue.  Not  only  the  chains  of  nodules  (farcy-buds), 
but  the  connecting  lymphatic  trunks,  are  the  seat  of  the  characteristic 
cellular  product,  and  in  -chronic  cases  there  is  the  enlargement  of  the 
adjacent  lymphatic  glands  as  well.  In  these  there  is  a  special  tendency 
to  early  disintegration  and  ulceration. 

In  the  diffuse  glanderous  swellings  (infiltrated  glanders,  inflammatory 
glanders)  the  affected  tissues  are  the  seat  of  an  inflammatory  process  with 
profuse  exudation  throughout,  while  in  the  interstices  of  the  connective 
tissue  are  numerous  granular  glander-cells.  The  same  tendency  to  necro- 
biosis  is  shown  as  in  the  other  forms  of  glanderous  neoplasms,  and  such 
diffuse  swellings  become  the  seats  of  very  extensive,  deep,  and  irregular 
ulcers,  or  frequently  of  fibroid  growth  and  induration,  forming  the  so- 
called  cicatricial  deposits.  These  are  hard,  firm,  and  resistant,  and  histo- 
logieally  consist  of  a  dense  fibrous  stroma  interspersed  with  the  spindle- 
shaped  cells.  They  are  especially  common  in  chronic  cases,  and  such  an 
appearance  on  the  nasal  mucous  membrane  is  always  suspicious,  as  this? 
dense  fibroid  appearance  rarely  follows  a  simple  traumatic  lesion. 


918  GLANDERS. 

Diffuse  glanderous  infiltrations  in  the  nose  may  implicate  the  entire 
mucosa  of  one  or  both  nasal  chambers,  and  the  ulcers  are  liable  to  be 
greater  than  from  the  nodular  form  of  the  disease.  They  are  also 
especially  associated  with  thrombosis  of  the  veins,  which  occurs  to  a  less 
extent  in  the  nodular  form  and  conduces  to  the  dark-blue  tint  of  the 
mucosa. 

Glanderous  infiltration  of  the  lungs  is  inflammatory  in  its  nature  (pnc-u- 
rnonia  malleosa),  attacking  an  area  of  two  or  three  inches  in  diameter  at 
or  near  the  margin  of  the  lungs,  and  proceeds  to  caseous  necrobiosis, 
suppuration,  calcification,  or  fibroid  induration.  In  the  skin  such  infil- 
trations also  frequently  terminate  in  induration,  while  ulceratiou  and 
abscess  tend  to  appear  when  the  proliferation  of  glander-cells  is  most 
abundant  (farcy-buds). 

The  glander-nodules  are  not  uncommon  in  muscles,  intermu§cular  con- 
nective tissue,  spleen,  liver,  kidneys,  and  testicles.  Leukemia  is  also  a 
constant  feature,  the  irritation  of  the  lymphatic  glands  manifestly  stimu- 
lating the  production  of  the  lymph-cells. 

DIAGNOSIS. — The  diagnosis  of  glanders  usually  rests  on  the  viscid 
nature  of  the  discharge,  the  painless  nodular  swelling  of  the  submaxil- 
lary  glands  and  the  indisposition  to  suppurate,  the  characteristic  appear- 
ance of  the  nodules,  elevations,  ulcers,  and  indurations  of  the  ua~al 
mucosa,  and  the  presence  of  the  specific  bacillus.  The  diagnosis  of  farcy 
rests  mainly  on  the  nature  of  the  nodules  and  corded  lymphatics,  of  the 
ulcers  and  their  discharges,  on  the  extension  of  the  affection  toward  the 
trunk,  and  the  tendency  to  implicate  the  respiratory  organs.  Usually, 
there  are  several  victims,  the  earlier  ones  chronic  cases,  the  later  ones 
acute,  or  there  is  a  history  or  presumption  of  exposure.  Yet  in  many 
cases,  and  especially  in  the  more  chronic  internal  forms  (laryngeal,  pul- 
monary, etc.),  the  diagnosis  is  difficult,  and  inoculation  of  a  horse,  goat, 
sheep,  or  rabbit  may  be  the  only  available  means  of  reaching  a  decision. 
Auto-inoculations  are  unreliable,  as  parts  not  yet  the  seat  of  active  disease 
will  often  resist  inoculation. 

PROGNOSIS. — This  is  always  unfavorable.  The  constancy  of  internal 
deposits  and  the  viability  of  the  germ  in  such  products  render  it  impos- 
sible to  eliminate  the  poison  from  the  system  in  the  great  majority  of 
cases.  In  external  glanders  only  is  there  any  reasonably  good  hope,  ami 
even  this  is  confined  to  the  chronic  cases.  In  stating  this  much,  it  is  not 
denied  that  recoveries  even  of  chronic  nasal  glanders  do  occur,  yet  these 
are  few,  and  the  majority  of  those  that  do  apparently  recover  usually 
succumb  as  soon  as  they  are  subjected  to  hard  work  or  specially  trying 
conditions  of  life,  so  that  but  little  faith  can  be  placed  in  most  of  the  alleged 
recoveries. 

TREATMENT. — Considering  the  great  danger  of  multiplying  and  pre- 
serving the  germs  of  a  disease  so  fatal  alike  to  man  and  boast,  the  treat- 
ment of  glanders  is  never  commendable.  The  danger  is  least  in  the  case 
of  chronic  farcy,  not  only  because  the  processes  are  less  active,  but  because 
the  virus  is  not  being  thrown  out  and  diffused  with  the  tidal  air  of 
respiration,  sneezing,  and  coughing.  The  unbroken  farcy-buds  and 
swollen  lymphatics  may  be  actively  treated  by  compound  iodine  ointment, 
and  the  ulcerous  nodules  freely  cauterized  with  corrosive  sublimate, 
biniodide  of  mercury,  chloride  of  zinc,  sulphate  of  copper,  or  iodized 


PEE  VENTIOX.—ETIOL  OGY.  919 

phenol.  Local  inflammations  may  demand  fomentations  and  astringent 
antiseptic  lotions.  Meanwhile,  the  system  must  be  supported  by  a  tonic- 
regimen  and  medication,  abundance  of  pure  air,  a  liberal  and  wholesome 
diet,  and  the  maintenance  of  the  various  bodily  functions  in  a  healthy 
condition.  Of  medicinal  agents  the  most  pronounced  tonics  have  the  best 
reputation — sulphate  of  copper  and  iron,  biniodide  of  copper,  arsenic, 
and,  above  all,  arseuite  of  strychnia.  Next  to  these  the  sulphites  rank, 
and  a  combination  of  the  two  last  named  is  perhaps  to  be  preferred. 

PREVENTION. — Theglandered  horses  and  all  animals  attacked  with  acute 
or  obstinate  farcy  should  be  destroyed  and  their  bodies  be  burned  or  deeply 
buried.  Every  State  should  legally  interdict  the  use  of  a  glaudered  horse 
or  his  exposure  in  any  public  or  other  place  where  infection  is  likely  to 
reach  other  animals  by  contact  or  through  fodder,  litter,  stable  utensils,  or 
any  other  objects  employed  about  animals.  No  less  imperative  should  be  the 
perfect  disinfection  of  all  stables,  harness,  and  other  objects  with  which 
glandered  animals  have  come  in  contact.  The  value  of  such  measures  is 
sufficiently  attested  by  what  has  been  stated  above  as  to  the  prevalence  of 
this  disease  in  the  French  army  so  long  as  the  doctrines  of  non-contagion 
dominated  in  its  management,  and  the  comparative  disappearance  of  the 
disease  so  soon  as  a  change  of  theory  and  method  had  been  inaugurated ; 
the  absence  of  the  disease  in  the  English  army,  where  the  doctrine  of 
contagion  and  its  extinction  has  long  prevailed ;  and  the  entire  absence  of 
the  disease  from  Australia,  New  Zealand,  etc.,  into  which  it  has  never 
been  imported,  though  prevailing  in  a  corresponding  latitude  and  climate 
at  the  Cape  of  Good  Hope. 


Glanders  in  Man. 

Up  to  1812  the  communication  of  glanders  to  man  failed  to  be  recog- 
nized. Then  Lorin,  a  French  surgeon,  published  a  case  of  the  kind  in 
which  inflammation  of  the  hand  was  induced  by  inoculation  from  a  horse 
suffering  from  farcy,  and  Waldinger  and  Weith  drew  attention  to  the 
dangers  of  infection  about  the  same  time.  In  1821,  Muscroft  in  Eng- 
land and  Schilling  in  Germany  simultaneously  reported  cases  of  infec- 
tion from  the  horse  in  which  the  true  symptoms  of  glanders  in  man  were 
recognized.  Rust,  Sedow,  and  Weiss  soon  followed  with  additional 
cases;  then  Forozzi  (1822),  Seidler  (1823),  Wolff,  Grossheim,  Eck, 
Bruuslow,  Lesser,  Travers  (1826),  Kries,  Grubb,  Brown  (1829),  Neu- 
mann (1830),  Vogeli  (1831),  Alexander  (1832),  and  Elliotson  (1833). 
Though  the  disease  was  now  well  recognized,  yet  its  nature  has  been 
elucidated  by  a  series  of  later  writers,  including  especially  Rayer,  Tardieu, 
Virchow,  Leisering,  Gerlach,  and  Koranyi. 

ETIOLOGY. — Man  is  rarely  infected  from  any  other  source  than  the 
horse.  In  a  very  few  instances  the  contagion  has  been  derived  from 
infected  men.  The  modes  of  infection,  immediate  and  mediate,  are  the 
main  points  to  notice  in  this  connection.  Those  employed  about  horses 
are  usually  infected  by  direct  contact  of  the  poisonous  discharges,  blood, 
or  tissues  with  abrasions  on  the  skin  or  mucous  membranes.  The  inocu- 
lation received  in  giving  medicine,  examining  the  nose,  performing  oper- 
ations with  effusion  of  blood,  dressing  cutaneous  ulcers,  slaughtering, 


920  GLANDERS. 

skinning,  making  a  necropsy,  burying,  etc.,  is  not  uncommon.  Again, 
direct  infection  is  sustained  through  snorting  of  the  horse,  so  that  par- 
ticles of  the  virulent  discharge  are  lodged  on  the  mucous  membrane  of 
the  eye  or  nose.  Closely  allied  to  this  is  infection  by  inhaling  the  exha- 
lations of  glandered  horses,  and  this  doubtless  accounts  for  some  few  cases 
which  have  been  recorded  as  communicated  through  the  unbroken  skin. 
The  bite  of  the  glandered  horse  is  a  rare  means  of  infection.  From 
infection  by  eating  glandered  animals  man  is  usually  saved  by  the  cook- 
ing of  his  food  and  by  his  inherent  power  of  resistance,  yet  with  instances 
of  this  kind  on  record,  as  recorded  by  Ringheim,  and  the  well-known 
conveyance  of  the  disease  to  animals  in  this  way,  it  would  be  folly  to 
ignore  the  risk  to  man  from  eating  the  flesh  of  glandered  horses,  sheep, 
goats,  and  rabbits. 

Among  the  mediate  forms  of  contagion  may  be  named  drinking  from 
the  same  pail  or  trough  after  a  glandered  horse,  using  a  knife  that  has 
been  employed  to  open  a  glanderous  abscess,  wiping  a  wound  with  an 
infected  blanket  or  handkerchief,  handling  infected  harness,  wagon-pole, 
or  manger  with  wounded  hands,  sleeping  over  glaudered  horses  or  in  a 
stall  or  on  litter  previously  used  by  such  horses. 

Conveyance  of  glanders  from  man  to  man  has  taken  place  through 
using  or  handling  the  same  dishes,  towels,  or  handkerchiefs,  through 
dressing  the  wounds,  or,  as  in  the  case  of  the  veterinarian  Gerard,  through 
making  an  autopsy  of  a  victim  of  the  disease. 

Fortunately,  the  susceptibility  of  man  is  slight,  but  few  out  of  the 
multitudes  handling  glandered  horses  becoming  infected.  It  is  essentially 
an  industrial  disease,  114  cases  being  distributed  as  follows  among  the 
different  occupations:  hostlers,  42;  farmers  and  horse-owners,  19  ;  horse- 
butchers,  13;  coachmen  and  drivers,  11;  veterinary  surgeons  and  stu- 
dents, 1 0 ;  soldiers,  5 ;  surgeons,  4 ;  gardeners,  3 ;  horse-dealers,  2 ;  police- 
men, shepherds,  blacksmiths,  employes  at  veterinary  school,  and  washer- 
women, 1  of  each. 

A  condition  of  ill-health  doubtless  predisposes  to  this  as  to  other  inva- 
sions of  infectious  disease,  yet  men  in  apparently  the  most  vigorous  health 
have  succumbed  to  the  poison. 

SYMPTOM?. — The  incubation  of  acute  glanders  in  inoculated  cases  usu- 
ally varies  from  one  to  four  days.  In  cases  in  which  the  mode  of  entrance 
is  not  so  manifest  it  may  apparently  extend  over  one,  two,  or  even  three 
weeks.  If  the  disease  has  occurred  by  external  inoculation,  the  seat  of 
the  wound  shows  the  first  symptoms,  consisting  of  tense  swelling,  pain, 
and  a  dark  or  yellowish  erysipelatoid  redness,  while  the  edges  of  the 
wound  are  puffy  and  everted,  the  matter  escaping  is  sanious,  and  the  sur- 
rounding lymphatics  are  swollen  and  red  and  the  lymphatic  glands 
enlarged  and  tender.  After  a  few  days  constitutional  disorder  sets  in — 
languor,  extreme  weakness  and  prostration,  aching  in  the  limbs  (muscles 
and  joints)  and  in  the  head,  rigors  alternating  with  fever  or  a  continued 
fever  after  the  first  violent  chill,  and  in  some  cases  nausea,  vomiting,  and 
even  diarrhoaa.  In  cases  not  resulting  from  external  inoculation  the 
febrile  symptoms  are  the  earliest  to  be  noticed,  and  the  muscular  and  artic- 
ular pains  may  be  at  first  mistaken  for  acute  rheumatism.  In  other  cases, 
in  which  the  gastric  and  intestinal  disorders  are  the  most  prominent  and 
the  prostration  and  weariness  extreme,  the  symptoms  at  first  strongly  sug- 


SYMPTOMS.  92] 

gest  typhoid  fever.  Soon,  however,  with  a  sense  of  formication  a  local 
yellowish  or  livid  erysipelatoid  inflammation  appears,  by  preference  on 
the  softer  parts  of  the  face,  the  nose,  eyelids,  cheeks,  or  on  one  of  the 
principal  joints,  the  shoulder,  elbow,  or  knee.  In  the  midst  of  the  phleg- 
monous  swelling,  or  even  antecedent  to  it,  there  appear  small  firm  red 
spots  or  nodules,  sometimes  as  small  as  those  of  variola,  at  others  like  a 
pea  or  as  large  as  a  walnut  or  larger.  These  gradually  blanch  in  the 
centre,  soften,  and  change  into  pustules  or  abscesses,  and,  bursting,  dis- 
charge a  slimy,  thick,  sanguineous  pus,  often  emitting  a  mawkish  or  fetid 
odor.  The  sores  thus  formed  are  ulcerous  and  unhealthy,  with  puffy, 
ragged,  everted  borders  and  a  grayish  or  yellowish  red  base,  which  often 
extends  deeply  between  the  muscles  and  exposes  tendons  and  bones. 
When  several  deposits  of  this  kind  are  closely  aggregated,  they  tend  to 
combine  in  one  slough,  which  may  involve  a  great  extent  of  tissue.  In 
all  cases  there  are  the  swollen,  reddened,  tender  condition  of  the  connecting 
lymphatics  and  the  tumefaction  of  the  lymphatic  glands.  At  times  the 
deposits  and  abscesses  are  deeply  seated  in  the  interstices  of  the  muscles, 
and  at  other  times  the  joints  are  enlarged  by  exudation. 

In  nearly  one-half  of  the  cases  glanders  supervenes  on  the  cutaneous 
symptoms.  At  first  a  viscid,  whitish  nasal  catarrh  appears  from  one  or 
both  nostrils,  mixed  with  striae  of  blood;  then  upon  the  pituitary 
membrane  appear  ulcers  like  those  already  described  in  the  horse ;  the 
same  form  on  the  buccal,  pharyngeal,  and  laryngeal  mucous  membranes, 
and  by  physical  examination  they  may  even  be  found  to  have  invaded  the 
lungs.  The  margins  of  the  nostrils  become  adherent  through  the  drying 
of  the  tenacious  mucus ;  the  meati  are  blocked  or  narrowed  by  the  swelling 
of  the  mucosa,  the  detachment  of  sloughs,  and  the  accumulation  of  the 
discharges ;  the  breathing  becomes  snuffling  and  difficult ;  the  voice  altered 
or  lost ;  the  cough  weak,  with  a  mucous  and  bloody  expectoration,  and 
the  breath  offensively  fetid.  The  submaxillary  lymphatic  glands  are 
inflamed  and  enlarged,  and  may  even  go  on  to  suppuration  and  ulceration. 
The  conjunctiva  is  usually  involved,  and  at  times  the  specific  formation 
and  ulceration  extend  to  the  stomach  and  intestines,  and  nausea,  vomiting, 
indigestion,  irregularity  of  the  bowels,  and  fetid  diarrhoea  ensue.  There 
is  complete  anorexia,  but  thirst  is  ardent,  especially  with  diarrhoea. 
With  the  advance  of  the  disease  dyspnoea  supervenes,  and  nervous  dis- 
order is  shown  by  the  extreme  weakness,  anxiety,  sleeplessness,  troubled 
dreams,  nocturnal  delirium,  dilated  pupils,  and  even  coma.  The  tempera- 
ture, though  at  first  unaltered,  may  later  rise  to  104°  F.,  and  the  pulse  to 
110  to  120  beats  per  minute.  The  diagnosis  is  confirmed  by  detection  of 
the  bacillus  in  the  discharges,  and,  above  all,  in  the  liquids  of  freshly- 
opened  pustules  (Wassilieff ). 

The  duration  of  acute  glanders  in  man  may  be  no  more  than  three 
days,  though  usually  it  is  protracted  to  fourteen  or  twenty-one,  and 
exceptionally  to  twenty-nine  days.  The  almost  constant  termination  of 
this  form  of  the  disease  is  in  death. 

Chronic  glanders  occasionally  appears  in  man,  and  is  in  most  respects 
the  counterpart  of  that  of  the  horse.  The  morbid  process  shows  itself 
in  the  integumental  or  other  tissues  of  the  body,  and  only  attacks  the 
nose  and  air-passages  later,  when  the  constitutional  symptoms  become 
more  intense.  The  general  malaise,  languor,  prostration,  aching  of 


922  GLANDERS. 

limbs  and  joints,  and  inappcteuce  are  usually  present,  complicated  by  a 
local  swelling  in  the  seat  of  inoculation  (face,  hands,  etc.),  with  small 
nodules  progressing  to  pustules,  congestion  of  the  lymphatics,  and  swell- 
ing of  the  lymphatic  glands.  These  lesions  may  subside  even  before  sup- 
puration, and  the  disease  is  manifested  for  a  week  or  two  only  by  a  gene- 
ral feeling  of  weariness  and  ill-health ;  but  sooner  or  later  the  local 
symptoms  reappear  in  the  same  or  another  seat,  and  the  neoplasms, 
though  indolent  for  an  indefinite  length  of  time,  finally  degenerate, 
soften,  burst,  and  form  ulcers.  These  ulcers  have  the  general  characters 
already  described — a  livid  grayish  or  yellowish  hue,  with  red,  puffy, 
irregular  edges,  and  a  viscid  greenish,  yellowish,  dirty  white,  or  bloody 
discharge.  They  tend  to  increase,  or  they  may  appear  to  heal  by  the 
peculiar  firm  cicatricial  formation;  but  on  the  swollen  margins  new 
deposits,  abscesses,  and  ulcers  tend  continually  to  form.  Sometimes 
these  are  of  considerable  size  and  seated  deeply  among  the  muscles,  but 
when  opened  they  show  the  same  unhealthy  serous  or  bloody  pus,  and 
manifest  a  tendency  to  extension  rather  than  to  healing.  When  the  disease 
extends  to  the  respiratory  organs,  often  two  or  three  months  after  the 
onset,  there  is  cough  and  sore  throat,  blocking  of  the  nose  by  the  tena- 
cious discharges  and  swollen  mucosa,  and  in  the  pharynx,  fauces,  and 
nose  the  characteristic  ulcer  may  be  detected.  The  attendant  constitu- 
tional symptoms  are  also  much  more  marked — indigestion,  nausea,  vom- 
iting, diarrhoaa,  rigors,  profuse  perspiration,  high  temperature,  excited 
breathing  and  pulse,  a  yellowish  or  earthy  hue  of  the  skin,  rapid  emacia- 
tion, and  great  prostration.  Though  great  emaciation,  debility,  and 
hectic  ensue  on  the  indolent  chronic  processes,  yet  the  disease  usually 
assumes  all  the  characters  of  the  acute  type  before  terminating  fatally. 

In  cases  that  recover  the  fever  diminishes,  exacerbations  cease,  ulcers 
granulate  and  cicatrize,  vesicles  dry  up,  the  nodules  and  enlarged  glands 
diminish,  the  erysipelatoid  swellings  of  skin  and  nose  subside,  and  a  very 
tardy  and  imperfect  convalescence  is  established. 

The  duration  of  chronic  glanders,  nasal  or  cutaneous  (farcy),  is  exceed- 
ingly indefinite,  varying  from  three  mouths  to  ten  or  eleven  years.  One 
of  the  most  protracted  cases  is  that  recorded  by  Bollinger  of  a  veterina- 
rian who,  after  an  eleven  years'  illness,  recovered  with  cicatricial  contrac- 
tion of  the  nose  and  larynx  and  a  decided  cachectic  appearance. 

MORBID  ANATOMY. — Besides  the  lesions  above  mentioned  as  occurring 
in  the  skin  and  mucous  membranes  of  the  nose,  mouth,  and  pharynx,  the 
frontal  sinuses,  the  larynx,  and  less  frequently  the  lungs,  are  the  seats  of 
the  specific  glanderous  processes.  In  the  lungs  there  are  then  the  nodules, 
hard,  caseous,  or  purulent  according  to  their  age,  and  varying  in  size 
from  a  millet-seed  and  pea  upward  to  the  involving  of  the  greater  part 
of  a  lobe.  Beneath  the  pleurae  may  be  seen  ecchymoses,  hard,  fibrous 
nodules,  and  yellow  elevations,  which  on  being  incised  furnish  grumous 
pus.  The  spleen  is  usually  enlarged,  gorged  with  blood,  gray  or  black, 
and  is  the  seat  of  suppuration.  The  liver  is  enlarged,  softened,  and  may 
be  the  seat  of  glanderous  processes,  with  ulcers  in  the  bile-duct  or  gall- 
bladder. The  joints,  like  other  serous  cavities,  become  the  seat  of 
specific  suppuration.  The  bones  are  often  implicated  in  adjacent  deposits, 
especially  in  the  face,  cranium,  and  hands,  so  that  the  compact  tissue  may 
become  reduced  to  the  merest  shell,  while  the  medulla  and  periosteum 


DIAGNOSIS.  923 

abound  in  the  specific  products.  The  cerebral  meningcs  and  brain-tissue 
are  frequently  the  seat  of  specific  growths  and  minute  abscesses.  It  is 
noticeable  that  the  enlargement  of  the  lymphatic  glands  is  usually  less 
than  it  is  in  the  horse,  though  they  are  never  entirely  free  from  lesions. 
Indeed,  the  tendency  in  man  to  the  formation  of  considerable  glanderous 
neoplasms  is  much  less  than  in  the  solipede. 

The  microscopy  of  the  lesions  is  essentially  the  same  as  in  the  horse. 
O.  Wyss  describes  the  cutaneous  nodules  as  formed  by  a  great  prolifera- 
tion of  round  cells  (like  pus-cells)  in  the  upper  layer  of  the  corium  just 
beneath  the  papillary  layer.  In  a  more  advanced  stage  the  corium 
and  papilla  are  filled  with  pus-cells,  and,  becoming  disorganized,  give 
rise  to  the  formation  of  pustules  and  small  abscesses.  Lagrange  describes 
in  a  chronic  ulcer  of  the  palm,  a  layer  about  2  mm.  in  thickness  of 
embryonic  cells  closely  packed  with  an  amorphous  intercellular  sub- 
stance. The  nuclei  appeared  larger  than  in  ordinary  ulcers  or  tubercles. 
Extending  into  this  layer  were  capillary  vessels  packed  with  red  globules 
and  with  blind  extremities,  or  in  some  instances  minute  ruptures  and 
hemorrhages.  Beneath  this  superficial  cellular  layer  was  a  stratum  of 
striated  muscle,  especially  noticeable  for  the  excess  of  condensed  connect- 
ive tissue  making  up  the  intermuscular  septa,  and  the  great  multiplication 
of  nuclei  with  large,  clearly-defined  uucleoli,  not  only  inside  the  sarco- 
lemma,  but  also  between  the  fibrillae  and  separating  them  widely.  At 
some  points  the  muscular  tissue  had  undergone  a  vitreous  degeneration, 
while  at  others  were  many  fusiform  cells.  At  one  point,  where  the  ulcer 
extended  to  the  phalanx,  the  compact  layer  of  the  bone  was  attenuated  to 
the  thinnest  shell  and  perforated,  so  that  the  medulla  was  continuous  with 
the  ulcer.  The  medulla  contained  a  great  number  of  white  globules, 
medulla-cells,  and  minute  embryonic  nuclei.  The  vessels  were  remark- 
able by  the  extensive  fibroid  thickening  of  their  coats.  On  section  of 
the  ulcer  many  orifices  stood  widely  open  because  of  the  rigidity  of  their 
walls.  The  internal  coat  was  plicated,  as  if  too  large  for  the  lumen. 
The  external  fibrous  layers  were  at  points  abundantly  interspersed  with, 
and  even  replaced  by,  groups  of  embryonic  cells,  the  active  proliferation 
of  which  meant  the  destruction  of  the  perivascular  fibrous  layer.  These 
embryonic  cells  even  invaded  the  lumen  of  the  vessel  and  partly  blocked 
it,  so  that  the  remnant  of  the  tube  remained  as  the  centre  of  a  disintegra- 
ting mass,  or  later  a  caseous  or  purulent  focus. 

DIAGNOSIS. — Acute  glanders,  when  well  developed,  is  unmistakable. 
The  presence  on  or  near  the  skin  of  the  characteristic  nodules,  pustules, 
phlyctenre,  and  ulcers,  the  oedema  or  erysipelatoid  condition  of  the  adja- 
cent skin,  the  redness  of  the  lymphatics,  the  presence  of  the  neoplasms 
and  ulcers  in  the  nose,  and  the  sticky,  fetid,  variously  colored  nasal  dis- 
charge, with  the  acute  fever,  prostration,  and  pains  in  the  limbs  and 
joints,  make  a  tout  ensemble  that  is  pathognomonic.  In  the  initial  stage 
only  it  may  be  confounded  with  rheumatism,  but  the  arthritic  pains  are 
not  usually  attended  by  the  same  amount  of  redness  and  swelling  of  the 
joints,  the  prostration  is  far  more  profound,  and  there  are  in  most  cases  an 
irritable,  unhealthy-looking  wound  and  a  history  of  exposure  to  infection 
from  glandered  horses. 

In  chronic  glanders,  and  especially  in  the  external  forni  (farcy),  the 
diagnosis  is  often  more  difficult.  From  pyaemia  and  septicaemia  it  is 


924  GLANDERS. 

usually  to  be  distinguished  by  the  comparative  absence  or  the  slightuess 
of  the  chills,  by  the  less  healthy  character  of  the  pus,  and  by  the  impli- 
cation of  the  nasal  mucosa,  the  larynx,  and  lungs.  When  the  nose, 
larynx,  or  lungs  are  but  slightly  affected,  there  may  be  a  strong  resem- 
blance to  syphilis  or  miliary  tuberculosis,  but  a  close  attention  to  the 
character  of  the  lesions,  the  absence  of  any  concomitant  history  or  symp- 
toms of  syphilis,  and  deductions  drawn  from  the  occupation  of  the  patient 
and  the  presumptive  exposure,  will  greatly  assist  in  reaching  a  diagnosis. 

The  detection  of  the  bacillus  is  not  conclusive,  as  in  tuberculosis  and 
some  forms  of  septicaemia  there  are  similar  organisms,  agreeing  with 
the  microbe  of  glanders  even  in  the  matter  of  size.  In  cases  of  doubt 
a  little  delay  will  usually  allow  the  development  of  new  and  more  cha- 
racteristic symptoms. 

The  final  resort,  however,  is  to  inoculation.  Auto-inoculation,  as 
practised  by  Poland,  is  rarely  satisfactory,  as  the  system  has  acquired  a 
partial  tolerance  of  the  disease  and  local  lesions  are  not  so  certainly 
developed  as  in  the  healthy  subject  (St.  Cyr).  Inoculation  on  a  healthy 
goat,  sheep,  or  rabbit  can  always  be  availed  of,  and  if  practised  on  more 
than  one  subject  can  be  relied  upon,  as  the  virus  loses  nothing  of  its 
power  in  passing  through  the  human  system,  but  usually  determines  an 
acute  form  of  the  disease  in  the  animal  inoculated. 

PROGNOSIS. — Acute  glanders  is  almost  constantly  fatal  to  man.  Of 
chronic  cases,  and  especially  the  external  form  (farcy),  from  one-third  to 
one-half  of  the  subjects  recover.  When  both  internal  and  external 
(farcy — glanders),  the  issue  is  usually  fatal.  Kiituer  claims  that  cases 
caused  by  external  inoculation  are  •  more  favorable  than  those  caused  by 
the  inhaled  poison.  This  accords  with  the  general  principle,  that  a 
poison  viable  in  the  comparatively  vitiated  air  of  the  lungs  or  on  the 
surface  of  the  intestinal  canal  is  better  fitted  by  its  habit  of  life  for 
survival  in  the  blood  and  plasma,  and  is  consequently  more  redoubtable. 
The  greater  the  duration  of  the  disease  in  any  particular  case,  the  more 
favorable  is  the  prognosis. 

TREATMENT. — In  the  treatment  of  glanders  in  man  the  same  princi- 
ples must  guide  as  in  animals.  In  external,  inoculated  cases  the  wounded 
tissues  should  be  early  destroyed  by  potent  caustics — fuming  nitric  acid, 
corrosive  sublimate,  iodized  phenol,  chlorine,  sulphate  of  copper,  carbolic 
acid,  or  the  hot  iron.  The  erysipelatoid  swellings  may  be  treated  by 
leeching,  followed  by  solutions  of  carbolic  acid,  iodine,  or  chlorine-water, 
by  ice,  and  internally  by  laxatives  and  iodide  of  potassium.  The  first 
two  antiseptics  may  be  freely  used  by  hypodermic  injection.  Abscesses 
and  tumors  should  be  laid  open  and  cauterized  as  above,  and  then  treated 
by  weaker  solutions  of  the  same  agents.  Nasal  ulcers  may  be  treated  by 
insufllation  of  iodoform  and  injections  of  creasote,  carbolic  acid,  nitrate 
of  silver,  or  permanganate  of  potash  solutions.  Of  the  greatest  import- 
ance is  a  general  tonic  and  stimulating  regimen.  A  nutritious  diet 
(including  beef-tea),  abundance  of  pure  air,  alcoholic  stimulants,  quiuia, 
tincture  of  the  chloride  of  iron,  and,  above  all,  arseniate  of  strychnia,  have 
been  used  with  advantage.  Various  anti-ferments,  such  as  the  bisulphites 
in  full  doses,  carbolic  acid,  and  iodide  of  potassium,  have  apparently 
proved  beneficial,  and  deserve  a  further  trial.  As  in  the  horse,  a  great 


PREVENTION.     .  925 

variety  of  other  agents,  mostly  of  a  tonic  nature,  have  been  employed, 
but  with  very  variable  results. 

PREVENTION. — The  first  step  toward  the  prevention  of  glanders  in 
man  is  the  systematic  restriction  and  extinction  of  the  affection  in  ani- 
mals. This  has  been  already  sufficiently  referred  to  above.  Further 
measures  of  prophylaxis  embrace  the  following  :  the  avoidance  of  contact 
with  glandered  and  suspected  horses  by  all  persons  having  any  wounds, 
abrasions,  or  ulcers  on  their  skins  ;  the  cauterization  with  nitrate  of  silver 
of  all  such  sores  on  persons  necessarily  brought  in  contact  with  glaudered 
or  suspected  animals  or  their  products ;  the  general  diffusion  of  informa- 
tion as  to  the  danger  from  glandered  animals;  washing  of  hands  and  face 
in  a  solution  of  carbolic  acid  or  chloride  of  lime  after  handling  infected 
or  suspected  animals  or  their  carcases  or  products ;  the  thorough  disinfec- 
tion or  destruction  (preferably  by  fire)  of  harness,  clothing,  racks,  man- 
gers, wagon-poles,  buckets,  troughs,  brushes,  combs,  litter,  and  fodder 
that  have  been  exposed  to  infection ;  and,  finally,  the  exclusion  from  the 
markets  of  all  meat  derived  from  suspected  or  infected  animals.  It  is 
generally  held  that  the  flesh  of  the  horse  alone  demands  inspection,  but 
with  the  known  susceptibility  of  sheep,  goats,  and  rabbits  it  can  easily  be 
conceived  how  the  infection  may  reach  man  through  his  food,  though 
horse-flesh  is  never  consumed.  That  glanders  has  never  been  recognized 
as  arising  from  the  consumption  of  diseased  sheep  or  rabbits  does  not 
prove  that  it  has  never  reached  man  by  this  channel,  any  more  than  the 
absence  of  all  recognition  of  the  infection  of  man  from  the  horse  would 
prove  the  non-occurrence  of  such  infection  until  the  beginning  of  the 
present  century.  The  knowledge  that  the  animals  used  for  food  in  this 
country  are  liable  to  contract  and  convey  this  disease  is  an  additional  rea- 
son for  the  systematic  and  universal  suppression  of  the  disease  among  the 
equine  population. 


ANTHRAX  (MALIGNANT  PUSTULE) 

BY  JAMES  LAW,  F.  K  C.  V.  S. 


SYNONYMS. — Latin,  Ignis  Sacer,  Anthrax  Epizooticus,  Pustulu  Ma- 
ligna,  Pustula  Pestifera,  Erysipelas  Carbunculosum,  Carbunculo  Conta- 
gioso,  Glossanthrax,  Angina  Carbunculosa,  Anthrax  HaBmorrhoidalis, 
Mycosis  Intestinalis,  Apoplexia  Spleiiitis,  etc.  English,  Black  Erysip- 
elas, Malignant  Vesicle,  Anthrax  Fever.  Splenic  Apoplexy,  Splenic 
Fever,  Inflammatory  Fever,  Carbuncular  Fever,  Black  Quarter,  Blood- 
Striking,  Bloody  Murrain,  Blaiu,  etc.  French,  Pustule  maligne,  Char- 
bon,  Fi£vre  putride,  Typhohemie,  Pelohemie,  Mai  de  Rate,  Splenite 
Gangreueus6,  etc.  German,  Karbunkelkrankheit,  Contagiose  Karbun- 
kel,  Milzbrand,  Milzseuche,  Milzbraudneber,  Brandbeuleuseuche,  Roth- 
lauf,  etc.  Russian,  Jaswa  (boil-plague).  Italian,  Antrace.  Spanish,  Car- 
bunculo, Lobado.  Swedish,  Boskapssjukan.  Mexican,  Calenturadel  piojo. 

DEFINITION. — Anthrax  is  an  acute,  infectious,  bacteridian  disease, 
occurring  mostly  in  the  Herbivora  and  Omnivora,  but  communicable  to 
other  mammals  (including  man),  to  birds,  and  even  fishes.  Its  local 
manifestations  are  exceedingly  varied  in  kind,  but  the  malady  is  charac- 
terized by  the  prasence  in  the  tissues  or  blood,  or  both,  of  specific  spher- 
ical and  linear  bacteria  (micrococcus  and  bacillus  anthracis),  leading  to 
arrest  of  hsematosis,  to  disintegration  of  the  blood-globules,  to  sanguin- 
eous engorgement  of  the  spleen,  to  capillary  embolism,  and  to  a  spreading 
gangrenous  inflammation. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — While  ancient  his- 
tory is  not  clear  as  to  the  specific  diseases  of  animals,  yet  there  is  the 
strongest  presumption  that  nearly  all  great  plagues  that  attacked  indis- 
criminately animals  and  man  were  of  this  nature.  Thus,  the  plague  of 
murrain,  with  boils  and  blaius  breaking  out  on  man  and  beast,  in  the 
days  of  Moses,  was  probably  of  this  kind  (Gen.  ix.  3.) ;  also  that  which 
at  the  siege  of  Troy  extended  from  animals  to  man,  and  many  later 
epizootics  in  all  parts  of  the  world.  No  infectious  disease  of  man  and 
animals,  with  the  single  exception  of  tuberculosis,  has  been  more  widely 
diffused,  and  none  can  be  considered  as  more  cosmopolitan.  Heusinger, 
in  his  classic  work  on  Milzbrandkrankheit,  traces  the  ravages  of  the  dis- 
ease from  the  highest  to  the  lowest  latitudes  in  the  northern  and  southern 
hemispheres  and  in  the  Old  World  and  the  New.  He  adduces  outbreaks 
in  Siberia,  Astrakan,  Lapland,  and  Finland,  in  Russia,  Prussia,  Poland, 
Silesia,  Bavaria,  Holland,  Belgium,  France,  Spain,  Portugal,  Italy,  Switzer- 
land, Austria,  Hungary,  Greece,  Turkey,  Egypt,  East  and  West  Indies, 

926 


HISTORY  AND   GEOGRAPHICAL  DISTRIBUTION.  927 

North  and  South  America,  etc.  We  can  now  add  all  the  great  English, 
.b  rench,  and  other  European  colonies  not  included  in  the  above  (South 
Africa,  Australia,  New  Zealand,  Algeria,  etc.),  together  with  China  and 
Japan.  We  find,  moreover,  that  the  disease  is  always  most  prevalent 
where  agriculture  is  in  its  most  primitive  condition,  so  that  there  can  be 
little  doubt  of  the  prevalence  of  the  affection  in  the  less-civilized  coun- 
tries as  well.  But  while  the  disease  is  prevalent  in  all  parts  of  the  world, 
its  ravages  are  largely  subordinate  to  the  nature  of  the  soil.  Wherever 
this  is  close,  impervious,  marshy,  or  charged  with  an  excess  of  organic 
matters,  the  gaseous  emanations  of  which  drive  out  most  of  the  oxy- 
gen, the  anthrax-germs,  once  introduced,  tend  to  be  preserved  indefinitely. 
Thus,  in  drying  up  basins  with  no  natural  drainage,  on  lake  and  river 
margins,  on  deltas,  in  forests,  in  mucky,  mossy,  or  peaty  soils,  and  on 
those  that  are  habitually  over-manured,  the  germs  of  anthrax  are  espe- 
cially liable  to  be  perpetuated.  It  has  long  been  noticed  that  herbivorous 
animals  are  the  most  susceptible  to  anthrax,  while  the  purely  carnivorous, 
and  to  a  less  extent  the  omnivorous,  have  relatively  a  far  higher  resisting 
power.  That  the  immunity  is  largely  due  to  the  food  is  manifest  from 
the  experiments  of  Feser  on  rats.  Those  fed  on  vegetable  aliment  con- 
tracted anthrax  readily  from  inoculation,  while  those  kept  on  an  exclusive 
diet  of  flesh  successfully  resisted.  The  same  rats  that  escaped  while  on  a 
flesh  diet  were  afterward  placed  on  a  vegetable  diet,  and  then  perished 
after  inoculation.1  Davaine  found  the  same  to  be  true  of  foxes  kept  on 
meat  and  vegetables  respectively,  and  inoculated  with  the  virulent  blood 
of  the  allied  disease,  septica3mia.  He  found,  moreover,  that  guinea-pigs 
were  much  more  susceptible  to  anthrax  than  rabbits.  One-thousandth  of 
a  drop  of  virulent  anthrax  blood  invariably  killed  the  guinea-pig,  while 
it  left  the  rabbit  unharmed.2  Klein  has  never  found  a  rabbit  insuscepti- 
ble. It  has  recently  been  claimed  that  pigs  are  insusceptible,  but  I  have 
known  of  many  instances  in  which  the  offal  of  anthrax  cattle,  when 
devoured  by  pigs,  has  determined  fatal  anthrax  in  the  latter.  Chickens 
too  prove  much  less  susceptible  to  anthrax  than  the  Herbivora.  Inocu- 
lations made  by  Cohn  and  others  proved  invariably  unsuccessful,  while 
Pasteur  has  showed  that  they  can  be  infected  easily  after  the  body  has 
been  cooled  by  partial  immersion  in  cold  water.3  Pasteur  attributes  this 
immunity  to  their  normally  high  temperature,  yet  rabbits,  sheep,  pigs, 
wolves,  and  foxes,  though  maintaining  a  correspondingly  high  temperature, 
are  still  subject  to  anthrax.  Even  the  herbivorous  mammal  suffering  from 
acute  anthrax  fever  has  its  temperature  raised  to  that  of  the  chicken,  yet  the 
disease  progresses  none  the  less  surely  to  a  fatal  result.  Again,  anthrax 
liquids  inoculated  under  the  skin  of  a  fox  proved  harmless,  while  if  thrown 
into  the  warmer  peritoneal  cavity  they  proved  fatal.  It  may  well  be  sus- 
pected that  the  relative  insusceptibility  of  chickens  is  in  part  due  to  the 
large  amount  of  animal  food  consumed  by  them,  and  that  the  chilling 
process  increases  the  receptivity  by  deranging  sanguinification  and 
nutrition. 

The  insusceptibility  to  anthrax  is  often  characteristic  of  certain  indi- 
viduals or  families  or  of  the  animals  living  in  a  particular  district.  Thus, 
Chauveau  found  that  some  French  sheep,  and  nearly  all  Algerian  ones, 

1  Wochenschri/t  f.  Thierheilhtmde  und  Thiersucht,  Nos.  24  and  25,  1879. 
*Rec.  de  Med.  Vet.,  Mar.  15,  1879.  *  Ibid.,  Mar.  15,  1880. 


928  ANTHRAX. 

resisted  inoculation  with  a  moderate  amount  of  anthrax  virus,  while  the 
introduction  of  a  maximum  amount  proved  fatal  to  these  as  to  others. 
In  the  same  way,  it  is  often  noticed  that  animals  living  in  an  anthrax 
region  escape  the  evil  effects  of  the  poison,  while  strange  animals  brought 
in  either  fall  ready  victims  or  for  a  time  do  badly  until  they  have  become 
habituated  to  the  locality.  In  view  of  the  subsequent  protective  effect  on 
the  system  of  a  first  and  non-fatal  attack  of  anthrax,  it  is  probable  that 
all  these  examples  of  immunity  in  the  Herbivora  depend  on  a  previous 
mild  attack  of  the  same  disease  or  on  the  extinction  of  the  more  suscept- 
ible races.  Even  in  the  case  of  the  animals  that  do  badly  on  first  coming 
into  an  anthrax  district,  and  recover  better  health  with  immunity  later, 
we  may  well  infer  that  a  mild  form  of  the  anthrax  infection  has  been 
passed  through. 

ETIOLOGY. — The  one  essential  cause  of  anthrax  is  the  introduction  into 
the  system  of  a  specific  bacteridian  germ  (bacillus  anthracis  or  its  spores). 
This  is  not,  as  a  rule,  carried  far  on  the  atmosphere,  but  demands  for  its 
propagation  contagion,  immediate  or  mediate.  Unless,  therefore,  it  meets 
in  the  soil  the  conditions  necessary  to  the  preservation  and  propagation 
of  the  germ,  it  is  transmitted  with  some  uncertainty  from  animal  to 
animal,  and  thus  the  disease  does  not  spread  widely  and  rapidly,  like  an 
ordinary  plague,  but  tends  to  become  localized  in  particular  districts  as  an 
enzootic. 

But  its  dangers  are  none  the  less  real  nor  its  existence  less  to  be  dreaded. 
In  predisposed  localities,  where  the  disease-germ  has  gained  a  footing,  the 
animal  mortality  may  exceed  that  caused  by  the  great  plagues,  while  the 
risk  to  human  beings  is  incomparably  greater  than  from  any  other  acute 
infectious  disease  of  the  lower  animals.  Thus,  in  San  Domingo,  in  1770, 
15,000  people  perished  in  six  weeks  from  eating  the  carcases  of  anthrax 
animals,  and  the  mortality  was  only  arrested  when  the  meat  was  legally 
interdicted.  In  the  worst  anthrax  years  on  some  of  the  Siberian  steppes 
as  many  as  one-fourth  of  the  whole  human  population  suffer  from  the 
malady.  The  prevalence  and  death-rate,  however,  vary  greatly  in 
different  localities  and  seasons.  Sometimes  only  one  or  two  solitary  cases 
of  the  affection  are  observed  ;  at  other  times  the  disease  becomes  moder- 
ately prevalent,  but  a  lack  of  virulence  in  the  poison  or  a  previously 
acquired  insusceptibility  of  the  individual  protects  the  great  majority  of 
the  animals  exposed,  while  at  others,  still,  the  poison  attacks  nearly  all 
exposed  to  its  contagion. 

The  animal  products  that  mainly  convey  the  disease  are  the  blood,  the 
liquid  exudations,  portions  of  the  diseased  carcase,  and  the  bowel  dejec- 
tions. The  virus  is  most  potent  when  derived  from  an  animal  still  living 
or  only  recently  dead,  yet  under  certain  conditions  (with  spore-formation) 
it  may  long  retain  its  virulence  under  the  most  extreme  changes  of 
climate,  temperature,  dryness,  and  humidity.  Russian  hides  tanned  in 
England  or  America  frequently  convey  anthrax,  which  is  known  especi- 
ally as  a  tanner's  malady,  and  wool  and  hair  sent  from  Buenos  Ayres 
have  repeatedly  produced  malignant  pustule  (woolsorter's  disease)  in 
Britain  and  the  United  States.  The  preserved  scabs  of  malignant  pustule 
have  been  often  successfully  inoculated  on  the  lower  animals,  so  that,  like 
other  forms  of  poison,  this  seems  to  be  preserved  indefinitely  by  desiccation. 

The  simple  contact  of  the  virus  with  the  slightest  abrasion  will  suffice 


ETIOLOGY.  929 

to  convey  the  disease.  It  has  often  been  communicated  where  no  lesion 
of  the  epidermis  could  be  found,  yet  the  presumption  is  that  even  in  such 
cases  the  cuticle  had  been  in  some  way  wounded.  Eating  the  flesh  of 
animals  killed  while  suffering  from  anthrax  has  often  conveyed  the  dis- 
ease. In  an  outbreak  in  Swineshead,  Lincolnshire,  England,  in  1863, 
I  found  a  dog  and  a  number  of  swine  suffering  from  eating  the  bodies 
of  dead  bullocks.  In  1864  an  East  Lothian  (Scotland)  farmer  fed  his 
pigs  with  the  offal  of  a  slaughtered  anthrax  bullock,  and  lost  nearly  the 
whole  herd.  The  carcase  of  the  bullock  had  been  sent  to  market.  About 
1860  cattle,  and  even  horses,  died  yearly  on  a  swampy  meadow  at 
Brighton,  Mass.  On  one  occasion  the  owner,  John  Zoller*  fed  the  offal 
of  a  dead  bullock  to  his  pigs,  which  were  speedily  attacked  with  anthrax, 
and  as  speedily  killed  to  save  their  bacon  (Dr.  Thayer).  Even  when 
cooked  the  flesh  is  not  always  safe.  Of  this  we  have  the  undoubted  case 
in  San^  Domingo  above  noticed,  the  alleged  death  of  60,000  people  in 
the  vicinity  of 'Naples  from  the  same  cause  in  1617  (Kircher),  and  the 
thousands  that  die  on  the  Russian  steppes  every  anthrax  year  from  eating 
the  sick  horses  (Rawitch).  But  in  all  these,  and  in  the  ever-recurring 
cases  in  which  families  suffer  from  eating  anthrax  meat,  there  is  the  pos- 
sibility, if  not  the  probability,  of  the  contamination  of  the  meat  subse- 
quently to  cooking  by  the  knives,  forks,  tables,  and  dishes  used.  The 
San  Domingo  slaves  had  few  appliances  for  cleanliness,  much  less  disin- 
fection, and  the  Tartars  eat  their  meat  from  the  same  board  on  which  it 
has  been  chopped  up  raw. 

In  accurate  experiments  it  has  been  found  that  the  bacilli  are  destroyed 
by  a  temperature  of  145°  F.  maintained  for  five  minutes,  but  the  spores 
are  capable  of  surviving  the  boiling  temperature  for  five  or  even  ten 
minutes.  The  varying  power  of  resistance  may  be  compared  to  that  of 
the  green  stalk  of  the  pea  and  the  dry  flinty  seed.  The  first  is  destroyed 
by  a  very  moderate  heat,  while  the  second  will  sprout  after  having  had 
boiling  water  poured  over  it.  The  resisting  bacillus-spores  are  never 
found  in  the  living  animal,  but  may  be  developed  in  the  blood  and  tissues 
after  death,  and  may  account  for  the  occasional  extraordinary  viability  of 
the  poison  when  exposed  to  a  boiling  temperature. 

Milk,  though  often  used  with  impunity,  conveyed  the  disease  when 
inoculated  by  Bellinger,  and  the  same  was  true  of  the  vaginal  mucus. 
Innocent  in  the  early  stages  of  the  disease  while  the  germs  are  still  local- 
ized, they  become  virulent  after  the  bacilli  swarm  into  the  blood. 

Healthy  men  and  animals  often  carry  the  poison,  though  themselves 
insusceptible.  The  question  of  its  conveyance  by  insects  lias  been  much 
debated,  but  the  constant  occurrence  of  malignant  pustule  on  the 
uncovered  parts  of  the  body  goes  far  to  settle  the  question.  Bourgeois 
long  ago  noticed  that  it  was  most  frequent  on  the  face,  hands,  neck,  and 
arms,  and  rare  on  the  trunk.  In  sixty  cases  recorded  by  A.  "W.  Bell 
of  Brooklyn,  all  occurred  on  the  face  except  two  on  the  hands,  one  on 
the  wrist,  and  one  on  the  forearm.  The  bite  of  a  fly  or  mosquito  had  in 
many  of  these  cases  proved  the  starting-point  of  the  malady.  Bollinger 
has  shown  the  presence  of  the  bacillus  in  the  stomach  of  such  flies  as  fed 
on  flesh  and  blood  (horse-flies,  bluebottles,  etc.),  and,  together  with  Raim- 
bert  and  Davaine,  has  produced  anthrax  by  inoculations  with  the  stomachs, 
legs,  and  proboscides  of  the^e  insects. 


Voi,    T_59 


930  ANTHRAX. 

Surgical  instruments  occasionally  convey  anthrax.  At  Cockburnspath, 
East  Lothian,  Scotland,  a  yearling  heifer  contracted  anthrax,  and  the  whole 
herd  was  bled,  commencing  with  the  sick  one.  Next  morning  seven  were 
found  dead,  the  disease  in  each  case  extending  around  the  fleam-wound. 
At  Brunt,  in  the  same  county,  a  shepherd  skinned  an  anthrax  bullock, 
and  after  washing  and  taking  a  turn  among  his  sheep,  on  the  same  day 
castrated  several  litters  of  pigs,  all  of  which  perished.  In  St.  Lawrence 
Co.,  N.  Y.,  in  1870,  a  surgeon  inoculated  himself  while  opening  a  vesicle 
on  the  hand  of  a  farmer. 

Harness,  stables,  stable  utensils,  vehicles,  fodder,  and  litter  are  frequent 
bearers  of  contagion.  At  Geneseo,  N.  Y.,  in  1877,  three  horses  and  a  cat 
died  in  midwinter  after  licking  the  blood  from  a  stone-boat  which  had 
conveyed  the  skin  of  an  anthrax  bullock  to  market.  Green  fodder  or 
hay  harvested  from  ground  formerly  occupied  by  anthrax  victims  or  from 
their  graves  often  convey  the  poison,  but  probably  only  by  the  adherent 
earth  and  dust  containing  the  anthrax-germ. 

That  the  anthrax  bacillus  and  its  spores  may  be  long  preserved  in  earth 
is  abundantly  proved.  At  Avon,  N.  Y.,  nine  months  after  any  cases  of 
the  disease,  the  liquid  leaking  out  on  the  river-bank  near  to  the  grave  of  a 
victim  of  the  year  before  was  licked  by  six  cattle,  and  in  two  days  they 
all  perished.  On  the  same  pasture  victims  were  seized  yearly  for  seven 
years,  but  with  a  rigid  seclusion  of  these,  their  products,  and  their  graves 
the  malady  has  finally  disappeared.  The  persistent  deadly  effect  of  some 
soils  on  animal  life,  apart  from  the  presence  of  the  carcases,  seems  to 
show  that  in  certain  soils  we  find  the  normal  home  of  the  anthrax 
bacillus,  while  the  migration  into  the  animal  economy  is  but  an  accident 
of  its  existence.  The  soils  that  are  especially  subject  to  anthrax  are  the 
dense  clays,  the  limestones,  and  the  rich  alluvials.  Among  the  essential 
conditions  are  the  exclusion  of  oxygen,  excepting  a  limited  amount  bear- 
ing some  relation  to  what  is  found  in  the  animal  fluids,  and  the  abundance 
of  some  alkaline  agent  (lime,  potash,  soda,  ammonia),  so  that  the  earth 
is  either  neutral  or  only  very  slightly  alkaline  or  acid.  An  acid  vege- 
table infusion  is  inimical  to  the  germ,  which  soon  disappears  from  such 
a  medium.  The  requisite  paucity  of  air  is  found  in  all  the  dense,  less 
pervious  soils  (clays,  etc.),  in  soils  habitually  waterlogged  (swamps,  deltas, 
river-bottoms,  low  meadows,  natural  basins,  drying  lakes  and  ponds),  and 
in  soils  rich  in  decomposing  organic  matter  (peat,  alluvial,  over-manured). 
The  antacid  is  often  found  present  as  lime  or  potash,  or  is  constantly 
being  produced  in  the  form  of  ammonia,  etc.  by  organic  decomposition. 
Such  plac.es  are  known  to  farmers  as  "dead  lots,"  because  no  stock  will 
live  on  them.  The  bacillus  in  the  buried  carcase  does  not  produce  spores 
(Bollinger),  though  it  may  in  the  soil  at  any  temperature  between  59° 
and  110°  F.  In  the  graves,  therefore,  at  a  lower  temperature,  the  poison 
can  only  be  preserved  by  a  continuous  generation  of  the  bacillus. 

Pasteur,  who  successfully  inoculated  the  casts  of  earth-worms  taken 
from  anthrax  graves,  attributes  to  these  an  important  role  in  bringing  the 
germs  to  the  surface.  A  more  important  agent,  however,  is  probably  the 
rise  and  fall  of  water  in  the  soil.  By  this  means  the  bacilli  and  spores 
are  washed  up  toward  the  surface,  and  when  the  superficial  layers  dry  out 
they  are  easily  carried  by  the  winds.  Hence  it  is  that  anthrax  is  usually 
prevalent  in  late  summer  and  when  the  soil  is  dried  and  heated  to  its 


ETIOLOGY.  931 

greatest  depth.  Thus  it  is,  too,  that  wet  seasons  followed  by  specially 
dry  and  hot  ones  are,  above  all,  productive  of  anthrax  in  herds.  Wet 
seasons  fulfil  the  further  purpose  of  carrying  off  the  germs  into  rivers 
and  depositing  them  on  the  banks  or  on  inundated  meadows,  where  after 
the  subsidence  of  the  flood  the  disease  appears,  for  the  first  time  perhaps. 

There  is,  however,  good  reason  to  believe  that  the  effect  of  a  warm 
season  is  not  confined  to  its  influence  on  the  soil  and  its  germs.  The  high 
temperature  deranges  the  vital  functions  of  the  animal  economy,  and, 
inducing  a  febrile  disturbance,  lessens  the  power  of  resistance  to  the 
anthrax  virus,  just  as  the  cooling  of  the  warm-blooded  bird  lays  it  open 
to  infection.  On  this  account,  and  because  of  the  frequently  recurring 
electric  storms,  the  hot  dry  season  is  especially  the  season  of  anthrax.  The 
hottest,  driest  autumns  of  Siberia  always  coincide  with  the  anthrax  years, 
and  in  the  last  fifteen  years  in  the  United  States  I  have  noticed  the  wide 
extension  of  anthrax  whenever  the  season  has  been  unusually  hot  and  dry. 
In  Corsica  the  herdsmen  confidently  pasture  their  stock  in  the  close  still 
valleys  throughout  spring  and  early  summer,  but  whenever  the  surface 
soil  is  dried  out  they  make  all  haste  to  remove  it  to  the  hills,  well 
knowing  that  delay  means  devastation  and  ruin. 

Plethora  is  undoubtedly  an  important  predisposing  cause  of  anthrax, 
and  so  is  the  alternation  of  cold  nights  with  hot  days.  The  febrile  con- 
dition induced  in  the  animal  economy  is  perhaps  the  main  factor  at  work 
in  each  case.  Finally,  youth  is  on  the  whole  more  liable  than  age,  but 
whether  because  of  the  greater  receptivity  of  the  growing  system  and  its 
tissues,  or  because  it  has  not  yet  acquired  some  immunity  by  exposure  to 
the  milder  effects  of  the  poison,  is  not  certainly  determined.  Sex  is  with- 
out influence. 

It  is  not  a  little  remarkable  that  the  bacillus  germ  has  not  yet  been 
found  in  the  placental  liquids  nor  fcetal  blood  of  sheep,  goats,  or  rabbits, 
though  swarming  in  that  of  the  mother.  Bellinger  attributes  this  to  the 
action  of  the  placenta  as  a  "physiological  filter" — a  conclusion  seemingly 
at  variance  with  the  passage  of  the  bacillus  through  all  the  other  animal 
membranes,  including  those  lining  the  mammary  glands  and  the  vagina. 
Two  other  possible  explanations  remain  :  first,  that  the  secretions  of  the 
uterine  glands  are  inimical  to  the  bacillus ;  and,  second,  that  the  foetus, 
being  in  some  sense  a  carnivorous  animal,  possesses  the  immunity  charac- 
teristic of  Garni vora.  Bacilli  have  recently  been  found  in  the  foetal 
guinea-pig. 

The  bacillus  anthracis  was  first  observed  by  Pollender  and  Branel  in 
1849  (Birch-Hirschfeld),  but  it  was  only  publicly  claimed  as  the  cause 
of  the  disease  in  1855  by  Davaine.  Branel  discarded  Davaine's  theory, 
because  blood  in  which  he  had  failed  to  find  bacillus  produced  anthrax 
with  bacillus  in  the  blood  of  two  foals  inoculated.  Later  observations 
by  Bellinger  and  others  have  shown  that  cultures  of  bacillus  can  always 
be  made  from  such  infecting  blood,  and  that  in  most  cases  the  presence 
in  the  infecting  blood  of  spherical  bacteria  can  be  demonstrated  by  the 
microscope.  That  the  bacillus  is  the  true  pathogenic  element  is  proved 
by  the  following  facts :  1st.  That  the  bacillus  is  the  only  ectogenous,  par- 
ticulate,  organized  structure  constantly  found  in  the  anthrax  blood  and 
fluids ;  in  cases  in  which  it  is  apparently  absent  cultures  show  its  actual 
presence.  2d.  After  cultivation  in  pork  or  beef  infusion  to  the  hun- 


932  ANTHRAX. 

dredth  generation  the  virulence  is  unimpaired,  though  it  must  be  assumed 
that  all  non-organized  poisons  derived  from  the  infected  animal  body 
must  have  been  diluted  or  decomposed  to  extinction.  3d.  That  filtration 
of  the  anthrax  liquids  through  a  plaster  or  other  efficient  filter  renders 
the  filtrate  innocuous,  while  the  solids  retained  in  the  filter  remain  infect- 
ing (Chauveau,  Bert,  Toussaiut).  4th.  That  the  clear  filtrate  injected  to 
excess  killed  by  virtue  of  its  contained  chemical  products  in  twelve 
hours,  while  the  solids  filtered  out  and  containing  the  bacillus  or  its 
spores  only  killed  after  thirty  hours.1  5th.  Anthrax  blood  from  the  liv- 
ing animal  or  one  just  dead,  and  destitute  of  spores,  when  subjected  to 
compressed  oxygen  (50  atmospheres),  is  non-infecting  (Bert).  6th.  The 
same  anthrax  liquid,  destitute  of  spores,  after  boiling  is  completely 
innocuous.  7th.  The  same  liquid,  if  kept  in  a  closed  tube  apart  from 
oxygen  for  eight  days,  shows  the  bacilli  broken  down  by  granular  degen- 
eration, and  proves  absolutely  harmless  when  inoculated  in  small  quan- 
tity. 8th.  The  same  sporeless  anthrax  fluid  when  treated  with  absolute 
alcohol  loses  its  virulence.  9th.  The  anthrax  liquid  which  has  been  cul- 
tivated with  free  access  of  air  in  a  temperature  varying  from  25°  C.  (77° 
F.)  (Klein,  Lofiier)  to  41°  C.  (105.5°  F.)  forms  spores,  and  then  remains 
infecting,  though  it  may  have  been  subjected  to  compressed  oxygen,  boil- 
ing for  several  minutes,  absolute  alcohol,  dilution  with  water,  putrefaction, 
or  the  exclusion  of  oxygen. 

The  bacillus  authracis,  as  found  in  the  blood  and  animal  fluids,  is  in 
the  form  of  fine  rods,  straight  (rarely  bent  or  angular),  motionless,  and 
0.007  to  0.012  Mm.  in  length.  Smaller  forms  are  seen  to  be  minute 
ovoid  or  oblong  bodies,  and  the  smallest  absolutely  spherical  (micro- 
coccus)  ;  but  in  all  cases,  as  seen  under  the  highest  powers  of  the  micro- 
scope, they  have  clear-cut,  even  margins,  linear  or  curved,  which  easily 
distinguish  them  from  the  irregular  normal  granules  of  the  blood  and 
tissues.  Under  the  highest  powers  of  the  microscope  the  bacillus  is  seen 
to  be  made  up  of  a  series  of  oblong  (Koch)  or  cubical  (Klein)  cells 
enclosed  in  one  common  sheath.  This  is  rendered  more  manifest  if  they 
are  first  swollen  by  the  addition  of  water.  The  motionless  form  of  the 
anthrax'  bacillus  is  of  especial  value  in  distinguishing  it  from  the  motile 
bacteria  of  putrefaction  (saprophytes). 

Within  the  living  animal  body  the  development  never  goes  aside  from 
these  forms.  The  growth  appears  limited  to  micrococcus  and  bacillus 
rods,  while  spores  or  bacillus  threads  are  never  found.  This  finds  its 
counterpart  in  the  micrococcus  poisoning  caused  by  the  inoculation  with 
the  spores  of  common  moulds  (Grawitz) ;  and  in  septicaemia  also  micro- 
coccus  and  bacillus  forms  only  are  found,  the  filamentous  never. 

When  grown  in  organic  infusions  out  of  the  animal  body  the  anthrax- 
germ  develops  from  micrococcus  or  bacillus  into  a  long,  branching,  fila- 
mentous product,  which  in  the  presence  of  oxygen  develops  into  spores. 
Apart  from  oxygen  or  when  the  proper  nourishment  of  the  bacillus  is 
exhausted  the  protoplasmic  'elements  within  the  filamentous  sheath 
undergo  granular  degeneration,  and  finally  the  empty  envelope  disin- 
tegrates and  disappears.  The  spores  appear  at  intervals  in  the  proto- 
plasm of  the  filament  as  clear,  brightly  refrangent  bodies,  at  first  sphe- 
roidal, afterward  larger  and  oblong.  Unlike  the  micrococcus  and  bacillus, 
1  Bert,  Compt.  Rend,  de  la  Societe  BioL,  p.  355,  1879. 


ETIOLOGY.  933 

they  do  not  stain.  Under  favorable  circumstances  the  primary  cell  is 
capable  of  forming  one,  or  if  extra  long,  two  spores  (Koch,  Klein).  Cossar- 
Ewart  claims  to  have  seen  the  formation  of  motile  flagellate  organisms 
aggregating  themselves  into  zooglaea  masses,  but  as  these  were  not  found 
in  the  carefully-conducted  cultures  of  Koch  and  Klein,  they  are  supposed 
to  have  been  aerial  microphytes  accidentally  introduced. 

The  great  tenacity  of  life  in  the  spores  in  heat  and  cold,  dryness  and 
wet,  excluded  from  air  and  under  several  atmospheres  of  oxygen,  in  the 
midst  of  putrefaction  and  in  pure  watery  fluids,  well  accounts  for  the 
persistence  of  infection  in  buildings  and  localities  where  the  poison  has 
gained  a  foothold.  In  order  to  their  destruction  in  a  natural  manner  it 
seems  necessary  that  they  should  germinate  and  develop  into  the  anthrax 
micrococcus,  bacillus,  or  mycelium.  This  germination  may  take  place  in 
the  presence  of  moisture,  oxygen,  and  suitable  nourishment,  whether  in 
the  soil,  the  animal  body,  or  elsewhere,  and  then  the  exhaustion  of  the 
aliment,  the  exclusion  of  the  oxygen  by  putrefaction,  the  submergence 
in  a  medium  unfavorable  to  development,  or  exposure  to  a  very  high  tem- 
perature, may  suddenly  destroy  the  poison. 

There  is  reason  to  believe  that  a  too  free  exposure  to  oxygen  proves 
destructive  to  the  virulence,  if  not  to  the  life,  of  the  poison,  and  thus  in 
all  porous,  well-drained  soils  the  anthrax  poison,  even  when  introduced 
from  without  and  concentrated  by  the  death  and  burial  of  many  vic- 
tims, soon  disappears.  This  feature,  which  is  common  to  many  zymotic 
diseases  the  germs  of  which  live  and  multiply  outside  the  animal  body 
(typhoid,  yellow  fever,  tuberculosis,  swine  plague,  chicken  cholera,  diph- 
theria, etc.),  offers  countenance  to  the  claims  of  Buchner  that  he  had  by 
prolonged  culture,  in  the  presence  of  air,  metamorphosed  the  bacillus  an- 
thracis into  a  harmless  mycrophyte,  and  that,  conversely,  by  continuous 
cultivation  under  the  surface  of  a  suitable  beef  infusion  he  had  changed 
the  harmless  bacillus  subtilis  of  hay  into  the  deadly  bacillus  anthracis. 
Koch,  Klein,  and  others  have  discredited  Buchner's  results,  on  the  ground 
that  he  had  not,  in  their  opinion,  taken  due  precautions  against  impure 
cultures,  and  that  his  alleged  transitions  took  place  too  abruptly ;  yet  fur- 
ther observation  must  determine  whether  he  has  been  condemned  too 
hastily.  The  diminished  virulence  of  Pasteur's  attenuated  virus,  which 
is  unaffected  by  the  next  subsequent  culture  or  by  the  formation  of  spores, 
shows  plainly  enough  that  the  bacillus  anthracis  is  capable  of  physiologi- 
cal changes  under  the  influence  of  varying  conditions  of  growth,  and  that 
such  changes  are  not  at  once  undone  by  a  return  of  the  former  conditions. 

How  anthrax-germs  enter  the  body  is  partly  known  and  partly  conjec- 
tured. Direct  inoculation  on  a  sore  by  contact,  by  insects,  by  harness,  by 
accidents,  etc.  is  an  undoubted  method.  The  sound  cuticle  is  probably  an 
efficient  barrier,  since  bacteria  habitually  inhabit,  without  hurt,  the  surface 
and  gland-ducts  of  the  skin ;  yet  the  entrance  of  these  saprophytes  through 
the  shell  and  membranes  of  the  egg  leaves  a  doubt  as  to  the  efficiency  of 
the  cuticular  obstacle.  The  mucous  membranes  are  manifestly  frequently 
penetrated  by  the  parasite.  Hence  the  local  affections  in  the  mouth  and 
throat  (glossanthrax,  anthrax  angina)  and  in  the  lungs  (pulmonary 
anthrax).  Cohn  claims  that  the  gastric  juice  of  Carnivora  especially  is 
destructive  to  the  anthrax  poison,  yet  the  constant  recurrence  of  intestinal 
anthrax  (mycosis)  seems  to  imply  that  the  germs  often  escape  destruction 


934  ANTHRAX. 

in  the  stomach.  Pasteur  supposes  that  anthrax-infected  food  is  only 
injurious  when  there  are  inoculable  sores  in  the  mouth  or  pharynx,  but  it 
seems  as  if  in  that  case  the  disease  would  be  first  shown  at  these  points 
and  in  the  nearest  lymphatic  glands  rather  than  in  the  bowels,  the  rule 
for  the  inoculated  anthrax  being  to  develop  first  in  the  tissues  and  thence 
to  reach  the  blood-vessels  through  the  lymphatics. 

The  anthrax  poison  expends  its  fatal  energy  especially  on  the  blood  and 
blood-vessels.  The  bacilli  in  the  blood  use  up  the  available  oxygen,  so 
that  the  circulating  liquid  becomes  venous,  dark,  and  unfitted  for  the  main- 
tenance of  the  normal  functions  of  life.  What  is  even  worse,  the  ability 
of  the  blood  to  absorb  oxygen  is  greatly  impaired.  In  men  and  dogs 
suffering  from  anthrax  the  consumption  of  oxygen  was  found  to  be 
reduced  in  one  instance  even  by  two-thirds,  probably  in  part  by  reason  of 
the  action  of  the' chemical  products  of  the  bacillus.  A  third  condition 
constantly  found  is  embolism  of  the  capillaries  by  the  bacillus  and  the 
occurrence  of  local  gangrene. 

SYMPTOMS. — Anthrax  shows  itself  in  three  principal  forms :  1st,  the 
apoplectiform  ;  2d,  anthrax  fever  without  local  external  lesions ;  and  3d, 
external  localized  anthrax.  The  two  last  forms  correspond  in  the  main 
to  the  acute  and  subacute  forms. 

The  period  of  incubation  varies  according  to  the  dose  of  the  poison  and 
the  receptivity  of  the  animal.  In  some  cases  infection  is  at  once  followed 
by  illnass.  In  these  it  is  probably  the  chemical  products  that  produce  the 
first  effect,  while  the  disease  caused  by  the  propagation  of  the  bacillus 
appears  later  should  the  animal  survive.  Such  incubation  is  shortest  for 
the  smaller  animals  (mice,  rabbits,  guinea-pigs,  cats),  in  which  illness 
usually  sets  in  in  from  twenty-four  to  forty-eight  hours.  In  sheep  and 
goats  incubation  may  be  extended  to  three  or  four  days,  while  in  horses 
and  cattle  it  may  last  a  day  longer. 

The  apoplectiform  type  attacks  animals  which  a  few  minutes  before 
seemed  in  fine  health,  appetite,  and  spirits,  striking  them  down  as  if  by 
lightning,  and  the  victims  struggle  convulsively  for  some  minutes,  expel 
blood  perhaps  by  the  nose  or  anus,  and  expire.  In  the  less  suddenly 
fatal  cases  there  may  be  muscular  trembling,  unsteady  gait,  excited  breath- 
ing, accelerated  pulse,  tumultuous  heart's  action,  bleeding  from  some  natu- 
ral orifice,  and  death  in  from  one  to  several  hours.  Occurring  as  these 
cases  often  do  in  summer,  the  sudden  death  is  probably  hastened  by  inso- 
lation. 

In  anthrax  fever  or  acute  internal  anthrax  there  is  loss  of  appetite, 
and,  in  ruminants,  of  rumination,  suppression  of  milk,  dulness,  languor, 
staring  coat,  or  even  a  rigor,  and  thirst.  Then  follows  the  hot  stage,  in 
which  the  temperature  may  rise  to  106°  or  107°  F.;  there  are  acceleration 
of  pulse  and  breathing,  petechiae  or  a  brown  or  yellowish  tinge  of  the 
mucous  membranes  and  white  parts  of  the  skin,  tenderness  of  the  spine, 
often  jerking  or  clonic  spasms  of  the  muscles  of  the  extremities,  and 
much  prostration  and  weakness,  the  patient  hanging  back  on  the  halter, 
leaning  against  a  wall,  or  swaying  when  made  to  move.  The  feces  are 
usually  more  or  less  mingled  with  blood-clots,  or  may  be  at  once  liquid 
and  bloody.  Bloody  urine  and  the  discharge  of  blood  from  other  natural 
channels  are  frequent.  Some  cases  are  manifestly  delirious,  and  in  others 
the  skin  crackles  on  being  handled.  Remissions  are  not  uncommon,  dur- 


MORBID  ANATOMY.  935 

ing  which  the  animal  remains  dull  and  prostrate.  As  the  disease  advances 
and  the  blood  is  robbed  of  its  oxygen,  the  temperature  descends  below  the 
natural  standard,  great  weakness  and  stupor  set  in,  the  pupils  are  widely 
dilated,  and  death  from  asphyxia  occurs  in  one  or  two  days  from  the 
onset. 

In  localized  external  anthrax  the  local  swellings  may  be  first  seen. 
There  are  usually  some  tenderness  of  the  skin,  erection  of  the  hair,,  and 
the  formation  of  a  little  nodule,  like  a  hazel-nut  or  walnut,  adherent  to 
the  deeper  parts  of  the  skin,  firm  and  comparatively  painless  even  when 
cat.  Sometimes  the  swelling  is  diffuse,  with  a  dropsical  or  erysipelatoid 
aspect,  and  crackles  like  parchment  when  handled.  Whether  the  affection 
attacks  the  tongue,  the  throat,  or  some  part  of  the  head,  body,  or  limbs, 
the  tendency  is  to  gangrene  of  the  part,  and,  if  the  subject  survives  long 
enough,  to  an  extensive  sloughing  and  unhealthy  sore.  The  sloughs  and 
sores  have  either  a  black  sanguineous  appearance  or  they  are  lardaceous 
and  intermixed  with  streaks  of  dark  red.  If  fever  is  not  present  at  the 
outset,  it  sets  in  early,  and  passes  through  the  same  stages  as  in  the  acute 
internal  anthrax,  the  animals  being  suddenly  plunged  in  prostration  and 
stupor,  with  dusky  yellow  or  blood-stained  mucous  membranes,  dyspnoea, 
dilated  pupils,  convulsions,  and  death.  On  the  mucous  membranes  (gloss- 
anthrax,  anthrax  angina)  the  engorgement  is  usually  complicated  with 
bullse  with  red  or  yellow  contents,  and  which  on  bursting  leave  unsightly 
gangrenous  ulcers.  In  all  such  cases  the  morbid  liquids  of  the  swellings 
teem  with  bacilli. 

MOEBID  ANATOMY. — The  most  characteristic  changes  are  usually  met 
with  in  the  blood.  This  is  black,  thick,  tarry,  uncoagulable  or  coagulates 
only  in  loose  diffluent  clots,  which  are  redissolved  before  squeezing  out 
the  serum ;  the  fibrin  is  diminished  (often  by  two-thirds),  the  red  globules 
are  not  adherent  in  rouleaux,  and  are  crenated  and  broken  down  and  the 
hsematin  diffused  through  the  liquid,  so  that  it  stains  the  hands  or  paper 
deeply ;  the  white  globules  are  increased,  probably  by  reason  of  the  early 
irritation  of  the  lymphatic  glands  and  spleen  by  the  poison ;  and  it  red- 
dens slowly  and  but  slightly  on  exposure  to  the  air,  and  speedily  passes 
into  decomposition.  The  blood  can  scarcely  be  made  to  flow  in  a  full 
stream,  but  often  trickles  down  the  hair  and  skin  by  reason  of  its  thick, 
consistent  character.  The  microphytes  above  described  are  usually  found 
in  the  blood,  and  always  in  the  affected  tissues  if  examined  just  after 
death. 

Next  to  the  blood,  the  spleen  presents  the  most  constant  lesions,  being 
enlarged  (by  one-third,  one-half,  or  to  double,  triple  or  quadruple  its  nor- 
mal size)  and  gorged  with  blood  (sometimes  even  to  rupture).  The  lym- 
phatic glands,  and  especially  those  adjoining  the  local  anthrax  swellings 
of  the  tissues,  are  always  enlarged,  marked  with  petechiae,  friable,  easily 
reduced  to  a  pulp,  and  swarming  with  bacilli  and  micrococci.  Next  to  the 
glands  of  the  affected  parts  the  central  ones,  the  axillary,  prepectoral, 
thoracic,  sublumbar,  and  abdominal,  are  the  most  constantly  affected. 
The  lymph  is  reddish  and  opaque. 

Decomposition  sets  in  early,  and  the  resulting  gases  cause  a  puffy, 
emphysematous  condition  of  the  connective  tissue.  The  fat  and  other 
white  tissues  are  dusky  brown  or  yellow,  and  petechiated ;  the  muscles 
are  soft,  flabby,  and  dark  red  or  brown,  with  occasional  blood  extravasa- 


936  ANTHRAX. 

dons ;  the  blood-vessels,  especially  the  veins,  and  the  right  heart  are  gorged 
with  black,  uncoagulable  blood,  and  have  their  inner  coats  blood-stained. 
The  serous  membranes  present  numerous  petechire,  and  contain  more  or 
less  of  a  reddish  serum.  The  intestines,  and  sometimes  the  stomach,  are 
dark  red  throughout,  marked  by  petechias,  and  are  often  the  seat  of  thick- 
ening from  sanguineous  or  transparent  colloid  infiltration.  The  lesions 
are  especially  extensive  on  the  small  intestines  and  rectum.  The  vagina 
and  womb  are  also  the  frequent  seats  of  sanguineous  infiltration.  The 
liver  and  kidneys  are  enlarged,  congested,  softened,  and  friable,  and  the 
ganglia  of  the  symphathetic  are  enlarged,  congested,  and  softened.  The 
swellings  are  of  two  kinds,  sanguineous  and  colloid.  The  former,  when 
cut  into,  present  one  or  more  loose  clots  of  black  blood  or  a  grumous  mass 
of  blood-elements,  separating  the  tissues  and  often  mixed  with  fetid  gases. 
The  colloid  exudations  are  glairy,  semi-solid,  jelly-like  masses,  infiltrating 
the  tissues.  The  tissues  affected  and  the  skin  covering  them  are  the  seat  of 
bacterial  embolism  and  gangrene,  and  there  is  no  tendency  to  suppuration. 
These  products  swarm  with  the  specific  microphyte. 

DIAGNOSIS. — The  differential  diagnosis  of  anthrax  from  other  affections 
due  to  the  propagation  of  microzymes  in  the  system  is  not  always  easy — 
so  much  so  that  a  variety  of  bacteridian  and  allied  diseases  (septicaemia  in 
its  various  forms,  erysipelas,  swine  plague,  chicken  cholera,  poisoning  by 
the  micrococci  of  fungi,  black  quarter  from  bacteria,  milk  sickness, 
and  Texas  fever)  have  been  erroneously  confounded  with  this  affection. 
These  all  show  the  same  dusky  or  cyanosed  mucous  membranes,  disinte- 
grating blood-globules,  loose  blood-clots,  petechise,  blood-extravasations, 
sudden  and  great  prostration,  and  enlargement  and  congestion  of  the  lym- 
phatic glands  or  spleen.  In  some  of  these  the  duration  of  incubation  (in 
swine  plague  six  to  fourteen  days  and  in  Texas  fever  one  month)  serves 
to  distinguish,  while  in  the  majority  the  microzyme  is  globular  (Texas 
fever,  micrococcus  of  fungi-poisoning,  chicken  cholera) ;  in  swine  plague 
the  cocci  are  arranged  in  pairs ;  in  black  quarter  the  microbe  is  a  refran- 
gent  ovoid,  single  or  in  chains  of  two  or  three  and  a  motile  linear  body 
with  a  refrangent  nucleus  in  one  end ;  and  in  milk  sickness  the  germ  is 
a  spirillum.  The  germs  are  far  more  likely  to  be  detected  in  the  local 
lesions  and  lymphatic  glands  than  in  the  blood.  The  specific  nature 
of  the  symptoms  and  lesions  can  usually  be  relied  on,  but  in  cases  of 
doubt  the  inoculation  of  a  small  animal  (rabbit,  guinea-pig,  sheep)  will 
be  a  material  guide. 

PROGNOSIS. — True  anthrax  leads  to  a  very  high  mortality.  The  apo- 
plectiform  cases  are  fatal  almost  without  exception ;  the  acute  cases  of 
anthrax  fever  in  many  outbreaks  perish  to  the  extent  of  75  or  80  per 
cent.,  and  the  more  tardy  ones  to  the  number  of  50  per  cent.  In  a 
general  outbreak  the  earlier  cases  are  usually  the  most  fatal,  while  later, 
when  the  less  susceptible  animals  are  attacked,  the  mortality  is  often 
decreased.  Again,  the  mortality  is  often  at  once  arrested  by  the  emigra- 
tion of  the  herd  to  a  more  healthy  soil,  a  large  proportion  of  those  already 
attacked  recovering. 

PROPHYLAXIS. — In  prophylaxis  the  soil  demands  the  first  attention. 
If  this  is  damp  and  calcareous  or  rich  in  organic  matter,  the  remainder 
of  the  herd  should  be  at  once  removed  to  a  drier  and  more  porous  soil, 
where  the  germ  is  less  likely  to  be  preserved  and  increased.  In  an  enzo- 


PROPHYLAXIS.  937 

otic  in  Livingston  County,  K  Y.,  in  1875,  40  bullocks  out  of  200  had 
perished  m  ten  days,  yet  after  removal  to. an  adjacent  dry  pasture  and  the 
use  of  antiseptics  with  the  food  and  water  the  attacks  abruptly  ceased 
and  48  out  of  50  head  already  sick  recovered.  The  drainage  of  anthrax 
soils  leads  to  a  steady  reduction  of  the  poison,  favoring  as  it  does  the 
germination  of  the  spores  and  the  destruction  or  modification  of  the 
germ.  When  drainage  is  impossible,  the  mortality  may  be  reduced  by 
driving  the  stock  to  drier  grounds  during  the  hot,  dry  season,  by  stabling 
them  morning  and  night  when  the  dews  are  on  the  grass, 'also  in  wet 
times  when  they  are  likely  to  pull  up  the  plants  by  the  roots,  or,  better 
still,  by  cutting  the  fodder  and  soiling  the  stock  in  stables  or  yards.  Yet 
m  all  these  cases  the  germs  will  at  intervals  find  access  to  the  animals  in 
the  green  food  or  hay,  so  that  badly  infected  soils  must  be  secluded  from 
live-stock,  and  either  be  abandoned  or  devoted  to  other  cultures.  A  point 
of  the  very  first  importance  is  the  safe  disposal  of  the  products  and  car- 
cases of  the  sick.  These  should  be  thoroughly  burned,  or,  failing  this, 
deeply  buried  (4  feet)  and  the  graves  covered  with  coal  tar  and  fenced  in 
from  all  other  stock  for  from  five  to  ten  years.  Contaminated  litter  and 
fodder  should  share  the  same  fate.  Stables  and  yards  where  the  sick 
have  been,  and  all  vehicles  and  implements  used  for  them  or  their  prod- 
ucts, should  be  thoroughly  disinfected.  In  the  epizootic  in  Livingston 
County^  above  referred  to,  these  measures  seem  to  have  eradicated  the 
disease  in  the  course  of  six  years,  though  the  land  was  neither  drained 
nor  subjected  to  cultivation,  and  the  dangerous  meadows  are  now  again 
pastured  with  impunity. 

In  the  case  of  sick  animals  the  greatest  care  is  requisite  to  keep  them 
from  common  drinking-  or  feeding-troughs ;  to  exclude  all  other  animals, 
even  the  smaller  quadrupeds  and  birds,  which  may  become  the  bearers 
of  the  poison ;  to  avoid  the  chance  of  the  drainage  of  infected  excreta 
into  other  yards  and  pastures,  and  to  carefully  disinfect  and  guard  the 
human  attendants  against  contamination.  The  sale  of  animals  out  of  an 
infected  herd,  and,  above  all,  for  the  meat-market,  and  the  use  of  the 
milk  or  other  products  of  such  animals,  until  attested  sound,  are  highly 
reprehensible. 

Finally,  there  are  the  diiferent  methods  of  protecting  the  system  by 
inoculation  with  modified  virus.  The  first  of  these  is  that  of  Burdon- 
Sanderson,  Dugnid,  and  Greenfield,  who  in  1878  and  1879  inoculated 
six  cattle  with  the  blood  of  guinea-pigs  dead  of  anthrax,  all  of  which 
survived  except  an  old,  emaciated,  worn-out,  and  pregnant  cow,  and  all 
the  survivors  would  only  afterward  contract  anthrax  in  a  mild  form. 
The  anthrax  blood  of  the  guinea-pig  inoculated  on  the  sheep  proved 
fatal.  The  second  mode  is  that  of  Pasteur,  who  cultivated  the  anthrax- 
germ  artificially  in  flasks  of  meat-infusion,  and  after  the  nourishment  in 
the  latter  had  been  used  up  left  the  bacilli  to  degenerate  until  their  viru- 
lence had  been  so  far  decreased  that  the  liquid  could  be  safely  inoculated 
on  animals,  so  as  to  produce  a  mild  anthrax  infection  and  thereafter 
secure  immunity  from  this  poison.  For  all  the  larger  domestic  animals 
he  found  that  the  eighth  day  of  the  culture  sufficed,  provided  there  had 
been  no  formation  of  spores ;  and  the  method  has  now  been  applied  on 
many  scores  of  thousands  of  domestic  animals.  Klein,  however,  has  found 
that  cultures  in  pork-broth  of  the  same  age  are  invariably  fatal  to  rodents, 


938  ANTHRAX. 

and  that  a  guinea-pig  which  survived  inoculation  with  culture  a  month 
old  did  not  possess  immunity .  against  fresh  virus.  The  third  method, 
that  of  Toussaint,  consists  in  heating  the  fresh  virus,  so  as  to  lessen  its 
activity,  and  then  inoculating  it  on  the  animals  to  be  protected.  He  found 
that  a  temperature  of  55°  C.  (131°  F.)  maintained  for  one  hour  rendered 
the  virus  non-fatal,  without  impairing  its  prophylactic  powers  on  animals 
inoculated.  In  spite  of  a  partial  failure  at  Alfort  from  insufficient  heat- 
ing of  the  virus,  the  method  has  now  been  firmly  established  as  at  once 
easy  and  effective. 

The  great  value  of  these  discoveries  can  hardly  be  overestimated,  yet 
it  is  to  be  feared  that  the  Sclat  of  their  reception  has  led  to  a  far  too  general 
adoption  of  the  methods.  No  one  of  the  methods  professes  to  destroy 
the  life  of  the  bacillus  nor  to  impair  its  power  of  self-propagation.  The 
bacillus,  therefore,  is  likely  to  be  planted  in  the  localities  where  it  is  being 
employed,  and,  if  the  soil  is  favorable,  to  be  perpetuated  there.  It  follows 
also,  from  the  susceptibility  of  the  bacillus  to  change  under  varying  con- 
ditions of  life,  that  the  modification  impressed  on  it  by  the  methods  of 
Pasteur  and  Toussaint  may  be  reversed  under  a  reverse  state  of  the 
environment,  and  that  the  harmless  virus  sown  by  our  inoculators  may 
in  favorable  soils  produce  the  more  deadly  types.  The  methods  secure 
the  safety  of  the  individual  herd  inoculated,  at  the  expense  of  planting 
in  the  pasture  a  seed  most  perilous  to  all  future  uninoculated  herds 
that  may  roam  there.  The  only  place  for  such  protective  inoculations  is 
on  pastures  already  charged  with  the-  anthrax  bacillus,  and  from  which 
that  cannot  be  eradicated.  On  the  dry,  healthful  soils  where  the  bacillus 
cannot  survive  the  inoculation  is  useless,  while  on  the  dense,  damp,  rich 
soils  favorable  to  its  preservation,  but  as  yet  uninfected  or  nearly  so,  this 
inoculation  is  but  sowing  deadly  seed  to  secure  a  very  temporary  and 
questionable  advantage. 

TREATMENT. — Bloodletting  and  laxatives  have  been  largely  used  in 
the  treatment  of  anthrax,  though  both  are  mostly  useless  in  acute  cases, 
their  possible  good  effects  being  anticipated  by  the  early  death.  "When 
of  service  at  all,  it  is  probably  mainly  in  reducing  that  plethora  which 
serves  often  to  enhance  the  virulence -and  severity  of  the  malady.  Apart 
from  these,  the  agents  resorted  to  are  more  or  less  of  an  antiseptic  nature, 
and  probably  exert  their  action  mainly  on  the  bacilli  undergoing  develop- 
ment near  the  surface  of  the  skin  or  intestinal  mucous  membrane.  In 
extensive  outbreaks  I  have  had  the  best  results  with  the  administration 
thrice  daily  of  carbolic  acid,  nitro-muriatic  acid,  or  bichromate  of  potas- 
sium, and  hypodermically  of  iodide  of  potassium  and  sulphate  of  quinia. 
Alcoholic  stimulants,  chlorate  of  potassium,  and  muriate  of  iron  are  equally 
indicated,  especially  when  the  period  of  prostration  has  set  in.  If  the 
local  anthrax  can  be  detected  when  there  is  as  yet  but  a  hard  nodule,  there 
should  be  no  hesitation  in  cauterizing  it  to  its  depth  and  treating  the 
resulting  sore  and  surrounding  parts  with  tincture  of  iodine  or  iodized 
phenol.  After  crucial  incision  the  nodule  may  be  treated  with  powerful 
caustics  (potassa,  nitric  acid,  chloride  of  zinc),  to  be  followed  by  iodized 
phenol,  with  or  without  poultices  or  fomentations. 


ETIOLOGY. 


939 


Anthrax  in  Man  (Malignant  Pustule  or  Vesicle,  Anthrax  Intes- 
tmalis,  Mycosis  Intestinalis). 

Fournier  in  1769  first  traced  the  communicated  anthrax  of  man  to  the 
consumption  of  the  flesh  of  diseased  animals  and  the  handling  of  their 
wool.  Until  quite  recently,  however,  the  form  which  originated  as  a 
local  external  affection  was  the  only  type  recognized,  while  internal 
anthrax  was  confounded  with  a  multitude  of  other  affections. 

ETIOLOGY.— That  anthrax  in  man  is  almost  invariably  derived  from 
the  lower  animals  by  infection  is  now  undoubted,  while  for  the  direct 
infection  of  man,  as  of  animals,  by  the  germs  propagated  in  the  soil,  there 
is  no  absolute  proof.  The  latter  mode  of  propagation  has  only  been 
recognized  in  the  Herbivora,  which  are  so  much  more  exposed  to  con- 
tamination from  the  soil ;  yet,  abstractly,  there  is  no  reason  to  suppose 
that  man  is  less  susceptible  to  the  earth-grown  bacillus  than  to  that  pro- 
duced in  the  animal,  if  only  he  were  as  frequently  exposed  to  its  infec- 
tion. The  ^  spontaneous  development  of  anthrax  apart  from  the  pre- 
existent  bacillus  in  animals  or  soil  is  a  chimera.  The  principal  modes 
of  infection  may  be  considered  as  direct  and  mediate.  Among  the  direct 
are  included  infection  from  handling  the  sick  animals,  their  carcases,  their 
wool,  hair,  bristles,  hides,  fat,  and  guts ;  the  inoculation  of  physicians, 
surgeons,  and  nurses  from  their  patients ;  and  the  infection  of  men  by  the 
meat,  milk,  and  cheese  eaten.  As  attested  modes  of  mediate  infection  may 
be  cited  the  inoculation  by  insects  (mosquitoes,  bluebottles,  and  other  blood- 
suckers), and  the  introduction  by  water  into  which  anthrax  products  have 
drained  or  been  washed ;  there  are  also  hypothetical  cases  in  which  anthrax- 
germs  from  the  earth  have  entered  the  system  in  the  air,  drink,  or  food 
(raw  vegetables).  The  direct  inoculations  are  especially  common  in  cer- 
tain classes  (shepherds,  farmers,  butchers,  knackers,  tanners,  veterina- 
rians, and  workers  in  hides,  hoofs,  glue-factories,  fat-rendering  works,  in 
hair,  wool,  bristles,  and  catgut,  and  in  felting  and  paper-making).  In 
such  cases  the  disease  usually  begins  as  a  local  one,  and  occurs  on 
uncovered  portions  of  the  body.  Three  such  cases  occurred  in  1875  on 
one  farm  at  Avon,  N.  Y.,  where  the  victims  had  assisted  in  burying  forty 
dead  cattle,  and  a  number  of  other  similar  instances  can  be  adduced  in 
different  parts  of  the  same  State,  in  one  of  which  a  physician  was  acci- 
dentally inoculated  in  dressing  a  farmer's  hand.  Physicians  whose  prac- 
tice includes  large  tanneries  become  very  familiar  with  the  disease  and 
recognize  it  very  readily. 

Infection  through  food  is  much  less  frequent  in  men  than  in  animals, 
the  process  of  cooking  combining  with  the  action  of  the  gastric  juice  in 
destroying  the  poison.  Yet  it  is  by  no  means  unknown.  The  records 
above  given  of  infection  in  St.  Domingo,  Naples,  and  the  Russian  steppes 
can  be  easily  supplemented.  Dr.  Keith  of  Aberdeen,  Scotland,  records  the 
case  of  a  family  that  suffered,  two  of  them  fatally,  after  partaking  of  broth 
and  meat  which  had  been  boiled  for  hours,  one  member  of  the  family  (a 
vegetarian)  having  alone  escaped.  Infection  through  milk,  butter,  and 
cheese  is  less  common,  the  gravity  of  the  disease  in  animals  leading  to  an 
early  suppression  of  the  mammary  secretion.  In  all  such  cases  the  infec- 
tion enters  through  sores  in  the  mouth  or  from  the  bowels. 

Those  cases  in  which  the  bacillus  enters  the  system  with  the  inspired 


940  ANTHRAX. 

air  are  probably  the  least  numerous.  Yet  the  germ  may  reach  the  lungs 
in  fine  dust,  and  then  find  in  the  delicate  respiratory  mucous  membrane 
the  most  accessible  of  all  channels  into  the  system. 

The  proportion  of  men  affected  is  much  greater  than  that  of  women 
and  children,  doubtless  by  reason  of  their  greater  exposure  to  infection, 
and,  as  in  the  lower  animals,  the  summer  months  are  most  productive  of 
anthrax.  The  susceptibility  of  the  human  race  appears  to  be  less  than 
that  of  the  Herbivora,  and  doubtless  varies,  as  in  these  animals,  with  the 
nature  of  the  food.  It  is  at  least  temporarily  exhausted  by  a  first  attack, 
though  in  exceptional  cases  and  under  a  strong  dose  of  the  poison  a  man 
may  be  affected  a  second  time. 

SYMPTOMS. — Symptoms  usually  set  in  within  twenty-four  hours  after 
inoculation  of  the  poison,  though  it  is  alleged  that  the  incubation  may  be 
extended  to  twelve  or  fourteen  days.  Itching  draws  attention  to  a  small 
red  spot  like  a  mosquito  bite,  but  with  a  black  central  point.  This 
speedily  increases  to  a  small  rounded  swelling  (papule),  and  in  fifteen 
hours  is  surmounted  by  a  minute  vesicle  with  dark-red  or  bluish  contents. 
From  the  size  of  a  millet-seed  this  increases  to  that  of  a  pea,  and  in  thirty 
hours  bursts  spontaneously  or  under  friction  and  forms  a  dark-red,  indu- 
rated, comparatively  painless  nodule  (parent  nucleus,  Virchow).  The 
adjacent  skin  shows  a  swollen  areola  livid  and  red,  on  which  there  appear 
vesicles  similar  to  the  first,  which  pass  through  the  same  stages,  burst, 
and  leave  a  livid,  hard,  or  doughy  gangrenous  surface.  By  this  time  the 
surrounding  skin  is  red,  shining,  and  puffy,  and  the  disease  continues  to 
spread  by  the  same  method  of  extension.  The  diseased  part  now  becomes 
the  centre  of  an  oedematous  swelling  which  may  invade  the  entire  arm, 
face,  or  neck,  and  is  attended  with  more  or  less  constitutional  symptoms. 
The  affected  part  may  be  cold  or  hot,  and  it  may  show  the  red  lines  of 
lymphangitis  and  the  swelling  of  the  adjacent  lymphatic  glands. 

The  pyrexia,  at  first  slight,  often  reaches  a  high  grade,  attended  with 
occasional  chilliness,  pains  in  the  back  and  loins,  great  prostration,  lan- 
guor, dulness,  and  even  delirium,  with  cold  sweats,  anxiety,  dyspnoea,  and 
at  times  muscular  spasms.  As  in  beasts,  there  are  the  dusky  skin  and 
mucous  membranes,  petechiae,  and  cyanosis,  and  in  bad  cases  there  may 
be  sudden  collapse  and  death.  The  symptoms  vary  much,  however, 
according  to  the  extent  of  the  local  lesion,  to  the  amount  of  poisonous 
chemical  products  thrown  into  the  blood,  to  the  degree  of  the  invasion  of 
the  blood  by  the  bacillus,  and  to  the  complication  (not  infrequent)  of  the 
affection  with  septicaemia.  In  the  very  mildest  cases  the  affection  never 
proceeds  beyond  a  local  slough,  the  size  of  a  quarter  or  half  dollar, 
the  germs  do  not  enter  the  blood  in  sufficient  numbers  to  survive,  the 
constitutional  symptoms  are  few  or  absent,  and  the  sore  heals  by  gran- 
ulation. 

The  disease  usually  lasts  from  six  to  ten  days,  and  for  the  first  forty- 
eight  hours  the  symptoms  are  generally  purely  local. 

Malignant  anthrax  oedema  (oedeme  maligne)  was  first  observed  by 
Bourgeois  as  occurring  in  the  eyelid,  and  has  since  been  recognized  in 
other  parts  of  the  body  (arm,  forearm,  head).  It  differs  mainly  from 
malignant  pustule  in  the  absence  of  the  preliminary  vesicle,  of  the 
hard  nodule  (parent  nucleus),  and  of  the  early  circumscribed  gangrene. 
It  has  this  further  peculiarity,  that  the  local  disease  often  appears  as  a 


MORBID  ANATOMY.  941 

sequel  rather  than  a  precursor  of  the  constitutional  disturbance.  It 
corresponds  in  the  main  to  the  diffuse  erysipelatoid  anthrax  of  the  lower 
animals,  and  has  been  attributed  to  the  authjax  poison  introduced  by  inha- 
lation. It  has  been  observed  to  follow  eating  of  anthrax  flesh  (Leube, 
Miiller).  Inasmuch  as  the  active  disease  is  often  delayed  a  week  or  ten 
days  after  exposure  to  infection,  it  may  reasonably  be  supposed  that  the 
bacillus  has  been  imprisoned  on  the  mucous  membrane,  or,  entering  the 
blood  in  small  quantity  only,  has  been  held  in  check  by  the  antagonism 
of  the  blood-globules  until  some  elements,  escaping  into  the  connective 
tissue,  have  started  the  local  disease.  The  symptoms  are  usually  first 
languor,  sleeplessness,  restlessness,  with  some  sense  of  chill,  debility,  and 
headache,  and  finally,  after  a  few  days,  the  formation  of  the  specific  osdema 
at  one  point  or  more.  This  has  a  pale,  semi-translucent,  slightly  yellow- 
ish or  greenish  aspect,  pits  on  pressure  nearly  equally  at  all  points,  and 
tends  to  a  rapid  extension,  with  concomitant  aggravation  of  the  constitu- 
tional symptoms,  and  in  many  cases  nausea  and  vomiting.  Gangrene  sets 
in — not  progressively,  as  in  malignant  pustule,  but  simultaneously  over  a 
more  extensive  surface — and  is  followed  by  great  prostration,  stupor, 
dyspnoaa,  cyanosis,  collapse,  and  death. 

Anthrax  intestinalis  may  be  looked  upon  as  the  counterpart  of  the 
internal  anthrax  or  anthrax  fever  of  animals,  described  above.  As  in 
animals,  the  constitutional  symptoms  may  result  early  in  a  fatal  issue, 
with  scarcely  any  local  lesion  save  in  the  blood  and  spleen  (Carganico, 
Leube,  Miiller,  Winkler,  Lorinser).  As  in  animals  too,  the  sanguineous 
engorgement  of  the  spleen  and  the  intestinal  anthrax  are  often  complicated 
by  external  anthrax  oedema  or  malignant  pustule  (Heussinger,  Virchow, 
Buhl,  Waldeyer,  etc.).  In  this  form  pyrexia  and  other  constitutional  dis- 
turbances are  first  seen.  There  is  a  general  feeling  of  languor  and  depres- 
sion, with  some  chilliness,  fever,  pains  in  the  limbs,  back,  and  head, 
vertigo,  and  ringing  in  the  ears.  Even  at  this  early  stage  there  is  noticed 
a  dusky  hue  of  the  skin  and  visible  mucous  membranes,  which  goes  on 
increasing  to  a  brown  or  yellow  tinge,  to  petechiae,  or,  with  the  superven- 
tion of  dyspnoea,  to  cyanosis.  Digestive  derangement  is  early  shown  in 
abdominal  pain,  nausea,  vomiting,  tenderness,  some  swelling,  and  finally 
diarrhoea,  often  bloody  and  sometimes  profuse  and  exhausting.  In  acute 
cases  the  symptoms  become  rapidly  worse,  and  then  follow  discharge  from 
the  moutlraud  nose  of  uncoagulable  blood,  dyspnoaa,  cyanosis,  small  pulse, 
dilated  pupils,  great  anxiety  or  drowsiness,  and  stupor,  or  there  may  be 
tonic  spasms  of  the  trunk  or  extremities.  Death  usually  results  from 
asphyxia  or  collapse,  as  in  animals.  These  cases  are  almost  invariably 
fatal  within  a  period  of  thirty-six  hours,  though  some  linger  six  or  seven 
days. 

Allied  to  the  intestinal  anthrax  is  anthrax  angina,  a  not  unknown 
occurrence  in  man.  This  begins  as  a  bad  sore  throat,  with  an  especially 
dark-red  hue  of  the  pharyngeal  mucous  membrane.  As  it  advances  the 
shade  becomes  increasingly  darker,  the  power  of  deglutition  is  lost, 
serous  phlyctenae  with  gangrene  and  deep  ulceration  set  in,  but  without 
any  tendency  to  the  formation  of  false  membrane  as  in  diphtheria.  There 
are  early  superadded  the  constitutional  symptoms  above  described,  and 
<  he  patient  dies  in  a  state  of  collapse  or  asphyxia. 

MOTIBID  ANATOMY. — The   lesions  closely  agree  with  those  already 


942  ANTHRAX. 

described  for  animals  in  general.  The  blood  presents  the  same  dark-red  or 
black,  tarry,  incoagulable,  or  only  slightly  coagulable  condition  in  the 
worst  cases,  yet  this  is  less  qpnstant  in  man,  as  the  bacteria  are  less  con- 
stant or  numerous  in  the  blood,  in  keeping  with  the  more  prolonged 
localization  of  the  external  anthrax  in  man,  and  the  more  pronounced 
antagonism  between  the  blood  and  the  bacillus  which  results  from  feeding 
exclusively  or  largely  on  flesh.  The  red  globules  do  not  tend  to  adhere 
together,  and  the  white  globules  are  in  excess  and  very  granular.  The 
spleen  is  less  extensively  enlarged  than  in  animals,  but  is  highly  charged 
with  blood,  bacilli,  and  micrococci.  The  lymphatic  glands  too  are 
enlarged,  hyperaemic,  cloudy,  hemorrhagic  at  points,  of  a  dark  grayish, 
deep  red,  or  blackish  color,  and  highly  charged  with  the  bacillus.  The 
surface  of  the  skin  and  mucous  membranes  (mouth)  presents  hemorrhagic 
spots  and  patches,  with  serous  vesicles  and  eschars.  The  malignant  pus- 
tule when  cut  into  presents  a  central  slough  and  a  surrounding  hard  indu- 
rated mass,  both  of  a  dark  blood-red,  with  similar  prolongations  down- 
ward into  the  adipose  tissue,  and  around  all  the  characteristic  oedeniatous 
infiltration,  often  streaked  with  blood.  The  bacillus  is  found  in  tufts  or 
dense  groups  at  intervals  in  the  rete  mucosum,  the  dermis,  and  the  sub- 
cutaneous connective  tissue.  The  serous  membranes  present  the  same 
general  lesions  as  in  animals.  The  walls  of  the  stomach  and  bowels  are 
the  seat  of  cloudy  red  infiltration,  with  at  intervals  small  hemorrhagic 
foci,  and  on  the  mucous  surface  distinct  sloughs.  Jelly-like  exudations 
are  also  found  in  these  membranes  in  the  mesentery  and  in  the  retro-peri- 
toneal tissue.  The  liver  and  kidneys  are  usually  congested  or  are  infiltrated 
with  an  cedematous  exudate,  and  in  these,  as  in  all  the  local  anthrax 
lesions,  the  characteristic  bacilli  are  found. 

DIAGNOSIS. — Malignant  pustule  is  distinguished  by  its  commencing 
from  a  minute  red  point  with  dark  centre,  and  by  its  progressive  exten- 
sion from  this  point  by  a  dark-red,  puny,  and  vesicular  areola,  with 
steadily  advancing  induration  and  gangrene.  The  bites  of  insects  have 
a  yellowish  central  point  with  red  areola.  A  boil  lacks  the  dark  centre 
and  the  rapidly  rising  elevated  red  areola.  Carbuncles  and  plague-boils 
tend  to  appear  on  clothed  parts  of  the  body,  respectively  on  the  back  of 
the  neck  and  shoulders  and  on  the  trunk  and  extremities.  In  carbuncle 
several  boils  rise  and  burst  simultaneously,  though  they  may  finally  slough 
into  one  sore,  while  in  anthrax  the  extension  is  from  one  point.  The 
plague-boil  is  usually  multiple  and  much  more  painful  than  anthrax. 
The  glanderous  nodule  is  usually  multiple,  situated  at  intervals  on  the 
course  of  a  lymphatic,  the  intervening  portion  of  which  is  inflamed,  hard, 
and  cord-like.  It  is  also  usually  associated  with  the  specific  glairy  dis- 
charge from  the  nose,  the  nasal  ulcers  and  nodules,  and  the  enlarged  pain- 
less, nodular,  and  indolent  submaxillary  lymphatic  glands.  As  a  last 
resort  the  detection  of  the  baccillus  in  the  indurated  nucleus  and .  the 
inoculability  of  the  disease  on  the  lower  animals  (rabbit,  guinea-pig), 
may  be  appealed  to. 

Malignant  anthrax  oedema  is  less  easily  recognized,  but  may  be  inferred 
from  the  sudden  swelling  with  a  dusky  yellow  or  greenish  hue  and  a 
tendency  to  vesiculation  and  gangrene,  the  whole  preceded  and  attended 
by  the  constitutional  symptoms  of  anthrax,  and,  above  all,  from  the  pres- 
ence of  the  bacillus  in  the  exudate. 


PROGNOSIS.— PROPHYLAXIS  AND  TREATMENT.  943 

In  both  of  these  forms  much  may  be  deduced  from  the  known  liability 
of  the  district  to  anthrax,  from  the  occupation  of  the  subject  as  being 
exposed  to  infection  (worker  in  hair,  wool,  bristles,  hides,  catgut,  etc.),  or 
from  his  having  eaten  meat  which  was  open  to  suspicion. 

Internal  anthrax  is  less  certainly  diagnosed  because  of  the  absence  of 
local  symptoms  until  the  constitutional  disorder  is  well  advanced.  Yet 
the  reasonable  suspicion  of  infection  and  the  sudden  and  violent  eruption 
of  the  disease  (headache,  nausea,  vomiting,  bloody  diarrhoea,  extreme  anx- 
iety, debility,  dyspnoea,  cyanosis,  convulsions,  collapse,  with  petechise,  and 
local  discharges  of  diffluent  blood)  serve  to  identify  it.  The  bacillus  is 
not  always  to  be  detected  in  the  blood  under  the  microscope,  but  its  pres- 
ence can  usually  be  demonstrated  by  inoculation. 

PROGNOSIS. — The  prognosis  of  malignant  pustule  energetically  treated 
in  its  early  stages  is  good.  The  disease  is  as  yet  a  local  one,  and  the 
germs  can  be  extinguished  by  local  treatment.  In  anthrax  districts, 
where  the  disease  is  feared  and  early  recognized,  the  mortality  may  be 
from  5  per  cent.  (Nicolai)  to  9  per  cent.  (Lengyel,  Koranyi).  Even  this 
mortality  is  mainly  due  to  delay  in  treatment.  In  districts,  on  the  other 
hand,  where  the  malady  is  infrequent,  and  where  efficient  measures  are 
applied  too  late,  the  mortality  is  often  30,  40,  or  even  50  per  cent.  After 
internal  infection,  and  where  local  symptoms  only  appear  after  general 
infection,  the  case  is  very  hopeless. 

PROPHYLAXIS  AND  TREATMENT. — The  prophylaxis  of  anthrax  in 
man  is  to  a  large  extent  identical  with  that  for  animals.  All  considera- 
tions as  regards  soil,  culture,  drainage,  sick  and  dead  stock,  cremation, 
burial,  disinfection,  etc.  have  a  most  important  if  only  a  secondary  bear- 
ing on  the  protection  of  man.  Still  more  important  is  the  free  use  of 
carbolic  acid,  chloride  of  lime,  or  tincture  of  iodine  for  the  hands  of  those 
dressing  unhealthy  sores  in  animals  or  handling  suspicious  cases  of  sick- 
ness or  cadavers,  and  of  those  working  in  hides,  wool,  hair,  horns,  hoofs, 
guts,  etc.  Similarly,  all  products  of  animals  with  anthrax  should  be 
withheld  from  general  use. 

In  external  anthrax  of  man,  before  the  system  has  been  contaminated, 
the  thorough  destruction  by  caustic  of  the  diseased  part  with  its  contained 
poison  is  most  'effectual.  Where  there  is  as  yet  but  the  preliminary 
papule  it  may  be  incised  and  thoroughly  destroyed  by  a  stick  of  chloride 
of  zinc,  caustic  potassa,  or  nitrate  of  silver,  or,  if  more  convenient,  by 
fuming  nitric  acid,  muriatic  or  sulphuric  acid,  or,  perhaps  preferably  to  all 
others,  iodized  phenol.  Should  the  parent  nucleus  have  already  formed, 
it  should  be  excised  with  the  knife  or  deeply  incised  in  a  crucial  direc- 
tion, and  then  thoroughly  cauterized  with  one  of  the  more  potent  eschar- 
otics  (caustic  potassa,  strong  nitric  acid)  or  with  the  iodized  phenol.  The 
latter  agent  may  be  further  applied  on  the  sound  skin  adjacent,  especially 
if  there  is  the  slightest  swelling  or  redness.  Should  the  peripheral  oedema 
persist  or  reappear  after  the  cauterization,  the  latter^  should  be  repeated 
until  this  tendency  is  overcome.  Hypodermic  injections  of  a  solution  of 
iodine  and  iodide  of  potassium  may  be  made  into  the  entire  swelling. 
After  the  caustic  has  done  its  work  the  eschar  may  be  softened  and  its 
separation  favored  by  a  warm  poultice  containing  a' small  amount  of  car- 
bolic acid  or  iodized  phenol.  This  treatment  is  often  highly  beneficial, 
even  after  constitutional  symptoms  have  set  in,  by  arresting  the  propaga- 


944  ANTHRAX. 

tion  of  the  bacillus  and  checking  its  introduction  and  that  of  its  chem- 
ical products  into  the  circulation. 

Constitutional  treatment  is  not  to  be  forgotten.  Carbolic  acid  may  be 
profitably  given  to  the  extent  of  fifteen  drops  daily,  iodide  of  potassium 
ten  to  twenty  grains  thrice  a  day,  and  sulphate  of  quinia  ten  grains  at  the 
same  intervals.  The  strength  should  be  sustained  by  iron  (tincture  of 
the  chloride)  and  wine  or  other  alcoholic  beverage,  both  being,  like  the 
agents  already  named,  calculated  to  retard  if  not  to  limit  the  propagation 
of  the  bacillus.  The  diet  throughout  should  be  nutritious  and  easily 
digested. 

When  a  person  is  known  to  have  eaten  anthrax  meat  an  emetic  will  be 
indicated,  followed  by  a  smart  oleaginous  purgative  combined  with  five 
drops  of  carbolic  acid,  and  subsequently  by  the  constitutional  treatment 
above  recommended.  In  case  of  extensive  anthrax  oedema,  incisions  may 
be  made  into  the  part  as  far  as  the  yellow  exudate  extends,  and  a  poultice 
containing  carbolic  acid  may  be  applied.  Or,  preferably,  the  swelling 
may  be  freely  injected  with  a  weak  solution  of  iodized  phenol  (1  :  100 
water),  and  then  painted  with  the  same  agent  or  with  tincture  of  iodine. 


BY  B.  A.  WATSON,  M.  D. 


^  HISTORY. — There  is  little  to  be  learned  from  existing  literature  of  the- 
views  which  were  maintained  by  the  ancients,  prior  to  the  birth  of  Christ,. 
in  regard  to  the  morbid  conditions  now  designated  pyaemia  and  septicaemia ; 
although  it  is  certain  they  were  recognized  by  the  "  Father  of  Medicine," 
who  reports  a  well-marked  case  of  puerperal  fever  terminating  fatally  on 
the  twentieth  day  of  the  disease,  and  also  a  case  in  which  death  was 
unquestionably  caused  by  septic  poisoning,  as  is  clearly  shown  in  the  fol- 
lowing :  *  "  Criton,  in  Thasno,  while  still  on  foot  and  going  about,  was 
seized  with  a  violent  pain  in  the  great  toe;  he  took  to  his  bed  the  same 
day,  had  rigors  and  nausea,  recovered  his  heat  slightly;  at  night  was 
delirious.  On  the  second,  swelling  of  the  whole  foot,  and  about  the  ankle,, 
erythema  with  distension  and  small  bullse  (phlyctrense)  ;  acute  fever ; 
he  became  furiously  deranged ;  alvine  discharges,  bilious,  unmixed,  and 
rather  frequent.  He  died  on  the  second  day  from  commencement." 
Additional  confirmation  of  the  fact  that  Hippocrates  was  familiar  with 
the  phenomena  of  these  diseases  may  be  found  in  his  dissertation  on 
empyema  and  fevers.  Prof.  C.  Heuter  says,  under  the  head  of  septic 
fever,2  "  Hippocrates  and  Celsus  observed  the  fever  in  cases  of  injuries 
which  proved  so  dangerous  that  this  danger  could  not  have  originated 
from  the  inflammation  or  from  the  wound  alone."  Jacotius,  a  com- 
mentator of  Hippocrates,  has  even  mentioned  putrid  fevers,  the  same  as 
Adrianus  Spigelius,  who  spoke  of  fevers  which  arise  from  putrefac- 
tion ;  but  both  authors,  as  well  as  their  followers,  did  not  discriminate 
between  septicaemia  arising  from  the  putrescence  of  wounds  and  pyaemia. 
In  the  mean  time  both  varieties  were  regarded  as  intermittent  fever. 

"  Aretseus  lived  during  the  middle  of  the  second  century  of  the  Chris- 
tian era.  In  his  remarks  on  pneumonia  he  observes  that  the  subjects  of 
this  disease  die  mostly  on  the  seventh  day.  '  In  certain  cases/  he  says, 
'  much  pus  is  formed  in  the  lungs,  or  there  is  a  metastasis  from  the  side 
if  a  greater  symptom  of  convalescence  be  at  hand.  But  if,  indeed,  the 
matter  be  translated  from  the  side  to  the  intestine  or  bladder,  the  patients 
immediately  recover  from  the  peripneumony/  He  speaks  of  a  metastasis 
to  the  kidneys  and  bladder  being  peculiarly  favorable  in  empyema.  He 
ascribes  suppuration  of  the  liver  to  intemperance  and  protracted  disease, 

1  Works  of  Hippocrates,  trans,  by  Adams,  vol.  i.  p.  377. 

"Pitha  und  Billroth,  Handbuch  der  Chirurgie,  I  Band,  2  Abth.,  1  Heft,  1  Liefg.,  S.  6. 

VOL.  I.— 60  945 


946  PYJEMIA  AND  SEPHO&MZA. 

especially  dysentery  and  colliquative  wasting.  The  symptoms  described 
by  him  resemble  those  of  chronic  pyaemia."  ] 

Galen  and  some  of  the  other  ancient  physicians  recognized  the  exist- 
ence of  septic  poisoning,  as  is  shown  by  the  opinions  expressed  on  the 
subject  of  putrid  fevers.  According  to  Galen,  putrid  fevers  may  either 
arise  from  the  conversion  of  ephemerals;  or  originally  from  putrefaction 
of  the  fluids  within  the  vessels. 

Aetius  states  that  they  arise  from  constriction  of  the  skin  or  viscidity 
of  the  humors,  whereby  the  perspiration  is  stopped,  and  the  quantity  of 
vital  heat  so  altered  as  to  give  rise  to  putrefaction,  first  of  the  fluids, 
and  afterward  of  the  fat  and  solid  parts.  When  these  corrupted  fluids 
are  contained  within  the  vessels  they  occasion  synochous  fevers,  but  when 
distributed  over  the  body  they  give  rise  to  iutermittents.  Synesius  and 
Oonstantinus  Africanus  give  a  similar  account.  Alexander  gives  an  inter- 
esting and  ingenious  disquisition  on  the  origin  and  nature  of  putrid  fevers, 
one  of  the  most  common  causes  of  which  he  holds  to  be  the  conversion 
of  ephemeral  fevers,  and  the  inseparable  symptoms  being  want  of  concoc- 
tion in  the  urine  and  quickness  of  the  pulse  with  systoles.  This  is  the 
account  of  them  given  by  most  of  the  other  authorities,  both  Greek  and 
Arabian,  so  that  we  need  not  enter  into  any  circumstantial  exposition  of 
their  views.  We  shall  merely  give  the  brief  account  of  those  furnished 
by  Palladius.  There  are,  he  says,  two  kinds  of  synochous  fevers,  the  one 
being  occasioned  by  effervescence,  and  the  other  by  putrefaction  of  the 
blood ;  of  these  the  latter  are  the  more  protracted  and  dangerous.  In 
them  the  pulse  is  contracted,  the  heat  pungent,  and  the  urine  white  and 
putrid.2 

A  new  era  in  the  literature  of  this  subject  dawned  during  the  six- 
teenth century.  Ambrose  Pare  and  Bartholomew  Maggi  each  published 
a  work  in  which  they  pointed  out  the  old  errors  and  announced  new 
truths.  Fare's  Treatise  on  Gunshot  Wounds  was  published  in  Paris  in 
1551,  while  Maggi's  treatise  appeared  a  year  later  at  Bologna.  Pare" 
gained  his  first  experience  in  the  treatment  of  gunshot  wounds  in  1536, 
which  is  described  as  follows:  "The  storming  of  the  small  mountain- 
fortress  Villane,  near  Susa,  probably  gave  him  for  the  first  time  full 
occupation,  and  he  followed  in  all  things  the  example  of  older  col- 
leagues. Like  them,  although  hesitatingly,  he  poured  into  the  gunshot 
wounds  boiling  oil  of  elder  to  destroy  the  poison,  but  the  oil  fell  short, 
and  then  he  was  compelled  to  dress  the  other  wounded  men  with  an  oint- 
ment of  oil  of  roses  and  turpentine.  Fearing  that  the  latter  would  soon 
become  victims  of  the  wound-poison,  he  passed  a  sleepless  night,  got  up 
early  to  see  the  ill  consequences,  but  was  greatly  surprised  to  find  those 
that  he  had  half  given  up  free  from  pain  and  without  inflammation  or 
swelling,  while  those  who  had  been  treated  with  boiling  oil  lay  in  a  state 
of  fever,  with  great  pain  and  much  swelling.  He  therefore  determined, 
as  he  tells  us,  never  again  to  burn  the  poor  subjects  of  gunshot  wounds 
so  cruelly."3  It  will  be  seen  that  Pare's  treatise  on  gunshot  wounds  was 
published  fifteen  years  after  this  impressive  experience  at  the  fortress  of 
Villane.  In  this  work  he  sought  to  correct  the  prevailing  idea  that  gun- 

1  Braidwood  on  Pyaemia,  p.  2. 

2Paulus  J^gineta,  trans,  by  Adams,  vol.  i.  p.  23G  (Sydenham  Soc.,  1844). 

3  German  Clinical  Lecture*,  2d  series  (New  Sydenham  Soc.,  1877),  p.  Go  et  seq. 


HISTORY.  947 

shot  wounds  were  poisonous,  and  was  ably  supported  in  his  effort  by 
Bartholomew  Maggi;  but  it  required  all  the  respect  which  Pare"  enjoyed 
in  riper  years  to  gradually  obtain  consideration  for  the  new  view,  the 
idea  that  gunshot  wounds  were  poisonous  is  supposed  to  have  originated 
in  the- feet  that  in  every  war  there  are  cases  of  acute  sepsis,  developed 
alter  the  infliction  of  these  injuries,  which  agree  in  all  their  essential 
points  with  the  results  of  the  bites  of  poisonous  snakes.  AVe  are  even 
informed  that  during  the  late  Franco-Prussian  AVar  there  were  cases 
which  even  excited  suspicion  among  the  laymen  that  the  enemy  had  used 
poisoned  missiles. 

The  nature  of  the  error  which  Pare"  and  Maggi  endeavored  to  correct 
is  shown  by  the  declaration  made  by  Johannes  de  Vigo  at  the  commence- 
ment of  the  sixteenth  century,  who  expressed  in  dogmatic  form  the  views 
then  firmly  held  by  physicians.  "A  gunshot  wound  is  a  contused  wound, 
he  says,  for  the  bullet  is  round ;  it  is  burnt,  for  the  bullet  is  heated;  it  is 
poisoned,  for  the  powder  is  poisonous.  The  poisoning  is  the  essential 
condition ;  therefore  the  treatment  must  be  directed  above  all  to  counteract 
this." 


^  next  step  was  that  a  poisonous  substance  may  develop  itself  or 
settle  in  the  wound,  and  especially  in  gunshot  wounds — a  substance 
which  has  nothing  to  do  with  powder  or  lead.  Pare  himself  adopted  .this 
view.  AVhen  he  took  part  in  the  siege  of  Rouen  many  wounds  sloughed 
and  had  a  cadaverous  smell,  and  on  opening  the  bodies  of  those  who 
died  numerous  collections  of  pus  were  found  in  different  parts  full  of 
greenish  ill-smelling  ichor.  Besiegers  and  besieged  believed  themselves 
to  be  wounded  with  poisoned  bullets.  Pare  looked  for  the  cause  in  a 
deterioration  of  the  air  by  the  large  quantity  of  decomposing  substances, 
and  he  appears  to  have  assumed,  as  is  done  at  this  day,  a  direct  action 
of  the  so-called  deteriorated  air  upon  the  wound  itself. 

The  evil  influence  of  air  vitiated  by  the  products  of  decomposition,  not 
upon  wounds  only,  but  upon  the  organism  generally,  has  never  been  lost 
sight  of  by  physicians  since  that  time.  That  rotten  straw,  decomposing 
bodies  of  men  and  animals,  surfaces  saturated  with  excrement,  and  over- 
crowding of  badly-ventilated  hospitals  give  rise  to  infectious  fevers  and 
unhealthy  state  of  wounds  is  not  a  result  of  modern  observation  only. 
That  it  was  a  question  of  the  processes  of  fermentation  which  became  com- 
municated to  the  body  by  means  of  the  exciters  of  fermentation  contained 
in  the  air  was  a  view  frequently  adopted.  "  To  quote  one  only  out  of 
many ;  John  Priugle,  in  his  Observations  on  the  Diseases  of  the  Army, 
published  in  1775,  devotes  a  chapter  especially  to  ( Diseases  resulting  from 
Bad  Air/  and  his  forty-eight  experiments  on  septic  and  antiseptic  sub- 
stances contain  numerous  hints  at  attempts  resembling  those  made  at  the 
present  day  to  determine  the  antiseptic  power  of  certain  things.  No 
advance  was  made,  however,  beyond  vague  surmises  concerning  the  nature 
of  the  exciters  of  putrefaction,  and  they  were  for  the  most  part  looked 
for  amongst  the  volatile,  ill-smelling  products  of  decomposition,  and  were 
believed  to  be  extremely  subtle  gaseous  matters." l 

Ambrose  Pare1  (1 582)  first  taught  that  secondary  abscesses  in  surgical 
cases,  "which  he  had  observed  in  the  spleen,  lungs,  liver,  and  other 
viscera,  were  due  to  a  changed  condition  of  the  fluids  produced  by  some 

1  German  Clinical  Lectures,  Second  Series  (New  Sydenham  Soc.,  1877),  p.  67  el  seq. 


948  PYJEMIA  AND  SEPTICAEMIA. 

unknown  alteration  in  the  atmosphere  and  determining  a  purulent  dia- 
thesis." l  The  following  quotations  force  the  conclusion  that  in  the  early 
history  of  medicine  there  was  supposed  to  be  some  important  relation 
between  wounds  of  the  head  and  multiple  abscesses.  "  Nicholas  Massa 
(1553)  mentions  a  case  of  abscess  of  the  left  lung,  following  an  -injury 
of  the  head."2  "  Valsalva  (1707)  was  induced  by  his  own  observation  to 
say  that  the  viscera  of  the  thorax  were  sometimes  affected  in  wounds  of 
the  head."  "Desault  (1794)  considered  abscesses  of  the  liver  to  be  a 
very  frequent  sequence  of  head  injuries."3  The  fact  that  wounds  of  the 
head  were  frequently  followed  by  abscesses  of  the  lungs,  liver,  and  other 
organs  probably  led  to  the  opinion  expressed  by  Desault,  Barthez,  Brodie, 
"W.  Phillips,  Copeland,  and  others,  that  the  disease  had  its  origin  in  a 
nervous  agency.4  "Bertrandi  and  Audouille  (1819)  sought  for  a  me- 
chanical explanation  of  the  occurrence  of  hepatic  abscesses  after  head 
injuries  and  in  cases  of  apoplexy."  Morgagni  (1740)  somewhat  obscurely 
hinted  at  the  doctrine  of  the  reabsorption  of  pus — a  doctrine  which  was 
afterward  elaborated  by  Quesnay  in  1819.  Morgagni,  after  quoting  a 
great  number  of  instances  of  wounds  of  the  head  followed  by  visceral 
abscesses,  opposes  the  idea  of  a  mechanical  transportation  of  pus  thither, 
and  states  that  abscesses  are  not  confined  to  the  liver  and  that  they  may 
follow  wounds  and  ulcers  of  other  parts  besides  the  head.  He  ascribes 
their  formation  to  particles  of  pus  (not  always  deposited  in  the  form  of 
pus)  resulting  from  the  softening  and  suppuration  of  small  tubercles, 
which,  having  been  mixed  with  the  blood  and  disseminated,  are  arrested 
in  some  of  the  narrow  passages,  perhaps  of  the  lymphatic  glands,  and 
by  obstructing  and  irritating  these,  as  happens  in  the  production  of 
venereal  buboes,  and  by  retaining  the  humors  therein,  distend  them  and 
give  origin  to  the  generation  of  a  much  more  copious  pus  than  what  is 
carried  thither ;  and  by  this  means,  he  says,  we  may  also  conceive  how 
it  is  that  much  more  pus  is  frequently  formed  in  the  viscera  and  cavities 
of  the  bodies  than  a  small  wound  could  have  produced.5 

Cheston  (1766)  believed  that  the  translation  of  matter  from  one  point 
to  another  was  a  frequent  occurrence  after  amputations  of  the  larger 
limbs.  John  Hunter  (1793),  and  after  him  Velpeau,  demonstrated  the 
existence  of  pus  in  the  blood.  Hunter  believed  that  the  pus  was  derived 
from  the  interior  of  the  inflamed  veins.  He  described  three  forms  of 
inflammation  of  these  vessels — viz.  adhesive,  suppurative,  and  ulcerative. 
Pyaemia -he  considered  to  be  an  aggravated  form  of  phlebitis.  Arnott 
(1829)  concluded  from  his  observations — 1,  That  death  docs  not  result 
from  the  extension  of  the  inflammation  of  the  veins  to  the  heart;  2, 
that  the  dangerous  consequences  of  phlebitis  have  no  direct  relation  to 
the  extent  of  the  vein  which  is  inflamed ;  and,  3,  that  the  presence  of 
pus  in  the  veins,  though  the  principal,  is  not  the  sole,  cause  of  the  sec- 
ondary affection.  He  accordingly  opposes  the  idea  of  Abernethy,  Car- 
michael,  and  others  that  the  constitutional  affection  is  owing  to  the  exten- 
sion of  the  inflammation  to  the  heart.  The  publication  of  Arnott's  and 
Dance's  treatises  led  to  the  general  opinion  being  held  in  England  and  in 
France  that  phlebitis  and  purulent  infection  were  identical  affections,  or, 
at  least,  that  the  latter  was  invariably  caused  by  the  former.6 

1  Kraidwood  on  Pvcemia,  p.  2  et  seq.  *  Ibid.,  p.  2.  s  Ibid.,  p.  3. 

4  Ibid..,  p.  10.  6  Ibid.,  p.  3  el  seq.  6  Ibid.,  p.  H. 


HISTORY.  949 

Cruveilhier  (1829),  admitting  the  doctrine  of  the  formation  of  second- 
ary abscesses  being  due  to  capillary  phlebitis,  further  laid  down  an  axiom, 
since  proved  untenable,  that  the  foreign  body  introduced  into  the  veins, 
whose  elimination  by  the  eniunctories  is  impossible,  will  produce  visceral 
abscesses  similar  to  those  which  occur  after  wounds  and  operations,  and 
that  these  abscesses  are  the  result  of  capillary  phlebitis  of  those  viscera."  * 

During  the  early  part  of  the  present  century  it  \vas  generally  admitted 
by  the  best  authorities  that  the  symptoms  and  lesions  in  pyaemia  were 
entirely  due  to  the  presence  of  pus  in  the  blood,  but  whether  absorbed 
from  the  wound  or  developed  by  an  inflammation  of  the  veins  was  at 
that  time  a  disputed  question. 

Haller  made  the  first  experiments  on  animals  with  putrefying  sub- 
stances in  the  latter  part  of  the  eighteenth  century,  and  was  convinced 
that  nothing  destroys  the  animal  fluids  more  powerfully  than  putrefac- 
tion. Gaspard  (1822)  published  a  complete  work  based  upon  his  experi- 
mental research  in  regard  to  the  action  of  putrefying  substances  on  living 
organisms.  He,  having  produced  septic  infection  in  animals  by  injecting 
into  their  blood  pus  or  other  putrefying  substances,  thus  prepared  the  way 
for  other  experimenters,  by  whom  he  was  quickly  followed.  Ernst  R. 
Virchow  repeated  the  experiments  of  Gaspard,  and  discriminated  with 
greater  precision  between  the  surgical  diseases — septicaemia  with  its  sharply- 
defined  group  of  symptoms,  the  opposite  of  pyaemia.  Furthermore,  "  he 
showed  that  the  changes  in  the  veins  which  had  been  regarded  as  due  to 
phlebitis  were  caused  by  the  coagulation  of  the  blood  and  by  subsequent 
degenerative  changes  in  the  thrombi  thus  formed  ;  that  the  infarctions  and 
abscesses  seen  in  the  viscera  were  due  to  emboli  which  had  become 
detached  from  softened  thrombi ;  that,  as  the  white  blood-globules  and 
pus-globules  were  identical  in  appearance,  they  could  not  be  distinguished ; 
and  that  it  was  improbable  that  pus-globules  made  their  way  into  the 
blood."2 

Panum  (1855)  conducted  a  series  of  important  experiments,  and 
endeavored  to  separate  the  infectious  substance  and  determine  its  real 
nature.  He  concludes  that  the  real  poison  is  not  identical  with  any  of 
the  chemical  combinations  or  any  of  the  single  substances  which  have  until 
now  been  isolated  by  chemical  analysis  from  the  products  of  nitrogenous 
decomposition,  but  a'dds  that  it  is  probably  a  concealed  ferment  belonging 
to  the  so-called  extractive  matters — carbonate  of  ammonium,  leuciu,  ty  rosin, 
fatty  acids,  acetic  acid,  etc.  Furthermore,  that  the  putrid  poison  is  stable, 
fixed,  and  non-volatile ;  that  it  is  neither  decomposed  by  boiling  nor  by 
evaporation  to  dryuess ;  that  it  is  insoluble  in  absolute  alcohol,  but  soluble 
in  water;  that  the  albuminous  substances  found  in  putrefying  liquids 
become  venomous  only  because  they  are  impregnated  with  the  septic  poi- 
son ;  and  that  washing  these  substances  in  a  large  quantity  of  water  ren- 
ders them  innocuous ;  and  that  the  energy  of  these  putrid  poisons  am  only 
be  compared  to  the  venom  of  serpents,  curare,  and  other  vegetable  alka- 
loids. 

The  prize  offered  by  the  Faculty  of  Medicine  at  Munich  for  the  best 
essay  on  the  action  of  putrefying  substances  in  the  animal  organism  was 
awarded  to  Heinmer  in  1866.  His  essay  was  distinguished  for  its  accu- 

1  Braid  wood  on  Pyaemia,  p.  14  el  seq. 

2  The  International  Encyclopedia  of  Surgery,  ed.  by  Ashhurst,  vol.  i.  p.  204. 


950  PYAEMIA  AND  SEPTICAEMIA. 

rate  delineation  of  the  pertaining  literature  and  for  the  number  of  experi- 
ments reported,  while  his  conclusions  bear  a  striking  resemblance  to  those 
of  Panuni. 

Bergmaun  in  1868  sought  to  determine  the  poisonous  element  contained 
in  decomposing  animal  substances,  and  for  this  purpose  chemically  treated 
putrid  fluids,  hoping  to  find  the  agent  that  would  excite  all  symptoms  of 
septic  poisoning.  He  obtained  a  body  of  this  nature  from  decomposing 
yeast,  which  he  called  sepsin,  although  we  have  no  proof  that  either  he  or 
any  one  else  has  ever  found  the  same  in  pus  or  any  decomposing  animal 
matters ;  and  even  if  it  had  been  found  in  these,  it  would  then  become 
necessary  to  demonstrate  the  fact  that  no  other  substance  contained  in 
the  putrefying  liquids  could  produce  septic  poisoning.  Many  other 
experiments,  similar  to  those  which  have  just  been  mentioned,  were  made 
in  the  mean  while  by  Magendie,  Stich,  Billroth  and  Hufschmidt,  O. 
Weber,  Duprey,  Learet,  Urfrey,  Saltzman,  Fischer,  Frese,  Muller,  and 
others.  Bergmann  had  extracted  the  sepsin  from  yeast,  but  Schmidt  and 
Petersen  (1869)  were  able  to  obtain  it  from  putrefied  blood.  In  1869, 
Zuelzer  and  Sonnenschein  claimed,  on  the  contrary,  to  have  separated  a 
new,  unnamed  septic  alkaloid,  which  was  not  the  sepsin,  and  the  action 
of  which  resembled  that  of  atropine  and  hyoscyamiue.  Nevertheless,  the 
separation  of  the  sepsin  or  of  the  alkaloid  of  Zuelzer  seemed  to  demand  a 
talent  in  the  manipulator  which  is  not  possessed  by  everybody,  and  rare 
are  the  chemists  who  possess  it — so  rare  that  these  substances  are  not  yet 
either  officinally  recognized  or  classified.  The  attention  of  the  medical 
profession  had  now  become  thoroughly  fixed  on  the  chemical  character 
and  the  physiological  action  of  these  newly-discovered  substances.  It  is 
therefore  only  natural  that  we  should  find  during  the  next  few  months 
that  the  medical  societies  were  much  occupied  with  discussions  on  these 
subjects,  although  no  important  progress  seems  to  have  been  made. 

Political  events  now  gave  a  new  direction  to  thought,  and  the  Franco- 
Prussian  War  filled  the  hospitals  of  both  nations  with  wounded  in  which 
there  was  opened  a  grand  field  for  the  practical  study  of  purulent  infection 
in  all  its  various  forms.  Humanity  now  demanded  the  best  efforts  of  the 
medical  profession.  Neither  the  mechanical  nor  chemical  theories  had  ever 
yielded  practically  any  beneficial  results;  consequently,  something  better 
was  demanded  in  this  emergency.  It  was  during  this  important  epoch 
that  the  germ  theory  began  to  assume  form  and  to  attract  some  general 
attention  in  the  medical  profession,  although  Schroeder  and  Du.sch  had 
shown  in  1854  that  the  filtration  of  the  air  through  cotton  was  sufficient 
to  prevent  the  putrefaction  of  albuminous  substances  which  had  been 
previously  boiled.  Pasteur  also  demonstrated  the  existence  of  germs  in 
the  air  in  1863,  and  likewise  showed  their  agency  in  the  process  of  fer- 
mentation. 

Lister  began  the  antiseptic  treatment  of  compound  fractures  in  1865, 
although  he  did  not  publish  his  report  until  1867.  The  cotton-wadding 
treatment  of  wounds,  which  is  based  on  the  fact  that  the  air  passed 
through  cotton  is  freed  by  it  from  all  germs,  was  first  employed  by 
Alphonse  Guerin,  who  refers  to  it  in  the  following  language:  "In  the 
latter  part  of  1870  I  had  the  idea  that  the  cause  of  purulent  infec- 
tion existed  in  the  germs  or  ferments  which  Pasteur  had  discovered 
in  the  air.  It  was  at  the  end  of  the  war;  all  the  cases  of  amputa- 


HISTORY.  951 

tion  had  succumbed  to  the  purulent  infection,  and  not  a  single  large 
wound  escaped  the  scourge.  The  studies  which  I  had  made  from  the 
month  of  September  to  the  end  of  December  in  1870  had  confirmed  me 
in  the  opinion  that  purulent  infection  is  neither  due  to  phlebitis  nor  to 
the  absorption  of  pus.  I  believed  more  firmly  than  ever  that  the 
miasma  emanating  from  the  pus  of  the  wounds  were  the  real  cause 
of  this  frightful  malady  to  which  I  had  been  compelled  to  see  the 
wounded  succumb,  whether  they  were  treated  with  charpie  or  cerate, 
whether  with  the  lotions  of  alcohol  or  of  carbolic  acid  applied  several 
times  a  day,  and  which  was  soaked  up  by  the  linen  which  remained  in 
contact  witli  the  wounds.  But  this  miasmatic  theory  remained,  never- 
theless, useless,  since  from  1847,  when  I  professed  it,  the  cases  of  ampu- 
tation in  my  service  succumbed  to  purulent  infection  in  about  the  same 
proportion  as  those  who  were  cared  for  by  my  partisan  colleagues  did 
from  the  absorption  of  pus  or  the  inflammation  of  the  veins.  In  my 
despair,  seeking  constantly  a  means  to  prevent  this  terrible  complication 
of  wounds,  I  had  thought  of  the  miasm  of  which  I  had  admitted  the 
existence,  because  I  was  not  otherwise  able  to  explain  the  production  of 
the  purulent  infection,  and  which  was  not  only  known  to  me  by  its  dele- 
terious influence,  but  which  appeared  to  consist  of  living  corpuscles  of 
the  nature  of  those  that  Pasteur  had  seen  in  the  air ;  and  then  the  history 
of  the  miasmatic  poison  possessed  for  me  a  new  clearness.  So,  said  I 
then,  the  miasms  are  the  ferments.  I  am  able  to  protect  the  wounded 
against  their  fatal  influence  by  filtering  the  air,  as  Pasteur  had  doae,  while 
maintaining,  in  opposition  to  Pouchet  of  Rouen,  that  there  is  no  sponta- 
neous generation.  I  thought  then  of  the  cotton-wadding  treatment,  and 
had  the  satisfaction  'of  seeing  my  anticipation  realized.  It  was  from  this 
time  that  dates  in  reality  the  theory  of  germs  or  of  ferments  as  a  cause 
of  purulent  infection."1 

A  series  of  important  experiments  were  made  in  1872  by  Coze  and 
Feltz,  which  consisted  in  injecting  into  the  jugular  vein  and  the  subcutane- 
ous cellular  tissue  putrid  liquids ;  and  they  record,  among  other  interesting 
results  observed  by  them,  that  the  blood  of  the  animal  thus  destroyed 
always  contained  infusoria.  These  experiments  have  been  repeated  and 
their  results  confirmed  by  several  observers,  and  in  particular  by  Da  vine 
in  1872. 

Another  series  of  experiments  were  made  by  Behier  and  Lionville, 
which  absolutely  confirmed  those  of  Coze  and  Feltz;  they  likewise 
found  in  the  blood  rounded  and  rod-shaped  corpuscles  possessed  of 
movements  more  or  less  energetic.  Vulpian  also  confirmed  the  results 
obtained  by  Daviue  and  Behier.  He  says  :  "  It  will  not  do  to  deny  to 
the  immovable  or  movable  vibrioues  and  corpuscles  found  by  Coze, 
Behier,  and  Daviue  a  very  important  role,  because  they  are  not  the  essen- 
tial contagion  of  the  poisonous  blood  •  it  is  at  least  necessary  that  they 
should  be  there  in  order  to  produce  the  alterations  which  have  occurred 
in  this  fluid."  Chauveau  has  experimented  extensively,  and  likewise 
admits  the  action  of  the  septic  vibriones  of  Pasteur. 

Pasteur  has  made  known  the  result  of  his  investigation  in  communi- 
cations to  the  Academy  of  Medicine  in  1877,  1878,  and  1879.  There 
exist,  according  to  him,  two  principal  vibriones — the  pyogemc,  or  the 
Dictionnaire  de  Medicine  d  de  Chirurgie  pratiques,  t.  xxx.  p.  265. 


952  PYAEMIA   AXD  SEPTIC&1IIA. 

producer  of  pus,  and  the  septic,  the  producer  of  the  properly  so-called 
septicaemia.  But  the  latter  is  not  a  unique  disease,  and,  as  we  have  seen 
from  the  outset,  there  are  confounded  under  this  name  different  states, 
light  or  grave,  corresponding  with  as  many  forms  of  vibriones. 

The  questions  of  greatest  practical  importance  in  regard  to  this  whole 
group  of  diseases  seem  to  us  to  be,  as  expressed  by  Dr.  Budd,  where  and 
how  the  specific  poisons  which  cause  them  breed  and  multiply ;  and  all 
who  have  closely  followed  the  scientific  investigations  bearing  on  these 
points  which  Prof.  Tyndall  has  conducted  during  the  past  few  years,  and 
who  have  repeated  even  a  portion  of  his  experiments,  cannot  fail  to  be 
powerfully  impressed  with  the  value  of  the  views  wliich  he  embodied  in 
his  work  entitled  Floating  Matter  of  Hie  Air. 

NOMENCLATURE. — The  want  of  a  systematic  classification  of  the 
various  morbid  conditions  arising  from  septic  infection  has  long  embar- 
rassed alike  authors  and  students,  and  even  at  the  present  time  the  vague 
manner  in  which  the  terms  pyaemia  and  septicaemia  are  used  leads  to 
much  confusion.  The  Pathological  Society  of  London  appointed,  in  1869, 
a  committee  to  investigate  the  nature  and  causes  of  those  infectious  dis- 
eases known  as  pyaemia,  septicaemia,  and  purulent  infection.  Tliis  com- 
mittee, having  spent  ten  years  in  the  study  of  these  affections  in  connection 
with  nearly  all  the  large  hospitals  of  London,  report  the  following: 
"Summary. — It  would  seem,  from  a  careful  study  of  all  the  cases 
here  collected,  that  it  is  probable  that  the  diseases  commonly  known 
clinically  as  pyaamia  and  septicaemia  may  be  grouped  as  follo\v> : 
1.  Septic  intoxication. — The  effects  of  poisoning  by  the  chemical  prod- 
ucts of  putrefaction.  A  non-infective  disease.  2.  Septic  infection. — A 
general  infective  process  arising  from  the  introduction  of  some  peculiar 
constituent  of  putrid  matter  into  the  blood-stream.  It  is  supposed  by 
some  to  be  due  to  the  multiplication  of  living  organisms  in  the  blood, 
and  by  others  to  the  effect  of  a  non-organized  ferment.  It  terminates 
fatally  without  secondary  inflammations.  3.  Pyaemia  (for  want  of  a 
better  name). — An  infective  process  probably,  similar  in  nature  to  septic 
infection,  but  differing  from  it  by  giving  rise  to  local  inflammation  and 
suppurations,  often  complicated  by  thrombosis  and  embolism,  probably 
due  to  the  blood  condition.  4.  Thrombosis  with  softening  and  decomposi- 
tion of  the  thrombus  and  embolism,  causing  local  abscesses  in  the  viscera 
wherever  the  septic  emboli  lodge,  but  without  the  development  of  any 
general  infective  process.  5.  Various  combinations  of  one  or  more  of 
the  foregoing  conditions  in  the  same  subject.  6.  Infective  periostitis  or 
acute  necrosis.  7.  InfectiVe  endocarditis  or  uleerative  endocarditis.  8. 
Infective  myositis.  9.  A  group  of  obscure  cases  hi  which  it  is  impo.s-i- 
ble  to  form  any  idea  as  to  the  exact  nature,  often  called  spontaneous 
septicaemia  or  pyaemia."  * 

It  will  be  observed  that  the  earlier  writers  on  medicine,  although  aware 
of  the  existence  of  septic  diseases,  wholly  failed  to  discriminate  between 
pysemia  and  septicaemia  until  1848,  and  even  since  that  date  these  terms 
have  been  only  partially  adopted  by  authors,  by  whom  frequently  the 
meaning  of  the  same  word  has  been  so  modified  as  to  refer  to  essen- 
tially different  conditions.  -  Custom  having  fully  sanctioned  the  use  of 
these  terms,  it  is  now  thought  that  a  separate  consideration  of  their 
1  Trans.  Pathological  Soc.  of  London,  vol.  xxx.  p.  38. 


NOMENCLATURE.  953 

nomenclature  may  be  advantageous,  and  consequently  we  shall  pursue 
this  course. 

NOMENCLATURE  OF  PYJEMIA.— In  Dunglison's  Medical  Dictionary 
the  definition  given  to  pyaemia  is,  "  Pyohcemia,"  and  the  latter  word  is 
defined  as  follows  :  "  Pyohaemia,  Pyaemia,  Pyoh&nie  (F.),  from  pyo,  and 
d:[*a,  ' blood;'  alteration  of  the  blood  by  pus,  giving  occasion  to  the 
diathesis  scu  infectio  purulentia." 

The  committee  appointed  by  the  Pathological  Society  of  London  in 
1869  report  on  this  subject  as  follows:  "The  most  common  definition 
of  pyaemia  is,  no  doubt,  that  adopted  by  the  College  of  Physicians  in  the 
nomenclature^ of  diseases.  It  is  as  follows :  'A  febrile  affection  resulting 
in  the  formation  of  abscesses  in  the  viscera  and  other  parts.5  " 

Birch-Hirschfeld  includes  under  the  name  pyaemia  "  all  cases  in  which 
any  general  infective  process  is  set  up  as  a  secondary  consequence  of  a 
wound." ]  Yirchow  has  proposed  the  name  ichorrluernia.  O.  Weber 
uses  the  name  embolhaernia  for  the  condition  in  which  ernboli  are  found 
in  the  blood.  Hueter  in  pure  cases  of  purulent  infection  without 
metastasis  calls  the  disease  pyohaemia  simplex ;  in  cases  with  metastasis, 
pyohsemia  multiplex ;  and  when  complicated  with  septicaemia  he  desig- 
nates it  as  septo-pyohaemia.  The  term  hospitalism  has  been  applied  to 
this  disease  by  Erichsen  and  Sir  James  Y.  Simpson,  and  the  former 
remarks  that  "the  term  pyaemia  is  used  in  a  very  wide  and  elastic 
manner,  and  by  many  is  made  to  include  various  forms  of  blood-poison- 
ing." :  Billroth  says  :  "  Pyaemia  is  a  disease  which  we  believe  to  arise 
from  the  taking  up  of  pus,  or  of  the  constituent  parts  of  pus,  into  the 
the  blood."  Koch  employs  the  term  pyaemia  merely  to  denote  a  general 
affection  accompanied  by  metastatic  inflammation  and  suppuration. 

The  French  definition  and  nomenclature  of  pyaemia,  according  to 
Gu£riu,  is  as  follows :  "  Purulent  infection,  or  pyohaemia,  purulent 
fever,  surgical  typhus."  The  purulent  infection  is  a  poisoning  of  the 
blood,  which  terminates  by  the  formation  of  multiple  abscesses,  which 
have  been  improperly  known  under  the  name  of  metastatic  abscesses. 

From  1820  to  1870  surgeons  admitted  that  these  abscesses  were  the 
result  of  a  phlebitis  having  its  origin  in  a  wound  exposed  to  the  air. 
Therefore,  this  disease  was  variously  designated  under  the  name  of  phlebitis, 
pyohaemia,  or  purulent  infection.  Tessier  called  it  purulent  diathesis;  "in 
1847,  I  compared  it  to  the  typhus,  and,  as  the  poison  is  absorbed  from 
the  surface  of  the  wound  in  the  purulent  infection,  I  gave  it  the  name 
of  surgical  typhus  or  purulent  fever." 3 

Having  given  enough  on  this  subject  to  answer  our  purpose,  we  will 
consider  the  nomenclature  of  another  septic  complication. 

NOMENCLATURE  OF  SEPTICAEMIA. — The  term  septicaemia  was  first 
employed  by  Piorry,  and  was  applied  for  a  considerable  time  to  all  those 
diseases  in  which  the  blood  was  submitted  to  a  septic  influence.  There- 
fore, the  term  was  made  applicable  to  the  morbid  conditions  existing  in 
anthrax,  glanders,  typhus  and  typhoid  fevers,  variola,  and  also  all  forms 
of  purulent  and  putrid  infectious.  Gu6riu  now  adds :  "  Fortunately, 
for  several  years  the  most  competent  authors  seem  to  have  wished  to 

1  Trans.  Pathological  Soc.  of  London,  vol.  xxx.  p.  22. 

8  On  Hospitalism,  p.  73. 

1  Nouveau  Diet,  de  Med.  el  de  Chir.  pratiques,  t.  xxx.  p.  222. 


954  PTJEM1A  ASD  SEPTICAEMIA. 

reserve  the  name  of  septicaemia  for  what  surgeons  call  putrid  infection, 
and  for  the  morbid  state  that  the  experimenters  produce  by  the  injection 
of  putrid  material  into  healthy  animal  tissues ;  it  is  consequently  the 
experimental  septicaemia  which  we  aim  at  first  and  foremost."  l 

Dunglisou  defines  septicaemia  with  a  single  word,  septaemia.  The  same 
authority  gives  the  following  derivation  and  definition  to  septaemia: 
"From  (T^/Troc,  'rotten/  and  alua,  'blood.'  A  morbid  condition  of  the 
blood  produced  by  septic  or  putrid  matters." 

Sanderson  says :  "  What  I  mean  by  septicaemia  is  a  constitutional 
disorder  of  limited  duration,  produced  by  the  entrance  into  the  blood- 
stream of  a  certain  quantity  of  septic  material.  It  must,  therefore, 
be  regarded  less  as  a  disease  than  as  a  complication,  differing  from 
pyaemia  not  only  in  the  fact  that  it  has  no  necessary  connection  with  any 
local  process,  either  primary  or  secondary,  but  also  in  the  important  par- 
ticular that  it  has  no  development.2 

Both  Daviue  and  Koch  designate  as  septicsemic  all  cases  of  general 
infection  from  wounds  in  which  no  metastatic  changes  occur.  "  Birch- 
Hirschfeld  limits  the  term  septicaemia  much  in  the  same  way  as  San- 
derson. He  describes  as  septicaemia  those  cases  in  which  the  disease 
results  merely  from  the  absorption  of  the  products  of  putrefaction,  and 
regards  it  merely  as  a  process  of  poisoning,  such  as  might  arise  from  the 
injection  of  any  other  noxious  chemical  substance  into  the  blood.  Pyae- 
mia, on  the  other  hand,  he  considers  a  truly  infective  process,  probably 
due  to  the  entrance  of  specific  organisms  into  the  body.  He  would 
therefore  include  many  of  the  cases  described  by  Koch  as  septicaemia 
under  pyaemia."  3 

Billroth  defines  septicaemia  as  an  "  acute  general  affection  which  arises 
from  the  taking  up  of  various  kinds  of  putrid  substances  into  the  blood, 
and  it  is  believed  that  these  putrid  substances  so  change  the  quality  of 
the  blood  that  it  can  no  longer  fulfil  its  physiological  functions."  * 

Heuter  defines  septicaemia  as  a  fever  caused  by  the  entrance  into  the 
circulation  of  the  products  of  putrefaction  from  local  centres  of  decom- 
position. He  draws  no  clear  distinction  between  an  infective  and  a  non- 
infective  form,  but  the  aifection  he  describes  as  pyaemia  simplex  or  pyaemia 
without  metastasis  seems  to  include  many  cases  which  Davine,  Koch, 
and  others  would  include  under  septicaemia.5 

Having  before  us  the  views  of  some  of  the  prominent  authors  who 
have  written  upon  the  nomenclature  of  pyaemia  and  septicaemia,  we 
observe  that  the  use  of  these  terms  is  based  either  on  known  or  imaginary 
morbid  conditions  of  the  body,  more  especially  of  the  blood.  It  there- 
fore seems  that  the  first  step  toward  determining  the  proper  limit  within 
which  these  terms  can  be  employed  consists  in  learning  their  accurate 
meaning,  which  is  fortunately  clearly  shown  by  their  derivation.  The 
next  step  consists  in  the  application  of  these  terms  to  the  morbid  condi- 
tions which  are  described  more  or  less  completely  by  these  words.  It 
may  be  here  added  that  there  will  be  frequently  required  for  a  full  and 
definite  expression  certain  modifying  words,  and  consequently  we  may 

1  Ab»miu  Diet,  de  Mcd.  et  de  Chir.  pratiques,  t.  xxx. 

*  British  Medical  Journal,  Dec.  2'2,  1877. 

s  Trans.  Pathological  Snc.  of  London,  vol.  xxx.  p.  9. 

4  Lectures  on  Surgical  Pathology  and  Therapeutics  ( trans,  from  8th  ed.),  vol.  ii.  p.  41. 

5  Trans.  Path.  Soc.  of  London,  vol.  xxx.  p.  9,  1879. 


ETIOLOGY  OF  PYAEMIA.  955 

properly  employ  such  phrases  as  puerperal  septicaemia,  spontaneous 
pyaemia,  etc. 

Having  carefully  examined  the  terms  employed  by  various  authors  in 
connection  with  the  morbid  changes  which  are  known  to  occur  in  certain 
cases  of  septic  contamination,  we  give  our  preference  to  the  following 
nomenclature :  Septicaemia,  septo-pysemia,  pyaemia  simplex,  and  pyaamia 
multiplex. 

The  term  septo-pyaemia  is  applied  to  a  morbid  condition  possessing 
certain  peculiarities  of  both  septicaemia  and  pyaemia,  and  it  is  supposed 


characterized  by  the  existence  of  metastatic  abscesses.  It  may  be  well  to 
add  here  that  this  nomenclature  is  not  intended  to  cover  all  cases  of  septic 
poisoning,  but  to  be  applied  to  those  cases  only  in  which  the  morbid 
changes  give  to  the  terms  a  certain  degree  of  appropriateness. 

Septic  poisoning  may  be  justly  regarded  as  a  single  chain  composed  of 
many  links.  Take,  for  example,  a  case  of  amputation  of  the  thigh, 
followed  within  a  few  hours  by  traumatic  fever,  later  by  septicaemia ; 
afterward  there  may  be  developed  secondary  fever;  formation  of  ichor- 
ous  pus,  with  absorption  and  its  concomitants ;  pyaemia,  accompanied  by 
embolism,  thrombosis,  abscess  in  the  lungs,  liver,  etc.  To  these  may  also 
occasionally  be  added  phlebitis  and  inflammation  of  the  joints,  terminating 
speedily  in  suppuration.  This  chain  may  in  this  case  be  further  length- 
ened or  varied  with  traumatic  erysipelas  or  with  hospital  gangrene.  In 
fact,  the  variations  in  these  cases  are  very  numerous,  and  all  these  condi- 
tions, together  with  many  others,  are  due  to  septic  blood-poisoning. 

ETIOLOGY  OF  PYAEMIA. — Four  theories  have  been  advanced  at  different 
times  to  explain  the  etiology  of  pyaemia,  and  they  have  been  designated  as 
follows :  the  mechanfcal,  the  nervous,  the  chemical,  and  the  germ  theories 
respectively;  and  their  action  is  based  on  the  following  hypotheses:  1,  that 
pus  enters  the  blood,  circulates  in  it,  and  acts  as  a  poison ;  2,  that  an  irrita- 
tion is  excited  in  certain  visceral  organs  in  sympathy  with  inflammation  of 
the  fibrous  membranes  of  the  cranium  or  the  bones  of  the  upper  or  lower 
extremity,  and  there  is  thus  produced  a  metastasis  to  these  organs  of  an 
ichorous  miasm  or  of  a  fluid  which  is  more  or  less  acrid ;  3,  that  a  chem- 
ical poison  is  generated  from  the  pus  in  the  wound,  and  when  it  is 
absorbed  produces  pyaemic  manifestations;  4,  that  the  putrefaction  of 
pus  in  wounds  is  caused  by  a  microscopic  organism  which  enters  the  cir- 
culation and  produces  pyaemia. 

The  first  hypothesis  was  somewhat  modified,  as  we  have  already  men- 
tioned, by  John  Hunter  and  others,  who  advanced  the  idea  that  pyaemia 
consisted  essentially  of  a  phlebitis,  and  that  the  pus  found  in  the  circula- 
tion had  its  origin  within  the  veins.  However,  it  has  since  been  shown 
conclusively  that  pyaemia  cannot  be  produced  by  the  injection  of  healthy  pus 
into  the  cellular  tissue  or  veins.  This  fact  having  been  generally  admitted 
by  the  profession,  it  is  thought  unnecessary  to  adduce  here  either  the  experi- 
ments or  the  arguments  which  have  been  accepted  as  conclusive  on  this  im- 
portant point.  It  is  not  even  necessary  to  bring  forward  the  disputed  ques- 
tion  of  the  possibility  of  the  entrance  of  pus  into  the  blood,  since  laudable 
pus  does  not  produce  pyaemia.  In  fact,  we  have  reached  a  point  in  the  prog- 


956  PY2EMIA  AND  SEPTICAEMIA. 

ress  of  medicine  when  the  discussion  of  either  the  first  or  second  hypothesis 
ceases  to  be  interesting  to  medical  men.  Consequently,  our  chief  interest 
in  the  study  of  the  etiology  of  pyaemia  centres  in  the  third  and  fourth 
hypotheses ;  and  we  believe  that  it  may  be  safely  asserted  that  the  origin 
of  this  disease  has  been  fully  demonstrated  by  an  almost  unlimited  num- 
ber of  experiments. 

The  injection  of  pus  into  living  animals  produces  local,  remote,  and 
constitutional  symptoms.  The  character  of  these  symptoms  depends 
principally  on  the  kind  of  pus,  laudable  or  ichorous,  the  quantity 
injected,  and  the  site  of  the  injection.  It  will  be  readily  perceived  that 
in  cases  where  the  pus  is  thrown  directly  into  a  vein  the  local  symptoms 
would  be  unimportant,  while  the  danger  of  remote  trouble — metastatic 
abscesses  in  the  lungs,  liver,  etc. — would  be  very  great ;  but  should  the 
injection  be  made  into  the  connective  tissue,  then  the  relations  would  be 
reversed.  Constitutional  symptoms  may  exist  in  both  cases,  but  will 
differ  in  character  and  degree. 

In  regard  to  the  character  of  the  pus,  and  its  agency  in  the  production 
of  this  disease,  Billroth  says :  "  The  old  view,  that  pyaemia  is  only 
induced  when  decomposed  pus  (ichor)  is  reabsorbed,  is  entirely  erroneous. 
There  are  cases  where  decomposed,  putrid  pus  enters  the  blood,  and  which 
present  a  combination  of  the  symptoms  of  septicaemia  and  pyaemia  (septo- 
pyaemia  of  Hueter)."  1  Dupuytren  failed  to  produce  metastasis  by  injec- 
tions of  pus  into  the  veins  of  dogs ;  these  results  were  confirmed  by 
Boyer,  who  only  obtained  metastasis  when  he  used  ichorous  pus  in  his 
experiments.  The  same  results  are  recorded  in  the  works  of  Giiuther  and 
Sedillot,  based  on  numerous  experiments.  Beck  made  fourteen  experi- 
ments very  carefully,  but  did  not  succeed  in  producing  metastasis  in  a 
single  case.  The  same  results  are  recorded  by  a  commission  of  the 
Physiological  Society  of  Edinburgh.  O.  Weber  has  recently  shown  by 
extended  experiments  that  carefully  filtered  pus  will  not  produce  meta- 
static abscesses  in  the  lungs.  Therefore,  it  may  be  considered  as  proved 
that  fluid  pus  injected  into  the  veins  of  an  animal  produces  no  metastatic 
points  of  inflammation. 

It  should  not  be  supposed,  however,  that  because  injection  of  fresh 
(non-ichorous)  pus  failed  to  produce  metastatic  abscesses,  it  was  therefore 
without  results,  as  the  earlier  experimenters  thought.  Billroth  and 
O.  Weber  have  shown  by  their  recent  experiments  that  these  injections 
are  uniformly  followed  by  fever,  and,  if  subcutaneous,  by  abscess ;  and  fur- 
ther, that  injections  of  fresh  pus  produce  even  a  higher  temperature  than  do 
those  of  ichorous  pus ;  but  the  pus  taken  from  cold  abscesses  has  apparently 
very  slight  effect.  The  fresh  nou-ichorous  dried  pus' was  found  to  possess 
in  a  similar  degree  the  power  to  excite  inflammation  and  suppuration ; 
even  the  removal  of  the  albumen  did  not  change  its  character  or  power. 
It  will  be  observed  that  these  injections  caused  not  only  local  inflamma- 
tions, but  severe  constitutional  symptoms,  as  high  temperature,  etc. 
Experiments  have  thus  far  completely  failed  to  show  the  agent  that 
excites  the  inflammation,  although  it  is  generally  admitted  that  it  at  least 
exists  in  the  molecular  bodies. 

Virchow  and  Panum  have  shown  conclusively  by  their  experiments 
on  living  animals  that  the  introduction  of  foreign  bodies  into  the  veins 

1  Surgical  Pathology,  p.  344. 


ETIOLOGY  OF  PYJEMIA.  957 

— as  powdered  coal,  wax  balls,  and  quicksilver — fail  in  all  cases  to  pro- 
duce metastatic  abscesses  in  the  visceral  organs  or  symptoms  of  pyaemia. 
These  foreign  bodies  were  frequently  found  blocking  up  the  terminal 
branches  of  the  pulmonary  artery,  in  some  cases  encapsulated,  frequently 
resembling  miliary  tubercles,  and  occasionally  surrounded  by  evidences 
of  slight  local  inflammation,  but  in  every  instance  without  suppuration. 
The  same  experimenters,  however,  observed  that  the  introduction  of 
ichorous  pus  and  decomposing  animal  tissue  into  the  veins  was  attended 
with  the  formation  of  metastatic  abscesses  and  other  symptoms  of  pyse- 
mia.  They  therefore  conclude  that  the  introduction  of  putrid  animal 
substances  into  the  veins,  and  the  further  transport  of  the  same  to  the 
branches  of  the  pulmonary  artery,  produce  metastatic  abscesses,  and  that 
the  origin  of  these  deposits  is  independent  of  the  mere  stopping  up  of 
the  branches  of  this  artery. 

The  occlusion  of  the  blood-vessels  in  this  diseased  condition  is  a  sub- 
ject which  has  given  rise  to  much  discussion.  Some  of  the  earlier 
writers  supposed  this  phenomenon  constituted  the  disease  pyaemia,  while 
others  believed  it  to  be  the  essential  cause.  Roser  says :  "  But  the 
thrombus  is,  as  can  be  easily  proved,  not  the  cause,  but  only  a 
symptom,  of  pyamia.  If  a  surgical  patient — e.  g.  one  suffering 
with  an  injury  of  the  head — is  attacked  by  inflammation,  and  occlu- 
sion of  a  large  vein,  as  of  the  common  iliac  vein,  for  instance, 
then  there  are  three  different  theories  for  the  inflammation  of  the 
occluded  vessel — viz.  Hunter's,  Rokitansky's,  and  Virchow's.  Ac- 
cording to  the  old  Hunterian  phlebitic  theory,  the  coagulation  of 
the  blood  should  be  the  result  of  the  inflammation  of  the  vein.  On 
account  of  the  circumstances  under  which  the  coagulation  of  the  blood 
in  the  vein  has  occurred,  one  might  suppose  that  the  cause  must  be 
the  oozing  of  coagulable  exudation  from  the  inflamed  wall  of  the  vein, 
but  pathological  dissections,  especially  Rokitansky's,  would  not  accord 
with  it.  Large  veins  were  found  plugged  up  without  the  existence 
of  corresponding  indications  of  inflammation,  and  perfectly  clear  in- 
dications were  often  present  that  occlusion  had  preceded  the  inflam- 
mation. Consequently,  the  occlusion  of  the  vein  was  the  primary 
condition,  and  this  must  be  explained  in  some  other  way  than  by  its 
inflammation.  Rokitansky  in  his  theory  recognized  an  independent 
disease  of  the  blood.  Yet  it  does  not  appear,  on  examination  of  the 
morbid  conditions,  that  this  theory  can  account  for  them.  If  it 
is  recognized  as  correct  that  a  primary  disease  of  the  blood  is  to  be 
admitted,  yet  the  coagulation  of  the  blood  in  a  large  vein  has^  not 
been  traced  back  to  it.  It  remained  wholly  unexplained  why  a  single 
vein,  especially  one  so  large  and  strong  as  the  common  iliac,  should 
become  the  seat  of  the  local  coagulation.  The  necessity  of  finding  a 
local  basis  for  the  local  coagulation  could  not  be  denied.  For  that  reason 
it  was  greeted  as  a  highly  desirable  advance  when  Yirchow  pointed  out 
that  the  occlusion  of  such  large  veins  could  be  dependent  on  the  coagula- 
tion of  the  blood  in  the  concave  spaces  behind  the  valves  of  the  veins, 
or  through  the  coagulation  in  the  small  branches — e.  g.  the  hypogastrio 
veins,. which  is  gradually  carried  fonvard  until  it  reaches  the  common 
iliac,  and  by  continual  increase  this  vein  may  also  be  filled  up.  At  the 
•^arne  time,  it  was  demonstrated  that  not  infrequently,  much  oftener  than 


958  PY^HIA   ASD  SEPTICAEMIA. 

was  formerly  supposed,  the  coagulated  masses  of  blood  are  broken  up  and 
carried  further  on  in  the  circulation,  in  this  manner  producing  occlusion 
of  the  pulmonary  artery  or  its  branches."  * 

The  examination  of  this  subject  finally  brings  Roser  to  this  con- 
clusion :  "  Contamination  of  the  blood  is  essentially  the  primary  cause 
of  pyaemia ;  thrombosis  is  only  a  result  of  this  morbid  contamination, 
and  cannot,  therefore,  be  regarded  as  the  cause  of  pyaemia,  but  only  as 
an  apparent  part,  as  one  of  the  symptoms  of  the  same." 2  The  opinion 
here  expressed  by  Roser  I  believe  to  be  the  one  generally  entertained 
by  the  profession  at  this  time. 

In  cases  of  pyaemia  there  are  recognized  two  principal  sources  of  con- 
tamination of  the  blood — viz.  the  wound  itself,  and  the  vitiated  condition 
of  the  atmosphere  surrounding  the  patient — contamination,  in  the  first 
place,  directly  from  the  wound  through  the  blood-vessels ;  and  in  the 
second,  by  the  passage  of  disease-germs  or  of  the  poisonous  elements  into 
the  blood  along  the  respiratory  tract.  E.  Wagner  says :  "  The  latest 
examinations  in  regard  to  the  vegetable  parasites  have  made  it  very 
probable  not  only  that  these  are  the  active  agents,  but  also — what  has 
been  clinically  quite  generally  accepted — that  septicaemia  and  pyaemia 
owe  their  origin  to  different  plants  (the  first  to  rod  bacteria,  the  latter  to 
globular  bacteria);  and,  finally,  that  both  may  combine."3  These  germs 
may  be  generated  in  the  wound  or  be  received  into  it  from  the  surround- 
ing atmosphere.  The  character  of  the  wound  and  the  conditions  sur- 
rounding the  patient  thus  become  important  subjects  for  the  consideration 
of  the  surgeon. 

It  has  been  observed,  and  is  now  generally  admitted,  that  wounds  compli- 
cated with  a  fracture  of  the  long  bones  of  the  extremities,  opening  large 
medullary  cavities  and  accompanied  by  extensive  laceration  of  the  soft  parts, 
always  increase  the  danger  of  blood-poisoning.  This  fact  may  be  more  thor- 
oughly understood  by  a  brief  consideration  of  the  condition  of  the  parts. 
Frequently  in  open  fractures  large  quantities  of  pus  constantly  remain  in 
contact  with  the  surface  of  the  wound,  while  detached  fragments  of  bone, 
which  become  speedily  necrosed,  move  about  with  every  motion  of  the  in- 
jured limb,  lacerating  more  or  less  the  surrounding  tissues,  and  thus  excit- 
ing inflammation  and  suppuration.  The  periosteum  becomes  inflamed;  a 
widespread  suppurative  periostitis  is  the  result;  necrosis  of  the  bone  from 
insufficient  nutrition  follows,  while  mechanical  pressure  on  the  pus  aids  in 
its  absorption.  The  medulla  frequently  takes  on  suppurative  inflamma- 
tion, and  here  the  surgeon  fails  to  receive  prompt  warning  of  danger ; 
slowly  the  suppuration  progresses,  without  pain  or  other  symptoms  unless 
the  disease  has  extended  to  the  other  tissues ;  the  medullary  cavity  at  the 
fractured  end  of  the  bone  may  be  completely  or  partially  occluded  by  a 
new  osseous  formation ;  and  in  such  cases  the  absorption  of  pus  by  the 
comparatively  large  venous  vessels  of  this  cavity  is  greatly  facilitated. 

The  soft  parts  may  also  be  the  seat  of  dangerous  trouble.  The  same 
force  that  produced  the  wound  and  fracture  may  have  also  contused  the 
soft  parts,  destroying  in  a  greater  or  less  degree  their  nutrition,  thus 
giving  rise  to  gangrenous  sloughs,  or  in  other  cases  to  the  formation  of 
abscesses,  etc.  I  will  also  call  attention  to  the  fact  that  the  laudable  pus 

1  Archiv  der  Heilkimde,  Erst.  Jahrg.,  Erst.  Heft,  S.  4.  'Ibid.,  S.  43. 

8  Manual  of  General  Pathology,  p.  593. 


ETIOLOGY  OF  SPONTANEOUS  PYAEMIA.  95<J 

in  these  cases  is  most  favorably  situated  for  a  rapid  change  into  that 
commonly  called  ichorous.  The  heat  of  the  parts  and  the  contact  of  the 
pus  with  the  atmosphere  will  not  fail  to  effect  its  rapid  decomposition. 

ETIOLOGY  OF  SPONTANEOUS  PYAEMIA. — It  is  unquestionable  that 
cases  of  true  pyaemia  have  been  observed  in  which  the  etiology  was  not 
traceable  to  a  wound ;  and  it  is  equally  certain  that  this  failure  to  dis- 
cover such  a  source  of  contamination  in  the  majority  of  cases  is  no  proof 
that  it  did  not  exist.  When  it  is  remembered  that  a  large  portion  of  the 
alimentary  canal,  the  respiratory  and  the  genito-urinary  tracts,  are  so 
situated  that  the  existence  of  a  contaminating  wound  might  be  absolutely 
tmdiscoverable,  we  are  compelled  to  admit  the  possibility  of  a  local  centre 
of  contamination  in  all  these  cases.  But  the  question  may  be  asked  here 
with  propriety,  "  Is  fatal  pyaemia,  independent  of  a  wound,  ever  pro- 
duced by  breathing  vitiated  air?"  The  answers  to  this  question  must 
generally  be  a  negative,  although  it  is  certainly  true  that  poisoning  of 
the  blood  does  take  place  to  a  certain  degree,  as  is  abundantly  shown  by 
the  different  symptoms  arising  in  patients  thus  exposed  who  are  not 
suffering  with  wounds.  It  is  said  that  dogs  exposed  in  this  way  are 
found  to  rapidly  emaciate  and  suffer  from  severe  and  constant  diarrhoea. 
The  various  symptoms  arising  in  patients  confined  in  overcrowded  and 
pus-infected  Avards,  among  which  may  be  mentioned  loss  of  appetite, 
with  diarrhoea  and  emaciation,  are  too  well  known  to  require  an  enume- 
ration here.  Therefore  it  appears  highly  probable  that  living  in  and 
breathing  a  vitiated  atmosphere  may  act  as  a  strongly  predisposing  cause, 
only  requiring  a  slight  scratch  or  abrasion  of  the  skin,  in  which  the 
infection  may  be  said  to  act  as  an  exciting  cause  of  pyaemia. 

In  reference  to  such  complications  the  following  questions  are  asked 
by  Roser :  "  Is  it  a  specific  deleterious  material,  a  miasmatic  or 
contagious  disease-poison,  or,  as  it  is  generally  expressed,  a  zymotic 
agent  ?  Must  we  regard  each  particular  typhus-like  fever,  with  its 
remarkable  changes  of  blood,  with  its  various  localizations  in  all  the 
organs  and  membranes,  with  its  chills,  furred  tongue,  petechiae,  delirium, 
etc.,  as  we  regard  typhus,  scarlatina,  variola,  etc.?  or,  as  Virchow  teaches 
us,  is  this  pyrcmia,  so  greatly  feared  by  all  surgeons,  only  an  ontological 
idea  ?  Is  the  word  pyaemia  only  a  general  name  for  three  different  condi- 
tions— viz.  leticocythaemia,  thrombosis,  and  embolism,  or  ichorrhamiia  and 
septicffimia?  or  are  there,  as  many  have  supposed,  two  ways  in  which 
pyaemia  may  originate  ?  Is  there  one  primary  miasmatic  pyaemia  analo- 
gous to  the  other  epidemic,  so-called  zymotic  diseases  ?^  and  again,  a  sec- 
ondary pyaemia  arising  from  suppurative  inflammation,  wherein^  the 
poison  is  formed  in  the  patient's  own  body,  which  is  infected  by  a  single 
organ  ?"  : 

That  this  disease  is  caused  by  a  specific  deleterious  material  in  the 

•'  "  n>  The 


same 

possible  for  pyaemia  to  originate  spontaneously?  Are 
there  any  cases  of  sporadic  origin,  or  are  they  always  duetto  en- 
demic or  contagious  influences?  No  definite  answer  can  be  given  to 
these  questions,  although,  undeniably,  the  weight  of  the  argument 
is  strongly  opposed  to  a  sporadic  origin.  The  term  miasmatic,  aa 

1  Loc.  cit.,  S.  39. 


960  PYAEMIA  AND  SEPTICAEMIA. 

used  by  Roser,  probably  refers  to  the  vitiated  condition  of  the  atmo- 
sphere, as  seen  in  the  overcrowded  surgical  and  obstetrical  wards  of 
hospitals.  In  no  other  sense  can  the  word  be  appropriately  used  in  con- 
nection with  the  subject  of  pyaemia.  It  is  true,  pysemic  diseases  are  found 
to  prevail  at  certain  seasons  and  in  certain  localities  much  more  exten- 
sively than  under  other  circumstances.  The  same,  however,  is  true  of 
cholera,  typhus  fever,  scarlatina,  variola,  and  other  contagious  diseases. 
That  pyaemia  is  contagious  has  been  frequently  demonstrated.  I  there- 
fore conclude  that  the  prevalence  and  spread  of  this  disease  must  be 
explained  by  the  same  rules  as  are  applied  to  the  existence  and  propaga- 
tion of  these  allied  affections. 

This  inquiry  into  the  etiology  of  pyaemia  brings  before  us  again  the 
four  hypotheses  which  have  been  given  in  explanation  of  the  same 
number  of  theories.  The  first  and  second  have  been  already  aban- 
doned by  the  medical  profession,  after  it  was*  satisfactorily  demonstrated 
that  they  were  based  on  false  theories,  and  consequently  there  remain 
for  our  consideration  only  the  third  and  fourth. 

The  third  hypothesis  assumes  that  a  chemical  poison  is  developed  in 
the  wound-secretions,  which  when  absorbed  produces  pyaemia.  An 
examination  of  the  subject  does  not  justify  us  in  asserting  that  this 
proposition  has  been  proved,  although  it  is  certain  that  the  results 
of  experimental  inquiry  demand  for  it  a  more  extended  investigation. 
In  all  the  analyses  which  have  thus  far  been  made  the  investi- 
gators have  entirely  failed  to  give  us  an  adequate  knowledge  of  this 
poison,  and  not  a  word  has  ever  been  said  in  regard  to  the  agency  by 
which  it  is  produced,  although  it  is  universally  admitted  to  have 
been  only  obtained  from  decomposing  animal  substances.  It  is  there- 
fore pertinent  to  the  continuation  of  this  inquiry  to  ask,  By  what 
agency  is  the  putrefaction  of  animal  substances  produced  ?  It  has  now 
been  fully  shown  that  there  can  be  but  one  answer  given  to  this  question 
— viz.  the  putrefaction  of  albuminoid  substances  can  only  be  effected  by 
living  organisms.  We  therefore  conclude  that  the  fourth  hypothesis 
brings  us  at  least  one  step  nearer  the  correct  explanation  of  the  etiology 
of  pyaemia  than  the  third,  since  we  justly  assume  that  if  there  is  a 
chemical  poison  in  decomposing  albuminoid  substances,  it  is  produced 
through  the  agency  of  living  organisms. 

ETIOLOGY  OF  SEPTKLEMIA. — The  first  question  which  arises  in  the 
discussion  of  the  etiology  of  this  morbid  condition  is  entirely  dependent 
on  the  scope  which  we  give  to  the  word  septicaemia.  Sternberg  says : 
"  The  view  which  is  entertained  by  high  authorities,  upon  clinical  and 
experimental  evidence,  is  that  there  are  two  forms  of  septicaemia — the 
one  a  septic  toxaemia  due  to  the  effects  of  a  chemical  poison  or  poisons 
evolved  during  the  putrefactive  decomposition  of  certain  organic  sub- 
stances, especially  of  nitrogenous  animal  products ;  the  other  an  infective 
disease  produced  by  the  rapid  multiplication  in  the  body  of  the  infected 
animal  of  a  parasitic  organism.  The  best-studied  and  most  widely 
known  form  of  septicaemia,  due  to  the  presence  of  a  parasitic  organism,  is 
the  disease  known  as  anthrax — charbon  of  the  French,  milzbrand  of  the 
Germans — but  several  other  varieties  are  now  well  established,  in  which 
similar  symptoms  and  pathological  results  are  produced  by  organisms 
morphologically  different  from  the  bacillus  anthracis.  Among  these  may 


ETIOLOGY  OF  SEPTICAEMIA.  9G1 

be  mentioned  the  form  of  septicaemia  in  the  mouse,  so  well  studied  by 
Koch,  which  is  due  to  a  minute  bacillus,  and  the  form  of  septicaemia  in 
the  rabbit,  produced  by  the  subcutaneous  injections  of  human  saliva,  due 
to  micrococci,  which  has  been  studied  by  Pasteur,  Vulpiau,  and  myself 
independently." l 

The  terms  septic  toxaemia  and  septic  intoxication  are  applied  indis- 
criminately to  the  same  disease,  and  the  committee  appointed  by  the 
London  Pathological  Society  to  investigate  the  nature  and  cause  of  those 
infectious  diseases  known  as  septicaemia,  etc.  further  report  that  "  ordi- 
nary wound-fever  is  merely  septic  intoxication  in  a  very  mild  form,  and 
it  is  only  necessary  for  the  dose  absorbed  to  be  sufficient  in  quantity  for 
fatal  consequences  to  ensue.  Septic  intoxication  is,  therefore,  of  the  com- 
monest possible  occurrence  as  a  complication  of  severe  surgical  injuries, 
but  it  is  in  so  mild  a  form  as  to  bear  but  little  resemblance  to  that  experi- 
mentally produced  on  animals."2  The  question  which  now  arises  is, 
Shall  septic  intoxication  be  classified  with  septicaemia  ? 

We  nave  been  long  accustomed  to  speak  of  this  complication  as  a 
surgical  or  traumatic  fever  ;  and  consequently  any  change  in  this  classifi- 
cation must  necessarily  lead  to  confusion.  Furthermore,  it  is  now  gener- 
ally supposed  there  is  much  difference  in  the  etiology  of  these  morbid 
conditions.  It  is  claimed  that  septic  intoxication  arises  from  the  absorp- 
tion of  a  chemical  poison  evolved  through  the  agency  of  living  organ- 
isms during  the  process  of  putrefaction  in  a  wound,  and  that  the  condi- 
tions are  unfavorable  for  their  development  within  the  blood  or  tissues  of 
a  living  animal ;  but  in  true  septicaemia  the  organisms  are  developed  in 
the  wound  during  putrefaction,  and  then  find  their  way  into  the  blood 
and  tissues  of  the  body,  where  they  rapidly  multiply.  Consequently,  the 
former  condition  tends  to  a  rapid  recovery — unless  the  quantity  of  poison 
primarily  admitted  to  the  system  has  been  excessive — while  the  latter  tends 
to  a  fatal  termination. 

Septic  intoxication  is  regarded  as  a  non-infective  disease,  and  true  sep- 
ticaemia as  an  infective  malady.  The  only  etiological  similarity  between 
these  morbid  conditions  is  found  in  the  fact  that  they  take  their  origin  in 
putrefaction,  which  is  effected  by  the  action  of  different  organisms  possess- 
ing marked  morphological  differences  and  requiring  essentially  different 
surroundings  for  the  maintenance  of  life  and  reproduction.  Thus,  it  is 
supposed  that  in  cases  of  septic  intoxication  the  organism  by  which  putre- 
faction is  caused  in  the  wound-secretions  can  only  live  in  the  open  air, 
and  that  its  life  is  commonly  only  of  a  few  hours'  duration.  The  brevity 
of  bacterial  action  in  this  instance  may  be  due  to  a  failure  of  the  absorp- 
tive power  or  to  a  changed  condition  in  the  wound-fluids,  rendering  them 
unfit  to  support  the  organism. 

It  is  now  a  well-recognized  fact  that  all  septic  absorption  ends  so  soon 
as  the  wound-surfaces  are  covered  with  healthy  granulations,  but  that 
septic  absorption,  which  produces  septic  intoxication,  is  most  commonly  of 
a  much  shorter  duration,  and,  consequently,  that  the  wound  complication, 
which  I  prefer  to  designate  traumatic  fever,  is  essentially  an  acute  disease, 
and  can  only  be  lengthened  out  by  unusually  favorable  circumstances  for 
the  continuance  of  the  absorption  of  the  poison  by  which  it  is  produced. 

lAmer.  Jour.  Med.  Sci.,  July,  1882,  p.  70. 

2  Trans.  Pathological  Soc.  of  London,  vol.  xxx.  p.  14. 

VOL.  I.— 61 


962  PYJEMIA  AND  SEPTICAEMIA. 

The  severity  and  danger  of  the  disease  will  necessarily  depend  on  the 
amount  of  poison  absorbed  and  the  resisting  power  of  the  patient ;  but 
since  there  is  no  multiplication  of  the  materies  morbi  within  the  body,  a 
rapid  elimination  by  the  natural  emunctories  may  be  reasonably  expected 
under  favorable  circumstances. 

It  should  be  observed  here  that  the  etiology  of  septicaemia  differs  from 
that  of  traumatic  fever,  since  the  organisms  in  the  former  condition  are  first 
formed  in  the  wound-secretions,  but  quickly  enter  the  body,  where  they 
rapidly  multiply ;  consequently,  Chauvel  has  defined  surgical  septicaemia 
as  follows  :  "  The  particular  intoxication  which  results  from  the  penetra- 
tion and  multiplication  in  the  body  of  a  specific  microbe  designated  by 
Pasteur  under  the  name  of  septic  vibrio."  The  bacterial  origin  of  this 
disease  is  now  generally  accepted,  and  the  only  question  in  the  profes- 
sional mind  seems  to  be  whether  the  organisms  are  the  direct  or  indirect 
cause  of  the  malady. 

There  are  also  some  other  interesting  questions  which  have  arisen  in 
connection  with  the  study  of  this  subject,  and  are  thought  to  be  of  suffi- 
cient importance  to  merit  mention  here.  It  has  long  been  known  that 
dissecting  wounds  are  most  dangerous  when  made  while  examining 
the  body  very  soon  after  the  death  of  the  subject.  Recent  observations 
seem  to  justify  the  conclusion  that  the  greatest  activity  of  the  septic  agent 
is  often,  if  not  always,  attained  before  the  odor  of  putrefaction  has  become 
fairly  perceptible ;  and  even  before  this  odor  has  reached  its  maximum 
degree  of  offensiveness  the  danger  from  septic  poisoning  has  generally 
disappeared.  In  some  cases  septic  intoxication  is  promptly  followed  by  a 
slight  inflammation  in  and  about  the  wound,  which  may  entirely  disappear 
within  a  few  hours,  but  only  to  reappear  after  a  lapse  of  eight  to  fifteen 
days,  with  the  first  vigorous  physical  exercise  of  the  patient.  Two  cases 
of  this  kind  have  recently  come  under  my  observation.  In  both  instances 
the  wounds  were  located  in  the  hands,  and  the  exercise  which  developed 
the  septicaemia  consisted  in  rowing  a  boat,  and  while  thus  engaged  the 
local  symptoms  reappeared  with  such  severity  as  to  cause  the  patients  to 
quickly  discontinue  the  labor.  The  reappearance  of  the  local  inflamma- 
tion in  both  these  instances  was  quickly  followed  by  a  rigor  and  the  rapid 
development  of  other  constitutional  symptoms,  although  prior  to  the 
recurrence  there  was  no  pus,  nor  even  marked  inflammatory  action,  in 
any  part  of  the  hands. 

Professional  attention  was  first  called  to  the  above-stated  facts  by 
Panum  in  1855,  who  discovered  that  the  maximum  toxic  action  of 
putrid  substances  is  generally  developed  during  the  first  hours  of  bodily 
activity.  In  this  stage  of  incubation  in  cases  of  surgical  septicaemia,  if 
we  admit  the  bodily  action  as  an  etiological  factor,  we  observe  a  striking 
resemblance  to  one  of  the  leading  characteristics  of  all  the  infectious  dis- 
eases, which  unquestionably  depend  on  some  sort  of  septic  poison. 
Furthermore,  this  analogy  becomes  most  striking  if  we  contrast  the  effects 
arising  from  dissecting  wounds  with  those  of  the  bites  .of  poisonous  ser- 
pents and  rabid  animals. 

Further  investigation  is  required  to  settle  the  perplexing  questions  of 
etiological  and  pathological  differences  in  these  allied  morbid  conditions, 
for  although  much  has  been  accomplished  during  the  last  two  decades, 
still  much  more  remains  to  be  done.  It  has  only  recently  been  discovered 


ETIOLOGY  OF  SEPTO-PY&MIA— PATHOLOGY  OF  PYAEMIA.  963 

that  the   septic  material  in  septicaemia  is  absorbed  by  the  lymphatics 
while  in  pyaemia  the  poison  enters  the  body  through  the  veins. 

ETIOLOGY  OF  SEPTO-PY.EMIA.— It  is  now  generally  admitted  that 
remittent  fever  and  typhoid  may  be  associated,  and  this  morbid  condi- 
tion is  commonly  designated  by  the  term  typho-malarial  fever.  The 
etiology  is  unquestionably  dependent  upon  the  action  of  the  two  distinct 
and  entirely  dissimilar  poisons.  Scarlatina  is  likewise  frequently  compli- 
cated by  diphtheria,  and  here  we  have  the  combined  action  of  two  poisons, 
each  commonly  designated  as  septic  and  supposed  by  many  physicians  to 
be  similar. 

In  a  like  manner,  it  is  believed  that  septicaemia  and  pygemia  may  be 
associated,  and  take  their  origin  in  dual  poisons ;  but  since  the  etiology 
of  both  these  morbid  conditions  has  been  already  described,  it  is  not 
deemed  necessary  to  dwell  longer  on  septo-pyaemia  under  this  division  of 
our  subject. 

PATHOLOGY  OF  PYAEMIA.— The  study  of  the  pathology  of  pyaemia  is 
advanced  by  adopting  the  following  classification,  which  is  based  on 
recognized  post-mortem  lesions.  The  pathological  appearances  in  these 
forms  of  the  disease  differ  widely,  although  the  clinical  symptoms  are 
often  similar.  In  pyaemia  simplex  the  pathological  conditions  are  essen- 
tially more  negative.  This  variety  of  the  disease  can  only  destroy  life 
by  the  height  and  duration  of  the  fever  which  is  maintained  in  connec- 
tion with  the  continued  existence  of  ichorous  pus.  There  is  found,  as  an 
essential  basis  of  this  form  of  disease,  extensive  suppuration  in  the  sub- 
cutaneous tissues. 

The  arguments  in  favor  of  the  admission  of  pus-corpuscles  into  the 
blood  are  as  follows:  1.  The  blood  in  pya3mia  is  known  to  contain  more 
white  granular  spherical  bodies  than  are  normal.  The  question  has  been 
raised.  Are  they  pus-cells  or  white  blood-corpuscles  ?  The  answer  is 
difficult,  and  has  not  yet  been  attained.  Virchow,  in  the  mean  time,  has 
proved  that  we  cannot  differentiate,  morphologically,  between  the  blood- 
and  pus-corpuscles.  2.  Cohnheim  has  demonstrated  the  existence  of  the 
wandering  corpuscles  in  cases,  of  inflammation.  Therefore  it  appears 
probable  that  in  cases  of  pyaemia  the  blood  may  contain  the  pus-corpuscles, 
but  further  investigation  is  needed  to  establish  this  fact.  However,  the 
establishment  of  this  point  would  still  leave  the  more  important  undeter- 
mined. 

There  are  often  important  changes  observed  in  the  blood  of  patients 
dead  of  pyaemia,  to  which  I  now  desire  to  direct  attention.  The  red 
corpuscles  of  the  blood,  even  in  the  early  stage  of  the  disease,  in  many 
cases  show  signs  of  disintegrating  into  molecules,  and  are  observed  to  be 
accumulated  in  masses  without  showing  the  slightest  tendency  to  form 
rouleaux.  There  is  a  steady  increase  in  the  number  of  pus-  or  white 
corpuscles  in  the  blood  of  pyaemic  patients  during  the  whole  course  of  the 
disease  in  fatal  cases.  The  condition  of  the  red  corpuscles,  already  men- 
tioned, becomes  more  and  more  marked  toward  the  fatal  termination. 

In  all  cases  of  pyaemia  multiplex  the  increased  coagulability  of  the 
blood  may  be  observed  in  the  early  stages  of  the  disease,  and  steadily 
increases  as  the  disease  progresses. 

In  pyaemia  simplex  this  condition  is  less  marked,  although  generally 
present,  "while  we  know  septicaemia  diminishes  or  destroys  the  coag- 


964  PYAEMIA  AND  SEPTICAEMIA. 

ulability  of  the  blood.  Hereby  the  possibility  is  given,  at  least  on  the 
cadaver,  to  differentiate  between  pyaemia  simplex  and  septicaemia,  although 
cases  occur  of  the  more  fatal  septic  infection  in  which  the  post-mortem 
condition  is  a  complete  or  almost  complete  negative.  Therefore,  iu  these 
cases  the  differential  diagnosis  on  the  cadaver  must  be  limited  to  this,  that 
we  are  able  to  demonstrate  the  existence  of  a  purulent  o'r  ichorous  deposit." 
It  will  be  readily  observed  that  the  difference  in  diagnosis  mentioned  above 
relates  to  pyaemia  and  septicaemia,  and  not  to  the  different  varieties  of  the 
former  disease. 

The  following  facts  should  be  constantly  kept  in  mind  by  the  surgeon 
to  enable  him  to  differentiate  between  the  two  forms  of  pyaemia :  In 
pure  cases  of  purulent  infection,  without  metastasis,  the  disease  is  called 
pyaemia  simplex,  and  in  cases  with  metastasis,  pyaemia  multiplex.  The 
various  conditions  on  which  the  metastasis  may  depend  are  shown  by 
Hueter,  who  says :  "  The  metastatic  abscesses  of  pyaemia  multiplex  met 
with  in  the  lungs,  liver,  spleen,  and  other  internal  organs  are  regarded, 
with  the  greatest  probability,  as  a  result  of  the  embolic  process.  The 
metastatic  inflammation  of  the  serous  membranes,  of  the  cellular  tissues, 
and  of  the  parotid  glands,  and  probably  also  a  few  metastatic  inflamma- 
tions of  the  internal  organs,  are  at  present  supposed  to  arise  from  a 
general  inflammatory  diathesis." '  It  has  already  been  shown  by  nume- 
rous experiments  on  animals  that  metastatic  abscesses  in  the  lungs, 
liver,  and  other  visceral  organs  only  arise  after  the  introduction  of 
ichorous  pus,  while  healthy  pus  has  uniformly  failed  to  produce  these 
results. 

It  now  remains  to  be  shown  how  the  introduction  of  ichorous  pus  acts 
in  the  production  of  pyaemia  multiplex.  The  ichorous  pus,  having 
found  its  way  into  the  venous  circulation,  gives  rise  to  the  formation  of 
thrombi  in  the  veins ;  these  clots  become  more  or  less  broken  up,  and 
are  carried  forward  by  the  blood  to  the  right  auricle ;  from  this  auricle 
to  the  right  ventricle ;  from  this  ventricle  to  the  pulmonary  artery,  and 
through  its  ramifications  to  every  part  of  the  lungs.  In  the  minute 
ramifications  of  this  vessel  are  found  wedge-shaped  clots  of  various  sizes 
in  different  conditions,  some  softened  and  others  still  firm.  The  possi- 
bility of  these  clots  ever  passing  through  the  lungs,  and  afterward  being 
arrested  in  other  visceral  organs,  has  been  demonstrated  on  animals.  It 
has  been  shown  that  fine  particles  of  foreign  matter  injected  into  the 
veins  have  passed  through  the  lungs  and  subsequently  lodged  in  the 
liver.  This  theory  enables  us  to  account,  upon  a  mechanical  basis, 
for  the  existence  of  the  metastatic  abscesses  in  the  liver  which  have 
apparently  originated  as  the  result  of  primary  infection. 

In  other  cases  these  abscesses  are  supposed  to  arise  from  secondary  infec- 
tion. Thus,  ichorous  pus,  having  found  its  way  into  the  venous  circulation, 
produces  primarily  venous  thrombi,  which,  as  in  other  instances,  break 
up,  the  clots  being  carried  in  the  same  manner  into  the  terminal  branches 
of  the  pulmonary  artery,  where  they  are  designated  as  emboli.  The  first 
action  of  the  emboli  is  the  mechanical  closure  of  these  vessels,  thus 
depriving  the  surrounding  parts  of  nutrition  to  a  greater  or  less  extent. 
It  will  be  proper  now  to  recall  the  fact  that  the  composition  of  these 
emboli  is  such  as  to  favor  rapid  suppuration ;  this  commonly  commences 
1  Billroth's  Handbuch  der  Chirurgie,  S.  88. 


PATHOLOGY  OF  PYAEMIA.  965 

in  the  clot  and  surrounding  tissues,  having  been  preceded  by  a  brief 
stage  of  congestion  and  inflammation.  There  is  also  occasionally  found 
around  these  points  more  or  less  extravasation.  The  metastatic  abscess 
thus  formed  in  the  lungs  is  favorably  situated  for  the  production  of  sec- 
ondary infection.  From  this  abscess  thrombi  arise  in  the  pulmonary 
veins,  which  become  disintegrated,  and  are  carried  to  the  auricle,  thence 
to  the  left  ventricle,  and  finally  through  the  aorta,  and  find  lodgment  in 
the  terminal  branches  of  the  arteries  of  the  various  organs,  where  they 
produce  the  characteristic  lesions. 

The  organs  which  most  frequently  become  the  seat  of  this  secondary 
infection  are  the  liver,  spleen,  kidneys,  brain,  and  eyes. 

Let  us  now  briefly  examine  this  mechanical  theory.  Do  metastatic 
abscesses  arise  from  a  single  cause  or  from  a  combination  of  causes  ?  I 
am  inclined  to  the  opinion  that  the  proximal  cause  of  metastatic  abscesses 
in  the  visceral  organs  is  the  existence  of  emboli  in  the  terminal  branches. 
The  vitiated  atmosphere  surrounding  the  patient,  the  existence  of  a 
wound,  and  the  formation  of  ichorous  pus  are  conditions  which  should 
not  be  lost  sight  of.  These  are  the  elements  acting  on  the  blood,  pro- 
ducing in  it  morbid  changes,  and  may  therefore  be  regarded  as  predis- 
posing causes.  The  morbid  conditions  of  the  blood,  the  increased 
number  of  white  blood-corpuscles  (possibly  pus),  the  disintegration  and 
other  changes  in  the  red  corpuscles,  may  be  regarded  as  the  exciting 
causes  of  metastatic  abscesses.  It  is  thus  readily  observed  that  emboli 
may  form  in  the  lungs  and  liver  at  the  same  time,  or  the  origin  of 
those  in  the  lungs  may  precede  the  formation  in  other  organs. 

Is  the  formation  of  emboli  in  the  terminal  branches  of  arteries 
always  dependent  on  the  disintegration  of  thrombi?  The  answer  to  this 
question  must,  I  think,  be  a  negative,  although  in  surgical  practice  it 
rarely  happens  that  the  emboli  take  their  origin  from  any  other  cause. 
In  the  large  majority  of  cases,  unquestionably,  the  thrombi  primarily 
exist  in  the  vicinity  of  the  wound  in  which  ichorous  pus  is  generated ; 
but  it  not  infrequently  happens  during  the  process  of  disintegration  th'at 
broken-up  clots  are  carried  forward  by  the  current  of  blood,  receiving 
accretions  on  the  way,  until  finally  they  fill  a  large  venous  trunk.  In 
confirmation  of  these  facts  relating  to  the  primary  origin  of  thrombi,  it 
is  said  to  have  been  observed  in  epidemics  of  puerperal  fever,  which 
were  complicated  with  metastatic  abscesses  of  the  visceral  organs,  that 
the  thrombi  occurred  in  the  pelvic  veins.  In  case  of  wounds  of  the 
lower  extremity  the  clot  is  frequently  found  in  the  common  iliac  vein, 
although  probably  it  should  always  be  regarded  as  a  secondary  forma- 
tion. In  rare  cases  the  only  thrombi  discovered  at  the  autopsy  are  found 
situated  far  away  from  the  injury. 

Observation  fully  establishes  the  fact  that,  after  death  from  pyaemia, 
pathological  changes  are  much  more  frequently  met  with  in  the  lungs 
than  in  any  of  the  other  organs.  This  certainly  strengthens  the  embolic 
theory.  Billroth  mentions  eighty-three  cases  of  true  pyaemia  multiplex, 
in  which  the  metastatic  abscesses  occurred  as  follows  :  seventy-five  times 
in  the  lungs,  seventeen  times  in  the  spleen,  eight  times  in  the  liver,  and 
four  times  in  the  kidneys.  Sedillot  remarks  that  in  one  hundred  cases 
of  pyaBinia  we  find  the  lungs  aifected  in  ninety-nine,  the  liver  and 
spleen  in  eight,  the  muscles  in  seven,  and  the  heart  and  peripheric  cell- 


966  PYAEMIA   AND  SEPTICAEMIA. 

ular  tissue  in  five  cases.  The  brain  and  kidneys  are  comparatively  sel- 
dom involved. 

The  theory  previously  mentioned  as  the  embolic  relates  to  the  aggre- 
gation of  fibrin  into  clots ;  but  another  theory  has  been  recently  advanced 
by  E.  Wagner,  who  found  in  many  cases  the  capillaries  in  the  lungs  filled 
with  fat,  and  was  inclined,  from  the  direction  it  extended  in  these  vessels, 
to  explain  a  certain  number  of  the  pysemic  cases  by  the  fat  emboli ;  but 
it  has  been  shown  that  the  existence  of  the  fat  emboli  in  pyaemia  is 
purely  accidental  and  possesses  no  significance.  Pyaemia  multiplex  very 
frequently  occurs  without  fat  emboli,  and  vice  versa;  either  process  may 
complicate  the  other,  and  so  the  fat  emboli  may  acquire  special  import- 
ance by  obstructing  the  respiration,  and  probably  also  in  their  M*ay  the' 
embolic  fat  may  serve  as  a  carrier  of  putrid  material. 

MORBID  ANATOMY. — The  external  appearance  of  the  body  varies 
greatly.  The  skin,  in  those  cases  in  which  the  patient  was  jaundiced  be- 
fore death,  will  be  found  in  every  part  of  the  body  to  be  of  a  dark  orange 
or  dirty  icteric  tinge,  but  in  other  cases  it  may  present  a  pale  or  anaemic 
appearance.  There  are  also  sometimes  found  circumscribed  ecchymoses 
or  purpuric  patches,  while  the  edges  of  ulcers  or  open  wounds  are  gen- 
erally of  a  blackish  or  dirty  yellow  color.  The  lips  and  finger-nails 
present  a  livid  appearance ;  epithelial  defects  are  observed  in  the  cornea, 
but  these  had  their  origin  there  before  the  death  of  the  patient. 

The  eyes  in  some  cases  are  sunken  deeply  in  their  sockets,  and  where 
the  disease  has  been  protracted  there  is  often  very  great  emaciation. 
Rigor  mortis  is  commqjaly  well  marked  after  a  few  hours.  When  death 
occurs  from  puerperal  pyaemia  there  are  generally  found  some  indications 
of  the  recent  parturition,  although  the  principal  lacerations  or  injuries 
may  be  confined  to  the  womb.  All  fluids  disappear  from  external  wounds 
before  the  death  of  the  patient,  and  they  remain  dry  afterward. 

In  some  cases  the  cellular  tissue  is  the  seat  of  diifuse  suppuration. 
The  pus  formed  is  thin,  fetid,  and  unhealthy.  This  suppuration  is  lim- 
ited to  certain  parts  of  the  body,  as  an  injured  extremity,  or,  as  fre- 
quently happens,  it  may  be  found  on  the  trunk  and  limbs  at  the  same 
time.  The  pus  in  this  form  of  suppuration  is  exceedingly  apt  to  burrow, 
on  account  of  the  peculiarities  of  the  tissue  in  which  it  occurs,  and  also 
the  condition  of  the  surrounding  structures,  especially  the  relaxed  and 
flabby  condition  of  the  skin.  These  abscesses  in  some  instances  are 
superficial,  in  others  deep-seated. 

There  are  few  changes  which  occur  in  the  muscles,  and  these  are  not  uni- 
form or  constant.  They  are  occasionally  the  seat  of  abscesses,  which  have 
been  observed  in  the  heart,  tongue,  and  other  organs.  The  muscles  may 
be  of  a  light-brown  or  greenish  color  when  they  have  been  covered  a 
considerable  time  with  pus,  and  are  sometimes  softened  and  pultaceous. 
Suppuration  may  also  take  place  beneath  the  fascia  of  the  tendons. 

The  brain  and  its  membranes  are  frequently  found  in  a  perfectly 
healthy  state  after  death  from  pyaemia,  although  when  the  diseased  pro- 
cess has  extended  during  the  life  of  the  patient  to  the  lungs  and  pleura, 
giving  rise  to  great  dyspnoea,  there  will  generally  be  observed  some  con- 
gestion of  the  membranes,  an  increased  quantity  of  fluid  in  the  brain- 
substance  and  ventricles,  and  also  an  increased  fulness  of  the  meningeal 
veins  and  sinuses.  Occasionally  there  have  been  observed  suppurative 


MORBID  ANATOMY.  967 

meningitis,  blood  extravasations  on  the  surface  of  the  brain,  lymph-deposits 
on  the  membranes,  softening  of  the  cerebral  tissues,  and  circumscribed 
abscesses  in  the  substance  of  the  brain,  which  in  some  cases  have  been 
traceable  to  embolism  of  its  vessels.  The  changes  in  the  spinal  cord  and 
its  membranes  are  probably  similar  to  those  found  in  the  brain,  but  these 
parts  appear  to  have  been  rarely  examined. 

Virchow  found  emboli  of  the  retinal  and  choroidal  vessels.  Heiberg 
found  these  vessels  occluded  with  colonies  of  micrococci.  There  have 
also  been  observed  opacity  of  the  cornea,  sloughing  of  the  conjunctival 
epithelium,  suppurative  infiltration  into  the  periphery  of  the  vitreous 
body,  and  deposits  of  pus  in  Petit's  canal  and  in  the  anterior  and  posterior 
chambers.  Pysemic  ophthalmia  has  been  observed  somewhat  frequently 
in  puerperal  cases,  especially  when  preceded  by  endocarditis,  with  deposits 
on  the  semilunar  or  mitral  valves.  In  surgical  cases  it  is  rarely  seen. 

Toynbee  "  relates  several  cases  of  purulent  infection  following  sup- 
puration of  the  ear.  Cases  of  disease  in  the  mastoid  cells  terminate 
fatally,  he  says,  from  two  different  causes  :  first,  from  purulent  infection, 
arising  from  the  introduction  of  pus  into  the  circulation  through  the 
lateral  sinus ;  second,  from  disease  of  the  cerebellum  or  its  membranes. 
Cases  of  purulent  infection,  he  further  remarks,  have  not  been  met  with 
where  the  disease  occurs  in  the  tympanic  cavity."  l 

Numerous  lesions  of  the  osseous  system  have  been  noted  in  pyaemia, 
probably  from  the  fact  that  this  disease  results  very  frequently  in  cases 
of  bone-lesions,  but  these  changes  have  very  little  diagnostic  importance. 
The  following  have  been  observed :  thickening  or  infiltration  of  the 
periosteum,  which  may  be  found  to  separate  readily  from  the  bone 
after  the  death  of  the  patient,  or  there  may  be  pus  found  between  the 
periosteum  and  the  bone.  In  the  bone-structure  there  were  found  caries 
and  necrosis,  "while  in  other  cases  the  whole  thickness  of  the  compact 
tissue  is  perforated  in  a  honeycomb-like  manner  by  minute  cavities  filled 
with  thickish  pus  or  caseous  matter  of  a  pinkish-white  color." 2  "  To 
sum  up,  the  chief  morbid  alterations  met  with  in  the  bones  are  congestion, 
dilatation  of  the  Haversian  canals  and  cancellated  tissue,  tending  to  abscess 
formation,  and  the  excavation  of  the  cavities  by  the  unhealthy  pus." ' 

The  pathological  lesions  of  the  joints  commence  with  marked  conges- 
tion of  the  synovial  membranes  and  increase  in  the  synovial  fluids,  and 
afterward  the  fluid  is  mixed  with  pus ;  these  conditions  are  followed  by 
erosion  of  the  cartilage  and  ligaments,  the  former  thus  becoming  separated 
from  the  bone.  Both  the  small  and  large  joints  are  occasionally  the  seat 
of  morbid  changes. 

The  parotid  gland  is  occasionally  the  seat  of  a  secondary  inflammation 
during  the  progress  of  pyaemia,  and  this  may  endanger  life  by  interfering 
with  respiration  and  deglutition.  The  lymphatic  glands  are  only  second- 
arily affected,  and  even  this  takes  place  very  rarely.  The  changes  in  the 
glandular  system,  when  observed,  are  similar  to  those  which  happen  in 
other  tissues  of  the  body — viz.  congestion,  inflammation,  and  suppuration. 

The  arteries  are  usually  found  empty  after  death  from  this  disease,  and 
the  coats  are  sometimes  apparently  thickened.  The  veins,  on  the  con- 
trary, are  commonly  found  filled,  or  even  distended,  with  firm  fibriuous 
clots.  They  are  sometimes  also  found  inflamed  or  altered,  although  more 

1  Braidwood  on  Pyaemia,  pp.  168,  169.  2  Ibid,  p.  192.  3  Ibid,  p.  194. 


968  PYAEMIA  AND  SEPTICAEMIA. 

commonly  healthy.  The  distended  condition  of  the  veins  gives  rise  to 
the  cord-like  feeling  often  mentioned  by  different  observers.  In  some 
cases  of  phlebitis  there  may  be  pus  deposited  between  the  coats  of 
these  veins.  The  most  important  pathological  changes  are  found  in 
the  blood.  These  changes  occur  early  in  the  disease,  become  more 
marked  toward  its  fatal  termination,  and  may  be  always  studied  after 
death.  It  is  generally  admitted  that  pus  is  frequently  found  in  the  blood 
of  these  patients ;  but  it  has  been  shown  by  numerous  experiments  thai 
healthy  pus  never  produces  the  pathological  changes  which  characterize 
this  disease.  Pyaemia  is  only  produced  by  the  presence  in  the  blood  of 
ichorous  pus  or  some  other  decomposing  animal  substance,  or  some  material 
having  its  origin  in  the  decomposition  of  the  same,  and  no  decomposition 
in  these  substances  is  ever  effected  except  through  the  agency  of  living 
organisms.  It  therefore  follows  that  the  discovery  of  living  organisms 
in  the  blood  of  those  sick  and  dead  of  this  disease  has  given  a  renewed 
interest  to  the  study  of  its  pathology.  The  recent  investigations  made 
by  Pasteur,  Koch,  Birch-Hirschfeld,  and  the  London  Pathological  Society 
show  conclusively  that  in  all  cases  of  pyaemia  and  septicaemia  organisms 
are  present  in  the  blood  during  the  entire  course  of  the  disease,  and 
that  in  the  former  there  is  found  the  globular,  and  in  the  latter  the 
rod  bacteria.  It  has  further  been  observed  in  each  morbid  condition  that 
the  severity  of  the  disease  is  always  increased  in  proportion  to  the  increase 
of  the  organisms  in  the  blood,  and  that  the  bacteria  found  within  the  body 
are  of  the  same  species  as  those  in  the  wound  from  which  they  have  gained 
admission.  The  micrococci  found  in  the  blood  of  pysernic  patients  are 
surrounded  by  the  decomposed  products  of  the  red  and  white  corpuscles, 
which  appear  in  the  blood-plasma  in  the  form  of  pale  granular  bodies. 
There  is  likewise  in  this  disease  an  increased  coagulability  of  the  blood, 
and  it  steadily  increases  as  the  disease  progresses.  In  this  condition  there 
may  be  found  in  the  blood-vessels  both  thrombi  and  emboli.  The 
thrombi  are  occasionally  observed  as  firm  fibrinous  clots,  but  they  may 
be  likewise  found  in  the  rapidly  fatal  cases  to  have  undergone  suppura- 
tive  changes.  These  changes  begin  in  the  centre  of  the  clots,  which  often 
contain  true  pus  or  a  greenish  or  puriform  fluid. 

The  pericardium  may  contain  a  small  amount  of  serum  tinged  with 
blood,  but  it  is  seldom  covered  with  recent  lymph.  Both  the  lung-tissue 
and  pleurae  are  commonly  inflamed  in  this  disease.  The  costal  and  vis- 
ceral layers  may  be  agglutinated  by  old  adhesions,  but  are  more  com- 
monly united  together  by  recently  formed  lymph.  The  pleural  cavities 
often  contain  some  opaque,  muddy,  sero-purulent  fluid,  mixed  with 
blood  and  having  masses  of  lymph  floating  in  it. 

The  lungs  are  more  frequently  the  seat  of  metastatic  abscesses  and 
other  morbid  changes  in  pyaemia  multiplex  than  any  other  organs  of  the 
body.  There  may  be  found  emboli  in  the  branches  of  the  pulmonary 
veins,  and  in  the  lung-tissue  metastatic  abscesses  surrounded  with  capil- 
lary congestion  and  other  evidences  of  inflammation;  "  The  smaller  ves- 
sels, trying  to  overcome  this  afflux  of  blood,  may  produce  ecchymosis  or 
extravasation  beneath  the  lining  membrane  of  the  air-vesicles,  but  the 
minute  capillary  congestions  are  generally  observed  as  red  points  studded 
over  the  pulmonary  surface,  which  by  and  by  exhibit  yellowish-white  or 
bluish-white  centres.  While  one  part,  generally  the  lower  half  of  the 


MORBID  ANATOMY.  969 

lung  is  thus  hepatized,  solid,  and  of  a  dark  greenish  color,  the  remainder 
of  the  lung  is  emphysematous  and  more  or  less  oedematous.  A  section 
of  the  former  presents  the  same  appearance  as  is  observed  in  the  luno-s 
of  pneumonic  patients.  Whether  these  incipient  abscesses  are  developed 
from  the  minute  points  of  congestion  before  mentioned,  by  the  breakino- 
down  of  the  thrombic  clots  in  their  centres,  or  whether  the  pus  is  devel- 
oped out  of  the  serum  exuded  by  the  walls  of  the  engorged  capillaries 
cannot  be  easily  determined,  and  has  as  yet  not  been  decided.  These 
secondary  Abscesses  vary  in  size  from  that  of  a  hemp-seed  to  that  of  a 
hen  s  egg.  These  are  generally  situated  on  the  periphery  of  the  lungs 
and  m  the  lower  lobe,  although  in  some  cases  they  are  found  imbedded 
deeply  m  the  pulmonary  tissue.  The  contents  of  these  abscesses  are 
similar  to  those  found  in  other  parts  of  the  body  in  this  disease.  The 
bronchial  mucous  membrane  is  commonly  of  a  bright  pink  color,  while 
its  secretion  is  increased  in  quantity,  and  may  be  clear  and  frothy.  These 
changes  are  the  result  of  acute  bronchial  catarrh.  Lobular  pneumonia 
has  been  frequently  observed  as  a  complication  of  pyaemia,  and  is  sup- 
posed by  some  authors^  to  be  caused  by  the  vitiated  condition  of  the 
blood ;  but  probably  it  is  more  frequently  occasioned  by  infarctions  and 
embplic  abscesses,  which  have  been  previously  mentioned  in  this  con- 
nection. 

Billroth  and  Sedillot  observed  pathological  lesions  involving  a  solution 
of  continuity  in  the  spleen,  liver,  and  kidneys,  in  the  order  in  which  they 
are  mentioned ;  other  authors,  however,  assert  that  the  liver,  next  to  the 
lungs,  is  the  most  frequent  seat  of  purulent  deposits.  Enlargement  of 
the  spleen  is  frequently  met  with  in  cases  of  pycemia  multiplex.  The 
metastatic  abscesses  found  in  the  spleen  and  kidneys  are  much  smaller 
than  those  found  in  the  lungs  and  liver,  but  in  other  respects  are  of  a 
similar  character.  The  capillary  congestion  and  the  accompanying 
infarctions  require  no  special  attention  here.  The  liver,  like  the  spleen, 
is  sometimes  enlarged,  and  at  other  times  is  found  to  have  undergone 
fatty  degeneration  to  a  greater  or  less  degree;  in  which  condition  its 
tissues  are  generally  soft  and  friable.  Abscesses  in  the  liver  are  so  much 
like  those  in  the  lungs  as  to  need  no  separate  description.  The  same 
may  be  said  of  other  pathological  changes  found  in  this  organ  in  pyaemia 
multiplex.  The  abscesses  found  in  the  kidneys  vary  from  the  size  of  a 
hemp-seed  to  that  of  a  bean,  and  are  surrounded  by  the  usual  zone, 
marking  more  or  less  definitely  the  extent  of  the  inflammation.  The 
capsule  is  generally  healthy.  There  are  also,  in  very  rare  cases  of  this 
disease,  abscesses  found  in  the  stomach  and  intestines,  involving  the 
thickness  of  the  mucous  membrane ;  and  it  is  further  supposed  that  these 
abscesses  may  be  found  occasionally  on  any  portion  of  the  mucous  mem- 
brane lining  the  alimentary  canal.  Post-mortem  examinations  in  pyaemia 
multiplex  have  established  the  fact  that  there  is  no  organ  in  the  body 
that  may  not  become  the  seat  of  pathological  lesions  in  this  disease ;  but 
there  is  unquestionably  a  vast  difference  in  the  relative  frequency  of  these 
changes  in  the  various  organs.  In  some  instances  of  this  disease  peri- 
tonitis is  developed,  with  its  concomitant  changes  in  this  membrane  and 
the  abdominal  fluid,  which  is  generally  increased  in  quantity  and  some- 
times slightly  tinged  with  blood,  but  more  frequently  remains  clear. 
1  Braidwood,  op.  at.,  p.  173  et  seq. 


970  PYAEMIA  AND  SEPTIC^MIA. 

This  inflammation  is  commonly  dependent  on  an  extension  of  the  inflam- 
matory process  from  a  metastatic  abscess,  which  may  be  situated  near 
the  periphery  of  some  organ  covered  with  peritoneum,  although  it  is 
claimed  that  pleuritis  occasionally  occurs  in  connection  with  pyaemia 
independent  of  metastatic  abscesses  in  the  lungs. 

The  careful  study  of  the  pathology  of  pyaemia  multiplex  renders  it 
exceedingly  probable  that  the  immediate  agency  in  the  production  of  all 
these  lesions  is  the  presence  in  the  blood  of  a  particular  species  of  living 
organism,  and  that  all  the  morbid  changes  which  occur  in  the  visceral 
organs  are  secondary  to  those  which  take  place  in  the  blood,  but  that 
the  former  are  only  dependent  on  the  latter  in  a  minor  degree.  The 
pathological  changes  effected  by  these  organisms  seem  to  be  as  follows, 
and  to  occur  in  the  following  order :  viz.  disorganization  of  the  blood, 
especially  a  destruction  of  the  red  and  white  blood-corpuscles ;  the  forma- 
tion of  granular  bodies  around  the  organisms  out  of  this  delms ;  the 
production  of  an  increased  coagulability  of  the  blood ;  the  lodgment  in 
the  blood-vessels  of  these  granular  bodies,  which  are  increased  in  size  by 
a  deposit  of  fibrin ;  these  obstructions  occur  most  frequently  in  minute 
ramifications  of  the  pulmonary  arteries ;  nutrition  is  effected  locally  by 
these  infarctions,  and  generally  by  the  vitiated  condition  of  the  blood, 
which  enables  the  organisms  under  these  favorable  circumstances  to  pene- 
trate the  adjacent  tissues  and  produce  the  metastatic  abscesses  and  other 
accompanying  lesions. 

The  pathological  changes  in  pyaemia  simplex  are  of  the  same  kind  as 
those  which  have  just  been  described  as  characterizing  pyaemia  multiplex, 
with  the  exception  of  the  metastatic  abscesses,  which  are  always  absent. 
Furthermore,  the  disease  in  both  instances  is  believed  to  have  its  origin 
from  the  same  causes,  and  the  dissimilarities  in  the  pathological  lesions 
are  equally  susceptible  of  a  rational  explanation,  as  are  those  of  scarlatina 
simplex  and  scarlatina  maligna. 

There  were  reported  by  the  committee  of  the  London  Pathological 
Society  some  interesting  details  pertaining  to  this  form  of  pyaemia.  Their 
report  shows  that  among  the  one  hundred  and  fifty-five  cases  classed  as 
pyaemia  there  were  twenty-four  xBases  without  visceral  abscesses;  and 
furthermore  it  shows  that  in  twenty-three  of  these  cases  there  was  no 
suppuration,  although  local  inflammations  affected  many  of  the  different 
tissues,  since  these  patients  suffered  with  arthritis,  cellulitis,  pleuritis, 
meningitis,  pericarditis,  and  carditis.  It  is  also  added  that  "the  post- 
mortem appearances,  in  addition  to  the  local  secondary  inflammation 
before  noted,  were  in  many  cases  those  changes  common  to  all  forms  of 
blood  poisoning.  Out  of  the  twenty-four  cases,  the  following  are  noted  : 
Swollen  spleen,  nine  times ;  congestion  of  the  lungs,  ten  times ;  swollen 
liver,  six  times;  cloudy  swelling  of  the  kidney,  fourteen  times."1 

In  this  form  of  pyaemia  it  has  been  supposed  by  some  authors  that  the 
materies  morbi  occasionally  produces  death  before  the  metastatic  abscesses 
have  had  time  to  develop,  but  this  is  not  always  the  case.  The  same 
committee  report  on  the  above-mentioned  twenty-four  cases,  on  this 
point,  as  follows :  "  The  duration  of  the  cases  before  the  fatal  ter- 
mination was  very  various.  It  is  tolerably  accurately  recorded  in 
eighteen  cases :  of  these  five  died  in  the  first  week,  five  in  the  second, 

1  Trans.  London  Pathological  Soc,.,  vol.  xxx.  p.  26. 


MORBID  ANATOMY.  971 

f°uVnAbe  thirdj  aud  tlie  remaim'ng  four  survived  to  the  thirtieth,  fortv- 
nmth,  fifty-second,  and  sixty-second  days." 1 

The  pathology  of  pyaemia  multiplex  having  been  already  fully  described 
and  since  the  only  essential  difference  in  these  morbid  conditions  consists 
m  the  complete  absence  of  the  metastatic  abscesses  in  cases  of  pyaemia 
simplex,  it  is  therefore  thought  unnecessary  to  dwell  here  longer  on  this 
subject. 

The  morbid  anatomy  of  septicaemia  has  been  carefully  studied  of  late 
and  it  is  now  known  that  the  most  characteristic  lesions  are  found  in  the 
blood  and  the  alimentary  canal. 

As  a  manifestation  of  the  general  poisoning  of  the  blood,  it  might  be 
expected  that  putrefaction  would  follow  rapidly  after  the  death  of  the 
patient.  In  fact,  Davine  defines  septicaemia  as  "putrefaction  of  a  living 
body."  Observation  has  now  thoroughly  confirmed  that  which  was 
formerly  an  ^  anticipation.  Panum,  Hemmer,  and  Bergmann  have  each 
called  attention  to  the  fact  that  rapid  decomposition  follows  the  death  of  all 
animals  in  which  septicaemia  has  been  produced  for  experimental  pur- 
poses. It  has  also  been  observed  that  putrefaction  in  the  human  cadaver 
begins  much  sooner,  and  progresses  much  more  rapidly,  under  similar 
circumstances,  when  the  death  has  been  produced  by  this  disease  than 
when  it  has  occurred  from  any  other  cause.  Furthermore,  this  rapid  de- 
composition is  not  limited  to  the  internal  organs,  but  may  be  frequently 
strongly  marked  on  the  surface  of  the  body  after  the  lapse  of  twelve 
hours,  although  it  has  been  kept  in  a  comparatively  dry  and  cool  atmo- 
sphere. In  those  cases  where  the  septicaemia  has  originated  in  an  external 
wound  it  has  been  uniformly  observed  that  putrefaction  goes  on  most 
rapidly  in  the  vicinity  of  the  wound  after  the  death  of  the  patient. 

In  every  case  of  fatal  septicaemia  the  post-mortem  examination  will 
show  that  the  coagulability  of  the  blood  has  been  diminished  or  destroyed. 
In  fact,  it  has  been  abundantly  shown  that  in  all  cases  of  true  septicaemia 
the  coagulability  of  the  blood  is  more  or  less  diminished.     The  few  im- 
perfect clots  of  blood  found  after  death  are  of  a  deep-black  color.     The 
putrefaction  of  the  soft  tissues  is  greatly  hastened  by  the  presence  of  this 
blood ;  and,  consequently,  this  process  goes  on  most  rapidly  in  the  most 
dependent  portions  of  the  body,  especially  along  the  course  of  the  large 
veins.     The  septicaemic  blood  possesses  a  peculiar  putrefactive  odor,  and 
it  is  occasionally  found  to  be  acid  in  its  reaction,  according  to  Vogel 
and  Scherer,  making  it  highly  probable  that  it  will  end  in  the  forma- 
tion of  the  carbonate  of  ammonium.    The  chemical  examinations  of  sep- 
ticaemic blood  which  have  heretofore  been  made  have  completely  failed  to 
give   satisfactory   results   in    regard    either  to  the   existence  or  nature 
of  the  materies  morbi  in  this  disease,  although,  without  doubt,  there  has 
occasionally  been  found,  principally  in  the  blood  of  those  who  have  died 
of  acute  septic  intoxication,  a  poisonous  substance,  which  Bergmann  des- 
ignated sepsin.     Microscopic  examinations  have  shown  that  in  the  blood 
and  also  in  various  organs  of  those  who  have  died  of  septicaemia  there 
are  always  present,  under  these  circumstances,  a  large  number  of  the  rod 
bacteria ;  in  fact,  they  are  more  numerous  than  after  death  jfrom  any  other 
infectious  disease.     Furthermore,  they  are  found  in  the  blood,  lymph- 
glands,  and  cellular  tissues  during  the  whole  course  of  the  disease. 
1  Trans.  London  Pathological  Soc.,  p.  25  et  seq. 


972  PYMML&.  AND  SEPTICAEMIA. 

There  are  no  pathological  changes  in  the  central  nervous  system  which 
arise  directly  from  septicaemia,  although  in  some  cases,  when  there  has 
been  some  cardiac  complication  or  very  severe  dyspnoaa  from  any  cause 
immediately  prior  to  the  death  of  the  patient,  there  may  be  found  hyper- 
semia  of  the  membranes  of  the  cerebro-spinal  axis.  The  brain  and  spinal 
cord  remain  unchanged. 

The  endo-  and  pericardium  occasionally  present  a  somewhat  mottled 
appearance  resembling  ecchymosis,  which  is  evidently  a  deposit  from  the 
blood,  and  may  be  washed  off  with  water.  The  inner  surface  of  the  ventri- 
cles presents  a  similar  appearance  from  the  same  cause.  In  addition  to  those 
changes  which  have  been  mentioned  there  are  occasionally  found  some  slight 
traces  of  an  inflammatory  process  in  these  parts  ;  but  it  never  extends  to  the 
formation  of  pus  or  ulceration,  which  frequently  happens  in  cases  of  pysemia. 
The  quantity  of  pericardial  fluid  is  sometimes  increased  in  septicaemia, 
and  is  generally  somewhat  thickened,  cloudy,  and  slightly  tinged  with 
blood.  The  changes  in  the  pleural  surfaces  are  the  same  as  those  which 
have  been  noted  in  the  pericardium,  but  any  increase  of  the  fluid  within 
the  pleural  sacs  is  an  exception  to  the  general  law,  and  is  very  rarely  seen. 
The  lungs  are  generally  found  slightly  congested,  but  there  may  be  some 
ecchymosis  in  exceptional  cases.  Pus  is  never  found  in  the  lungs  or 
within  the  pleural  cavities  in  pure  unmixed  septicaemia.  The  patholog- 
ical changes  in  the  liver  resemble  those  in  the  lungs.  This  organ  is 
commonly  found  in  a  state  of  passive  congestion,  while  the  color  of  its 
tissues  is  slightly  darkened.  The  congestion  of  the  kidneys  and  spleen  in 
this  disease  is  much  more  marked  than  that  of  the  lungs  and  liver.  The 
parenchymatous  tissue  of  the  kidneys  is  commonly  found  in  an  cedematous 
condition,  and  the  tubuli  uriniferi  are  more  or  less  affected  by  a  catarrhal 
inflammation,  which  is  manifested  by  the  exfoliation  of  granular  epithe- 
lium. The  same  catarrhal  condition,  but  in  a  milder  form,  is  found  to 
affect  the  mucous  membrane  of  the  bladder.  In  females  the  ovaries, 
uterus,  and  vagina  are  in  a  state  of  hypersemia,  with  more  or  less 
catarrhal  inflammation  of  the  latter  organ.  Septicaemia  invariably 
causes  pregnant  females  to  abort.  There  is  commonly  softening  of  the 
spleen.  The  alimentary  canal  is  almost  constantly  affected  by  acute 
intestinal  catarrh,  with  enlargement  of  the  intestinal  follicles  and  mesen- 
teric  glands,  while  there  are  frequently  hemorrhages  from  the  serous  and 
mucous  membranes.  The  various  muscles  of  the  body  and  the  extrem- 
ities are  found  to  be  of  a  dark  brownish-red  after  the  death  of  the 
patient,  instead  of  possessing  their  natural  pale-red  color.  It  may  now 
be  stated,  finally,  that  the  pathological  changes  in  septicaemia  are  less 
marked  than  those  of  pyaemia  multiplex. 

The  semiology,  etiology,  and  pathology  of  septo-pyaemia  consist  in  a 
blending,  in  different  degrees,  of  the  essential  parts  of  pyaemia  and  septi- 
caemia ;  and  since  the  pathology  of  both  these  diseases  has  been  presented 
separately,  it  is  deemed  unnecessary  to  enter  into  a  consideration  of  this 
combination. 

SYMPTOMS  OF  PY^MIA. — Pyaemia  very  rarely,  if  ever,  develops  except 
in  connection  with  an  open  suppurating  wound,  and  consequently  it  must 
generally  be  regarded  as  a  wound  complication  or  as  a  secondary  diseased 
condition. .  Those  open  wounds  are  unquestionably  the  most  favorably 
situated  for  the  development  of  this  disease  which  involve  the  medullary 


SYMPTOMS  OF  PYAEMIA.  973 

cavities  of  the  long  bones,  owing  to  the  liability  of  unhealthy  <uppura- 
tion  the  difficulty  of  complete  drainage,  and  the  favorable  anatomical 
conditions  for  absorption. 

Every  form  of  pyaemia  is  frequently  preceded  by  a  distinctly  marked 
prodromal  stage,  which  varies  in  duration  from  four  days  to  two  weeks 
In  fact,  the  ordinary  precursor  of  this  disease,  in  all  those  cases  in  which 
the  bones  are  involved,  is  an  attack  of  osteo-myelitis ;  but  in  other  cases 
the  patient  often  complains  of  malaise,  giddiness,  headache,  pain  in  the 
limbs,  weakness,  and  loss  of  appetite,  while  the  experienced  surgeon 
will  be  deeply  impressed  with  the  patient's  rapid  emaciation  and  cadav- 
erous face.  These  symptoms  are  soon  followed  by  jaundiced  skin,  etc. 
The  Commencement  of  an  attack  of  pyaemia  is  commonly  manifested  by 
a  chill.  The  importance  which  will  naturally  be  attached  to  this  phe- 
nomenon in  connection  with  an  open  wound  must  depend  to  a  certain 
degree  on  the  circumstances  attending  its  occurrence ;  and  therefore  the 
following  question  will  present  itself:  Is  the  chill  associated  with  sup- 
puration ?  A  negative  answer  to  this  question,  based  on  the  fact  that 
insufficient  time  has  elapsed  since  the  occurrence  of  the  injury  to  render 
suppuration  possible,  can  never  fail  to  be  a  source  of  satisfaction  to  the 
surgeon,  whose  experience  has  taught  him  to  dread  pyaemia. 

Billroth  has  observed  in  83  cases  of  true  pyaemia  multiplex  that 
62  commenced  with  a  chill,  and  21  without ;  in  81  cases  of  septicaemia 
and  simple  pyaemia  24  commenced  with  a  chill  and  57  without.  The 
number  of  chills  in  each  individual  patient  occurred  according  to  the 
following  table : 

Number  of  patients 19     21     14     15      9      5      2      3      4      1       1       1 

Number  of  chills 1       234       5      6      7       8      9     10     13     14 

In  one  patient  during  three  weeks  sixteen  chills  were  observed,  and 
probably  the  longer  the  duration  of  the  disease  the  greater  is  the  number  of 
chills.  Still,  there  are  chronic  cases  with  a  single  chill,  and  acute  cases  with 
many.  It  rarely  occurs  that  a  patient  has  more  than  one  chill  in  twenty- 
four  hours.  Billroth  noticed  among  his  patients  only  sixteen  who  had  two 
chills,  and  only  six  who  each  had  three  chills,  in  one  day.  The  experi- 
ence that  fewer  chills  occur  during  the  evening  and  night  than  in  the 
morning  and  afternoon  has  been  confirmed  by  statistics.  Among  287 
chills,  220  occurred  from  8  A.  M.  to  8  P.  M.,  while  during  the  night,  from 
8  P.  M.  to  8  A.  M.,  only  67  were  observed.  By  this  arbitrary  division  of 
the  twenty-four  hours  Billroth  desired  to  take  into  consideration  the  daily 
exacerbation  in  cdnnection  with  the  usual  daily  irritation  of  the  wound, 
the  bandaging,  and  other  manipulations.  He  saw,  for  example,  a  chill 
occur  three  times  from  the  introduction  of  a  sound,  and  twenty  times 
after  the  opening  of  an  abscess.  The  time  which  elapsed  from  the  first 
injury  to  the  first  chill  is  shown  in  the  following  table : 

First  chill  began,  times 14      19       15      9      4      3      2      4 

Length  of  time  after  injury,  in  weeks 1         2        345678 

Patients  who  had  fever  before  the  operation  were  more  inclined  to 
early  chills  than  recently-injured  healthy  individuals.  Billroth's  experi- 
ence was  to  have  only  the  first  chill  before  the  end  of  the  first  week.  It 
may  be  further  stated  that  nervous,  irritable  patients  suffer  much  more 


974  PY^MIA  AND  SEPTIC^MIA. 

frequently  from  chills  than  those  of  a  phlegmatic  temperament.  This 
fact  h;>s  given  rise  to  the  opinion  that  the  absorption  of  pus  acts  especially 
on  the  central  nervous  system. 

The  chills  in  pyaemia  are  supposed  by  Billroth  to  be  associated  with 
inflammation,  and  he  says  :  "  It  must  be  mentioned,  as  a  matter  of  obser- 
vation, that  chills  occur  almost  exclusively  in  the  commencement  of  an 
acute  inflammation,  and  are  intermittent  only  in  intermittent  fever  and 
reabsorption  of  pus,  while  they  do  not  occur  in  acute  septicaemia. "  * 
But  the  fever  in  pyaemia  rarely  intermits  entirely  ;  it  is  generally  lower, 
however,  in  the  morning  than  in  the  afternoon.  This  symptom  is  even 
more  important  than  the  rigors  in  enabling  the  surgeon  to  make  a  correct 
diagnosis.  Let  it,  however,  be  remembered  that  the  temperature  fre- 
quently becomes  very  high  within  a  few  hours  after  the  receipt  of  an 
injury  or  the  performance  of  a  surgical  operation ;  that  this  high  tem- 
perature may  be  due  to  septic  absorption,  and  that  this  diseased  condition 
is  what  we  designate  as  septicaemia.  Another  condition,  less  marked,  with 
an  elevated  but  somewhat  lower  temperature,  is  usually  spoken  of  as  trau- 
matic fever.  In  this  condition  the  fever  may  gradually  increase  for  a  few 
days,  and  then  disappear. 

One  important  peculiarity  of  the  temperature  in  pyaemia  are  the  sud- 
den and  great  changes ;  thus,  at  one  hour  the  temperature  may  be  slightly 
raised  above  the  normal,  and  at  the  next  the  thermometer  may  mark  105° 
F.  These  sudden  changes  of  temperature  are  of  frequent  occurrence,  are 
not  observed  to  the  same  extent  in  any  other  disease,  and  therefore  sup- 
ply a  very  important  diagnostic  indication.  It  is  impossible  to  kiiow^ 
or  even  to  anticipate  with  any  degree  of  certainty,  when  the  highest 
temperature  will  exist;  consequently,  Billroth  and  other  writers  have 
suggested  the  desirability  of  having  a  thermometer  constantly  kept  in  a 
position  to  indicate  every  change  in  the  heat  of  the  body,  and  a  careful 
attendant  to  note  the  same ;  but,  thus  far,  I  am  not  aware  that  this  has 
been  attempted,  probably  on  account  of  the  inconvenience  to  the  patient 
and  the  additional  labor  in  nursing  it  would  entail.  It  has  been 
further  observed  that  during  the  existence  of  a  chill  the  temperature 
continues  to  steadily  increase,  and  the  maximum  seen  during  the  whole 
course  of  the  disease  is  attained  during  the  hot  stage  which  immediately 
follows  the  rigors.  "  This  condition  is  followed  by  profuse  cold  perspira- 
tions. The  perspirations  which  accompany  this  disease  are  most  profuse, 
like  those  of  advanced  phthisis.  They  never  precede  the  rigors,  but  may 
occur  independently  of  them.  They  are  either  continuous  in  their  dura- 
tion, or  exhibit  more  or  less  distinct  exacerbations.  They  are  occasionally 
accompanied  by  sudamina,  and  they  do  not  abate  with  the  use  of  any 

known  remedy Occasionally  perspiration  is  scanty ;  but  before 

death  a  cold  clammy  sweat  and  a  tawny  discoloration  of  the  skin  occur."  2 

Besides  the  sudamina  there  are  frequently  observed  on  the  skin  vesicles, 
pustules,  and  boils,  purpuric  patches,  and  various  discolorations.  There 
is  frequently  observed  to  arise  in  the  neighborhood  of  the  wound  a  reddish 
erythematous  blush,  which  soon  extends  to  the  whole  limb,  and  commonly 
begins  to  disappear  in  the  early  part  of  the  second  week.  This  recent!}' 
occurred  to  a  patient  under  my  care,  and  was  speedily  followed  by  an 
abscess  of  the  knee-joint.  The  wound  was  situated  at  the  hip-joint, 

1  Surgical  Pathology,  p.  344.  2  Braid  wood,  op.  cit.,  p.  112. 


SYMPTOMS  OF  PYMMIA,  975 

and  the  first  change  in  the  color  of  the  integument  took  place  around 
its  lips.  The  redness  extended  rapidly  downward  until  it  covered  the 
foot,  and  even  the  toes ;  but  the  extension  upward  was  slight,  not  much 
above  the  nates,  on  which  there  was  situated  at  the  time  a  bed-sore.  It 
observed  the  same  order  in  passing  off  as  in  coming  on — i.  e.  where  it  first 
made  its  appearance  it  first  disappeared.  The  superficial  veins  leading 
from  the  wound  were  inflamed  and  cord-like.  This  condition  of  the 
integument  and  the  abscess  of  the  knee-joint  were  followed  by  diarrhoea, 
on  which  medicines  had  no  beneficial  effect.  It  continued,  with  occa 
sional  vomiting,  until  the  death  of  the  patient. 

The  pulse  in  pyaemia  may  be  nearly  normal  as  regards  frequency,  while 
at  other  times  very  rapid.  It  has  been  remarked  in  some  cases  that 
the  pulse  seldom  rose  above  90  per  minute  until  near  death.  The  pulse, 
although  only  moderately  accelerated  at  the  commencement  of  the 
disease,  always  becomes  more  rapid,  quick,  feeble,  and  irregular  toward 
the  termination  of  the  unfavorable  cases,  while  in  cases  of  recovery  it 
returns  gradually  to  the  normal  standard. 

In  all  cases  in  which  the  blood  has  been  examined  during  the  progress 
of  pyaemia  the  examiners  have  agreed  in  regard  to  its  extreme  coagula- 
bility, the  diminution  of  the  number  of  red  corpuscles,  and  the  increase 
of  the  granular  spherical  bodies.  The  red  corpuscles,  even  in  the  earlier 
stages  of  the  disease,  show  evident  indications  of  disintegrating ;  and  these 
become  more  and  more  marked  as  the  disease  progresses,  while  there  is  a 
steady  increase  in  the  number  of  pus-  or  possibly  of  white  blood-corpus- 
cles. Epistaxis  occasionally  occurs,  and  also  venous  oozing  from  the 
wound. 

The  condition  of  the  tongue  in  pyaemia  may  be  regarded  as  an 
important  symptom,  indicating  the  state  of  the  alimentary  canal — not, 
however,  during  the  prodomal  stage,  but  after  the  disease  has  progressed 
a  few  days.  It  is  then  observed  that  the  tongue  has  become  peculiarly 
smooth,  dry,  and  often  excessively  red.  This  smoothness  is  caused  by 
the  collapse  of  the  papillae,  and  the  dryness  by  a  diminished  secretion. 
The  organ  now  frequently  appears  as  if  covered  with  a  thin  layer  of 
collodion  which  had  been  caused  to  dry  on  the  surface,  so  as  to 
present  a  glazed  look.  Again,  the  tongue  may  be  covered  with  brown 
crusts  and  the  teeth  with  sordes.  These  brown  crusts  and  sordes  are 
usually  seen  in  advanced  cases,  following  the  first  condition  described. 
Much  importance  is  attached  to  these  brown  crusts  by  many  experienced 
surgeons,  and  although  there  may  be  very  marked  improvement  in  all 
other  symptoms,  still  they  insist  on  a  very  guarded  prognosis  until  the 
tongue  has  assumed  a  healthy  appearance.  Aphthae  on  various  parts  of 
the  mouth  and  pharynx  are  frequently  present  in  the  more  chronic  cases, 
but  are  usually  absent  in  acute  cases.  Herpes  of  the  lips  sometimes 
occurs  in  the  commencement  of  the  disease. 

Vomiting  is  comparatively  rare,  but  there  is,  even  in  the  early 
stages,  a  complete  failure  of  the  appetite,  with  great  thirst.  Singultus 
is  rarely  present  in  genuine  .pyaemia,  but  frequently  so  in  septicaemia, 
and  occasionally  in  septo-pyaemia.  Diarrhoea  is  ^  not  so  frequent  or  the 
stools  so  copious  in  pyaemia  as  in  septicaemia.  Billroth  observed  in  one 
hundred  and  eighty  cases  of  pyaemia  thirty-two  cases  of  diarrhoea.  It  is 
impossible  to  determine  whether  those  cases  in  which  the  diarrhoea 


976  PYJEM1A  AND  SEPTICAEMIA. 

occurred  were  pure  or  mixed  pyaemia.  The  stools  are  often  of  a  pappy 
consistence,  and  passed  involuntarily  in  bed.  There  are,  however,  severe 
cases  of  pyaemia  with  high  fever,  and  accompanied  by  obstinate  con- 
stipation. 

Examination  of  the  heart  may,  in  rare  cases,  show  the  existence  of 
pericarditis,  although  usually  the  only  indications  of  disease  are  the  too 
feeble  sounds.  Auscultation  and  percussion  of  the  lungs  may  yield  un- 
satisfactory results  when  the  metastatic  abscesses  are  small  and  scattered, 
for  the  same  reason  as  in  miliary  tuberculosis.  The  large  deposits  in  the 
lungs  are  by  these  means  readily  determined.  There  may  be  a  sensation 
of  suffocation,  the  pneumonic  sputa,  the  friction  sound  of  pleurisy,  or  the 
signs  of  pleuritic  effusion;  and  the  existence  of  these  symptoms  or  signs 
would  naturally  aid  in  the  diagnosis  of  metastatic  abscesses. 

Enlargement  of  the  liver  and  spleen  may  be  determined  before  death, 
and  in  connection  with  other  symptoms  would  aid  in  diagnosing  deposits 
in  these  organs. 

The  urine  in  the  first  stage  of  this  disease  is  scanty,  high-colored,  con- 
tains a  large  amount  of  salts,  and  is  of  a  high  specific  gravity.  Epithelial, 
fibrinous,  and  blood  casts,  and  also  albumen,  are  occasionally  found  in  it 
during  the  course  of  the  disease.  Billroth  mentions  a  case  in  which  there 
was  complete  suppression,  with  uraemia. 

In  many  cases  of  pyaemia  suppuration  of  the  joints,  one  after  another, 
takes  place  with  great  rapidity  and  with  comparatively  little  pain,  but 
occasionally  some  swelling,  redness,  etc.  are  present.  In  most  cases  these 
suppurations  are  easily  diagnosed.  Instead  of  suppuration  taking  place 
in  the  joints,  there  are  cases  in  which  it  occurs  in  the  cellular  tissue ;  and 
I  have  recently  seen  a  case  where  abscess  after  abscess  formed  with  such 
rapidity  that  within  a  single  week  the  patient  was  literally  covered  with 
abscesses  from  the  crown  of  his  head  to  the  soles  of  his  feet. 

Delirium  generally  exists  during  some  stage  of  the  disease,  more  fre- 
quently the  last,  and  is  then  mild  in  its  character,  although  active  delirium 
has  been  observed  in  the  first  stage.  Patients  are  low-spirited  and  very 
apprehensive  of  death.  The  face  at  the  beginning  of  the  attack  may  be 
flushed  or  pallid,  but  toward  the  end  it  always  becomes  careworn  and 
haggard.  The  breath  occasionally  has  a  sweetish  or  purulent  odor. 

The  changes  in  the  wound  are  in  some  cases  very  marked,  even  in  the 
first  stage  of  the  disease.  The  suppuration,  which  has  been  previously 
free  and  healthy,  may  be  suddenly  checked,  the  wound  becoming  dry. 
The  discharge,  if  it  continues,  becomes  scanty,  thin,  ichorous,  or  greenish. 
The  granulations,  if  previously  healthy,  may  soon  slough.  These  changes 
may  not  always  appear  in  the  first  stage,  but  should  they  not  then  take 
place  they  may  be  expected  later  in  the  disease. 

SYMPTOMS  OF  SEPTIC^MIA. — These  are  commonly  developed  within 
twenty-four  hours  after  the  receipt  of  an  injury  or  the  performance  of 
a  surgical  operation,  and  they  may  be  sketched  as  follows :  Frequent 
pulse;  tongue,  lips,  and  throat  dry;  skin  hot  and  the  temperature 
of  the  body  high.  The  patient  replies  accurately  to  questions,  but 
\\ith  some  hesitation.  He  is  much  inclined  to  sleep,  has  entirely 
failed  to  take  nourishment,  drinks  frequently  when  aroused  from  his 
lethargic  condition,  and  has  vomited  everything  taken  into  his  stomach 
since  the  receipt  of  the  injury  or  the  performance  of  the  operation.  If 


SYMPTOMS  OF  SEPTICAEMIA.  977 

the  dressings  are  now  removed  from  the  wound,  the  foul  odor  of  putre- 
faction greets  the  attendants.  In  cases  of  amputation-wounds  consider- 
able discoloration  of  the  flaps  may  be  observed,  the  edges  being  black- 
ened. Above  these  blackened  edges  the  integument  is  reddened  and 
slightly  cedematous.  The  wound  having  been  closed  with  sutures,  which 
are  now  removed,  there  escapes  a  few  drachms — possibly  ounces — of 
highly  offensive  fluid,  the  decomposed  remains  of  blood,  etc.  A  fur- 
ther examination  of  the  flaps  on  their  inner  surfaces  show  that  their 
capillary  circulation  has  ceased.  The  tissues,  instead  of  presenting  a  life- 
like appearance,  are  now  of  a  very  dark  color  and  occasionally  mottled 
with  dull  grayish  spots,  although  the  movements  of  the  ligature  at  the 
point  where  it  embraces  the  femoral  artery,  for  example,  show  that  the 
blood  still  rushes  against  the  artificial  boundary. 

Let  us  now  leave  our  patient,  without  further  comment,  for  the  next 
forty-eight  hours,  when  we  will  resume  the  examination.  We  now  find 
the  same  dryness  of  the  mouth  that  was  previously  noticed  ;  the  pulse  is- 
more  frequent,  and  has  become  very  feeble ;  he  complains  of  much  thirst, 
has  vomited  frequently,  and  has  taken  very  little  nourishment,  and  that 
only  at  the  earnest  solicitations  of  the  attendants.  The  temperature  is 
higher  than  at  the  former  examination,  and  has  been  steadily  increasing ; 
in  the  morning  it  is  lower,  however,  than  in  the  evening  of  the  same  day. 
The  patient  is  lethargic,  and  is  suffering  with  a  profuse  diarrhoea.  The 
odor  of  the  stools  is  highly  offensive ;  they  are  properly  described  as  rice- 
water  evacuations.  The  abdomen  is  tympanitic;  the  body  bathed  in  per- 
spiration ;  thje  respirations  rapid ;  the  urine  scanty,  high-colored,  and  con- 
tains albumen.  The  examination  of  the  stump  shows  that  gangrene  has 
extended  rapidly,  involving  not  only  the  flap,  but  a  portion  of  the  adja- 
cent tissues.  The  stench  arising  from  the  wound  is  almost  stifling.  The 
decomposing  fluids  are  continually  forming.  That  portion  of  the  thigh 
not  already  gangrenous  is  now  very  cedematous,  and  the  integument  cov- 
ering it  is  much  discolored,  being  of  a  dark,  icteric,  or  reddened  hue. 

We  now  allow  twenty-four  hours  to  elapse,  and  then  make  our  final 
examination.  The  patient's  tongue  is  more  moist;  the  body  still  bathed 
in  perspiration ;  the  eyes  dull ;  the  conjunctive  icteric,  and  the  same  hue 
extends  to  the  body,  though  in  a  less  marked  degree ;  the  pulse  has 
become  very  frequent,  feeble,  and  not  easily  counted ;  the  temperature  is 
below  normal.  Singultus  is  now  present,  and  has  been  so  during  the  last 
twenty-four  hours.  Bronchial  symptoms,  combined  with  marked  oedema 
of  the  right  lung,  have  appeared ;  the  diarrhoea  continues  the  same ;  the 
gangrene  is  still  extending. 

It  must  be  admitted  that  the  report  here  offered  shows  only  the 
symptoms  that  are  found  in  a  single  class  of  cases.  The  symptoms 
vary  greatly  in  different  cases,  but  they  are  especially  marked  in  the 
acute  sepsis  mentioned  by  Massanneuve  under  the  head  of  ganyrtne 
foudroyante.  In  these  cases  there  appears,  immediately  after  the  receipt 
of  an  injury,  enormous  oedema  about  the  wound,  which  extends  rapidly 
in  every  possible  direction,  followed  by  the  death  of  the  patient  within 
a  few  hours  unless  prompt  measures  are  adopted.  The  puncture  of  the 
cellular  tissue  or  of  the  blood-vessels  involved  in  the  oedema  prior  to  the 
death  of  the  patient  gives  rise  to  the  escape  of  a  highly  offensive  gas. 
Roser  mentions  a  case  of  this  disease  in  which  he  promptly  amputated 


VOL.  I.— 62 


978 


PYJEMIA  AND  SEPTICAEMIA. 


the  limb  of  the  patient  through  the  healthy  parts,  without  even  waiting 
for  the  administration  of  an  anaesthetic,  and  his  patient  recovered. 

The  symptoms  of  septicaemia  must  necessarily  depend  greatly  on  the 
condition  of  the  patient  and  the  amount  of  septic  material  introduced, 
but  it  is  not  deemed  necessary  to  dwell  longer  on  this  subject. 

DIAGNOSIS. — It  is  thought  that  a  brief  presentation  of  the  etiological, 
pathological,  and  semiological  differences  may  be  advantageous  to  busy 
physicians  who  desire  to  obtain,  with  the  least  expenditure  of  time,  an 
accurate  knowledge  of  the  chief  points  of  distinction  between  these  morbid 
conditions.  This  effort  at  differentiation  is  merely  intended  to  place  the 
most  important  characteristics  in  marked  contrast ;  and  consequently  it 
should  be  remembered  that  it  is  not  our  intention  to  give  here  the  complete 
etiology,  pathology,  or  semiology  of  either  of  these  morbid  states,  but  only 
tHeir  essential  differences.  Furthermore,  it  is  thought  that  the  following 
arrangement  will  facilitate  the  object  which  we  desire  to  accomplish : 


ETIOLOGY. 


PY^IMIA. 


1.  Pyaemia  generally,  commences  with 

the  putrefaction  in  an  open  wound 
of  the  secondary  wound-fluids — pus, 
etc. — in  which  there  are  developed 
globular  bacteria,  which  enter  the 
blood  and  certain  tissues  of  the 
body,  where  they  multiply  and  pro- 
duce constitutional  disturbances. 

2.  Pyaemia   is  commonly  preceded    by 

some  local  inflammatory  wound- 
complication,  such  as  suppurative 
periostitis,  osteo-myelitis,  etc.,  and 
is  rarely  developed  before  the  end 
of  the  second  week  after  the  receipt 
of  the  injury. 


SEPTIC^MIA. 


1.  Septicaemia  generally  commences  with 

the  putrefaction  in  an  open  wound 
of  the  primary  wound-fluids — blood, 
serum,  etc. — in  which  there  are  de- 
veloped rod  bacteria,  which  enter 
the  blood  and  certain  tissues  of  the 
body,  where  they  multiply  and  pro- 
duce constitutional  disturbances. 

2.  Septicaemia  is  commonly  a  primary 

wound-complication,  which  is  gene- 
rally developed  within  forty-eight 
hours  after  the  receipt  of  the  in- 
jury- 


PATHOLOGY. 


1.  Increased  coagulability  of  the  blood. 

2.  There  are  metastatic  abscesses  in  va- 

rious parts  of  the  body,  especially 
in  the  lungs,  liver,  and  kidneys : 
serous  cavities  frequently  contain 
sero-purulent  deposits;  similar  de- 
posits are  often  found  in  the  joints; 
abscesses  in  the  cellular  tissue  ;  and 
also  abundant  evidence  of  the  ex- 
istence during  the  life  of  the  patient 
of  pyaemic  endo-  and  pericarditis. 


1.  Diminished  coagulability  of  the  blood. 

2.  Complete  absence  of  purulent  or  ich- 

orous  deposits  in  all  cases  of  un- 
mixed septicaemia.  Post-mortem 
appearances  may  be  completely 
negative,  with  the  exception  of  the 
condition  of  the  blood,  although 
there  is  often  some  oedema  of  the 
lungs. 


SEMIOLOGY. 


1.  Pyaemia  commonly  commences  with 

a  chill. 

2.  Fever  variable,  but   rarely  entirely 

intermits. 

8.  Sudden  and  great  changes  in  temper- 
ature, followed  by  profuse  perspira- 
tion. 


1.  Septicaemia     commonly    commences 

without  a   chill. 

2.  Fever  steadily  increases,  but  is  lower 

in  the  morning. 

3.  The  temperature  is  high  at  the  be- 

ginning of  the  disease,  increases 
until  near  the  fatal  termination, 
when  it  falls  below  the  normal. 
The  skin  is  moist,  but  without 
profuse  sweatings. 


TREATMENT. 


979 


PYAEMIA. 

4.  Pulse  variable;  toward  the  fatal  end 

rapid,  feeble,  and  irregular. 

5.  Fades  at  the  beginning  flushed  or 

pallid,  toward  the  end  careworn. 

6.  Tongue  smooth,  dry,  and  excessively 

red,  later  brown-coated,  and  even 
the  teeth  coated  with  sordes. 

7.  Diarrhoea  with  stools  of  a  pappy  con- 

sistence. 

8.  Epistaxis. 

9.  Mild  delirium  toward  the  fatal  end. 


10.  Aphthae  in  the  mouth  and  throat, 
sudamina,  vesicles,  pustules,  and 
purpuric  patches. 


SEPTICAEMIA. 

4.  Pulse  rapid,  and  gradually  increases 

in  frequency  toward  the  fatal  end. 

5.  Facies   expressive  of  a  dull,  listless 

condition    throughout    the    whole 
course  of  the  disease. 

6.  Tongue,  lips,  and  throat  dry  at  the 

commencement,    toward    the    end 
_moist.     Thirst  is  marked. 

7.  Eice- water  evacuations,  very  offensive ; 

obstinate  vomiting. 

8.  Epistaxis  rarely  occurs. 

9.  A  lethargic  condition  from  the  begin- 

ning, increasing  toward   the  fatal 
end. 

10.  Icteric  hue  of  conjunctivas ;  singul- 

tus  often  present. 


The  differences  in  the  local  manifestations  occurring  in  and  around  the 
wound,  during  the  progress  of  these  diseases,  may  be  summed  up  as 
follows  : 


At  the  commencement  of  this  disease 
the  suppuration  is  commonly  checked, 
the  wound  becoming  dry,  and  if  a 
discharge  continues,  it  becomes  scanty, 
thin,  ichorous,  greenish,  etc.  The 
granulations,  when  previously  healthy, 
soon  slough,  and  venous  oozing  some- 
times takes  place.  There  occasionally 
appears  in  the  later  stages  of  this 
disease  around  the  wound  a  reddish 
erythematous  blush,  which  soon  ex- 
tends over  the  whole  limb. 


The  odor  of  putrefaction  is  commonly 
very  marked  within  twenty-four  hours 
after  the  receipt  of  the  injury,  the 
integument  slightly  reddened  about 
the  wound,  and  the  surrounding  parts 
somewhat  cedematous.  The  wound- 
tissues  soon  assume  a  dark-brown 
color,  and  are  occasionally  mottled 
with  dull  grayish  spots,  while  the 
edges  of  the  wound  are  at  the  same 
time  blackened,  although  the  move- 
ments of  the  ligature,  when  arteries 
have  been  tied,  show  us  that  the  blood 
still  rushes  against  its  artificial  bound- 
ary. 

TREATMENT. — It  must  be  admitted  that  the  management  of  either 
pyaemia  or  septicaemia,  when  fully  developed,  is  always  unsatisfac- 
tory, and  generally  unsuccessful;  consequently,  the  success  which  has 
attended  the  use  of  the  prophylactic  measures  employed  in  connection 
with  the  treatment  of  wounds  during  the  last  ten  years  has  given  much 
satisfaction  to  the  medical  profession.  The  committee  of  the  London 
Pathological  Society  reports  as  follows  on  this  subject:  "The  accumu- 
lation of  septic  matter  in  the  uterus  after  labor,  in  contact  with  the 
raw  surface  left  by  the  separation  of  the  placenta,  would  also  present  the 
conditions  favorable  to  acute  septic  intoxication.  In  the  present  day, 
when  the  necessity  of  thorough  drainage  of  wounds  is  so  thoroughly 
understood,  and  the  means  at  the  surgeon's  command  for  carrying  it  out 
are  so  efficient,  it  can  only  be  under  peculiar  circumstances  that  a  suffi- 
cient quantity  of  putrid  serum  or  pus  to  yield  .the  fatal  dose  of  the  septic 
poison  is  allowed  to  accumulate  in  the  wound.  Moreover,  the  antiseptic 
treatment  of  wounds,'  now  so  'largely  adopted,  by  preventing  decomposi- 
tion of  course  renders  septic  intoxication  impossible.  Ovariotomy  would 
seem  to  furnish  conditions  most  favorable  to  septic  intoxication,  and  a 
large  proportion  of  the  deaths  occurring  in  the  first  forty-eight  hours 


980  PY^MIA  AND  SEPTICAEMIA. 

have  always  been  attributed  to  it.  The  proportion  of  fatal  cases  from 
this  cause  has,  however,  of  late  been  greatly  diminished  by  drainage,  and 
more  especially  by  the  employment  of  the  antiseptic  treatment."  l 

AVe  cannot  repeat  too  frequently  or  too  emphatically  the  fact  that  the 
treatment  of  pyaemia  and  septicaemia,  when  fully  developed,  is  almost 
invariably  unsuccessful,  and  that  consequently  he  who  desires  to  save  the 
greatest  number  of  lives  must  make  every  exertion  and  use  all  avail- 
able means  to  prevent  their  development — a  task  which  fortunately 
has  now  been  brought  within  the  scope  of  possibility  in  the  large 
majority  of  cases.  Every  surgeon  will  readily  admit  that,  were  it 
possible  to  secure  union  by  first  intention  in  all  cases  of  wounds,  then 
it  would  be  impossible  for  either  septicaemia  or  pyaemia  to  occur  in  sur- 
gical practice.  Therefore,  it  follows  that  the  character  of  the  wound,  the 
method  of  operation,  the  surroundings  of  the  patient,  the  character  of  the 
treatment,  become  proper  points  to  consider  in  this  division  of  the  sub- 
ject. The  character  of  the  wound  and  its  relations  to  pyaemia  and  septi- 
caemia have  already  been  briefly  referred  to  under  the  etiology  of  these 
disease^.  The  various  methods  of  operating,  with  their  respective  advan- 
tages and  disadvantages,  are  of  course  not  suitable  topics  for  discussion 
in  this  work. 

The  surroundings  of  the  patient  form  a  subject  of  vast  importance  in  a 
prophylactic  view,  and  should  never  be  lost  sight  of  in  the  construction 
of  hospitals.  I  desire  here  to  express  my  firm  conviction  that  surgical 
pyaemia  is  essentially  and  almost  wholly  a  hospital  disease.  The  question 
of  surroundings  for  the  patient  presents  to  my  mind  the  following 
demands  as  a  sine  qua  non  for  obtaining  the  best  possible  results  in  sur- 
gery :  (1)  Absolute  cleanliness.  This  demand  should  be  strictly  enforced 
in  regard  to  the  wound,  the  patient's  body,  the  bedding,  and  everything 
else,  including  nurses  and  instruments.  (2)  Absolute  purity  of  the 
atmosphere.  (3)  Moderate  and  equable  temperature,  containing  a  proper 
amount  of  moisture.  (4)  Froper  quantity  of  nutritious  and  easily 
digestible  food,  with  suitable  drinks,  etc.  (5)  Cheerful  and  pleasant 
surroundings,  especially  in  companions,  nurses,  and  other  attendants. 
It  may  be  objected  to  these  conditions  that  they  can  never  be  obtained. 
I  must  confess  that  perfection  in  every  detail  cannot  always  be  attained, 
but  I  am  thoroughly  convinced  that  he  who  makes  a  determined  effort  in 
this  direction  will  succeed  far  better  than  that  person  who  is  constantly 
looking  about  for  some  excuse  for  negligence. 

The  question  of  treatment  brings  up  the  entire  subject  of  antiseptics.  The 
favorite  remedies  of  this  class  are  carbolic  and  salicylic  acids,  permanganate 
of  potassium,  chloride  of  zinc,  bichloride  of  mercury,  and  liquor  sodae  chlor- 
inatae.  There  is  no  doubt  that  good  results  may  be  obtained  with  any  of  these 
remedies.  The  surgeon  should  never  forget  that  he  uses  medicines  merely 
as  agents  to  enable  him  to  accomplish  certain  objects ;  and,  keeping  this 
in  mind,  he  need  very  seldom  fail  with  his  antiseptic  when  the  object  is 
to  prevent  putrefaction  in  an  open  wound.  Therefore  it  appears  certain 
that  each  method  of  treatment  may  possess  special  advantages  in  par- 
ticular cases,  and  probably  the  same  may  be  said  of  the  antiseptic  itself. 
The  importance  of  this  subject  may  be  more  fully  appreciated  when  it  is 
remembered  that  it  is  generally  admitted  by  the  best  surgical  authorities 
1  Trans.  Path.  Soc.  of  London,  vol.  xxx.  p.  15. 


TREATMENT.  981 

that  more  lives  are  lost  from  septic  infection  than  from  all  other  causes 
combined  during  a  war.  The  further  consideration  of  this  subject  may 
be  arranged  for  convenience  under  the  heads  of  local  and  general  treat- 
ment. 

The  local  treatment  of  the  wound  should,  if  possible,  be  of  such  a 
character  as  to  prevent  the  absorption  of  either  putrid  substances  or  pus. 
It  therefore  becomes  highly  important,  in  cases  of  amputation  and  other 
operations,  that  all  tissues  injured  to  such  a  degree  as  to  be  likely  to 
excite  either  putrefaction,  irritation,  or  inflammation  should  be  removed. 
The  same  care  is  necessary  in  removing  all  foreign  bodies  from  the  wound 
in  cases  where  no  operation  is  to  be  performed.  The  amputation  of  the  in- 
jured limb  may  be  necessary  to  prevent  the  development  of  these  diseases, 
or  it  may  be  resorted  to  in  certain  rare  cases  after  the  origin  of  pyaemic  symp- 
toms ;  however,  in  the  latter  instance  great  care  should  be  taken  to  remove 
all  the  tissues  already  infiltrated  with  serum,  otherwise  nothing  will  be 
gained.  The  use  of  the  surgeon's  knife  at  the  proper  time  may  be  the  best 
prophylactic  against  both  pyaemia  and  septica3iuia,  but  it  should  be  directed 
by  an  intelligent  mind  and  the  instrument  guided  by  a  practiced  hand. 
Again,  it  is  found  that  opening  a  large  medullary  cavity  may  be  attended 
with  danger  to  the  patient.  This  fact  teaches  us  an  obvious  lesson. 

The  wound  existing  or  the  operation  having  been  performed,  the  surgeon 
now  turns  his  attention  to  the  prevention  of  putrefaction  and  inflammation. 
The  first  source  of  danger  requiring  attention  from  the  surgeon  is  the 
fluid  escaping  from  the  wounded  surface.  Do  not  allow  it  to  undergo 
putrefaction  in  contact  with  the  wound.  It  should  not  be  forgotten  that 
pyaemia  is  an  infectious  disease,  having  its  origin  in  a  local  nidus,  an 
open  wound,  in  which  putrefaction  of  pus  or  other  wound-fluid  is  taking 
place.  The  question  of  amputation,  or  of  the  extirpation  of  the  parts  for 
the  relief  of  this  disease,  should  only  be  entertained  when  the  surgeon  is 
confident  that  he  can  remove  the  whole  of  the  infiltrated  tissues.  In 
other  words,  the  performance  of  these  operations  after  the  disease  has 
become  constitutional  can  never  be  advantageous  to  the  patient.  Even 
in  those  cases  where  infiltration  is  limited  to  the  lymphatics,  unless 
all  these  glands  so  affected  are  removed  the  operation  will  be  unsuccess- 
ful. It  has  been  further  recommended  in  the  treatment  of  this  disease, 
in  order  to  prevent  the  formation  of  metastatic  abscesses,  to  ligate  the 
veins  in  which  thrombi  have  formed  or  may  be  reasonably  expected  to 
form,  at  some  convenient  point  between  the  heart  and  these  obstructed 
points.  The  value  of  this  proceeding  has  never  been  fully  determined, 
and  may  be  reasonably  questioned.  The  formation  of  metastatic  abscesses 
in  various  parts  .of  the  body  within  the  reach  of  the  surgeon's  scalpel 
demands  his  attention  ;  and  we  have  been  taught  by  experience  that  they 
should  be  speedily  opened,  which  generally  lowers  the  temperature  and 
diminishes  the  danger  from  septic  absorption.  In  the  performance  of 
this  operation  Lister's  antiseptic  system  of  wound-treatment  should  be 
strictly  adhered  to,  since  it  unquestionably  gives  the  best  results  which 
can  be  obtained  under  the  circumstances.  When  the  metastatic  inflam- 
mation which  occasionally  appears  in  the  thyroid  and  parotid  glands  dur- 
ing the  course  of  this  disease  terminates  in  the  formation  of  pus,  this 
should  be  speedily  evacuated.  This  prompt  action  is  often  required, 
particularly  for  the  relief  of  the  grave  symptoms  which  are  apt 


982  PYAEMIA  AND  SEPTICAEMIA. 

to  arise  in  connection  with  respiration  and  deglutition.  The  accumula- 
tion of  pus  within  the  joints  in  pysemic  cases  should,  it  is  now  thought, 
be  treated  in  the  same  manner  as  abscesses  in  the  cellular  tissues — i.  e. 
the  articulations  should  be  opened  and  thoroughly  disinfected,  and  after- 
ward kept  in  a  perfectly  aseptic  condition,  and  also  rendered  absolutely 
immovable  during  the  treatment. 

Having  directed  attention  to  the  more  important  local  measures,  we 
may  now  briefly  enter  on  the  consideration  of  some  of  the  constitutional 
remedies.  In  the  general  treatment  of  pyaemia  there  have  been  recom- 
mended at  various  times  a  great  variety  of  drugs,  but  the  general  want  of 
success  attending  their  use  leaves  comparatively  few  to  be  mentioned  here. 
The  mineral  acids  are  still  employed,  and  are  found  to  be  at  least  agreeable 
drinks,  and  as  such  can  be  still  recommended.  The  sulphites  of  magne- 
sium, sodium,  potassium,  and  lime  were  recommended  by  Giovanni  Polli 
for  the  treatment  of  typhus  fever,  scarlet  fever,  small-pox,  septicaemia,  and 
pyaemia.  He  further  suggested  that  the  medicine  should  be  given  until 
the  whole  quantity  taken  bore  to  the  weight  of  the  patient's  body  the  pro- 
portion of  1  to  1000.  The  experiments  made  on  animals  with  these  salts 
seem  to  confirm  their  value  in  the  treatment  of  septic  diseases.  It  is  cer- 
tainly true  that  animals  treated  with  these  salts  are  not  so  easily  affected 
by  septic  poison  as  those  which  have  not  received  this  treatment.  Fur- 
ther, it  has  been  shown  that  putrid  substances  when  mixed  with  either 
permanganate  of  potassium  or  the  sulphite  of  sodium,  and  then  injected, 
are  harmless,  although  the  same  quantity  of  putrid  matter  injected  with- 
out either  of  these  salts  destroys  life. 

Brandy  and  other  alcoholic  stimulants  have  been  strongly  recommended 
an  account  of  their  well-known  antiseptic  properties.  The  sulphate  of 
quinia  is  certainly,  in  most  cases  of  pyaemia,  a  valuable  agent.  In  large 
doses  it  enables  the  surgeon  to  reduce  the  temperature  of  the  patient,  and 
in  smaller  doses  it  frequently  serves  a  valuable  purpose  as  a  tonic.  It 
has  also  considerable  value  as  an  antiseptic. 

Lattiu  has  recommended  the  use  of  large  doses  of  ergotine  in  infec- 
tious fevers,  but  this  substance,  when  employed  in  the  treatment  of 
pyaemia,  should  be  given  in  the  formative  stage  of  the  disease.  The  use 
of  drastic  cathartics  should  be  avoided,  as  should  that  of  sudorifies,  on 
account  of  their  prostrating  effects.  In  some  cases  hypnotics  may  be 
required  to  secure  sleep. 

Tonics  are  always  more  or  less  useful.  The  free  use  of  stimulants  and 
nutritious  food  is  also  indicated.  Brandy,  wine,  and  whiskey  may  be 
advantageously  used  as  stimulants.  Musk,  ammonia,  and  camphor  are 
occasionally  required.  However,  it  should  not  be  forgotten  that  in  cases 
where  the  disease  has  become  fully  developed  the  usual  termination  is 
death,  few  recoveries  being  recorded.  In  the  early  stages  of  tin's  affec- 
tion, by  the  removal  of  the  patient  from  an  overcrowded  hospital  ward 
to  some  place  where  pure  air  and  proper  hygienic  arrangements  can  be 
obtained,  recovery  may  take  place,  but  under  other  circumstances  the 
prognosis  is  exceedingly  grave. 

The  treatment  of  septicaemia  in  most  particulars  is  the  same  as  that  of 
pyaemia.  The  first  effort  should  be  to  prevent  the  development  of  the  dis- 
ease, and  the  second  to  care  for  the  patient  in  cases  where  the  affect iou  has 
already  developed.  It  is  not,  of  course,  in  our  power  to  limit  or  in  any  way 


TREATMENT.  983 

regulate  the  primary  injury,  for  we  are  obliged  to  take  the  patient  as  he 
is.  The  amount  of  injury  to  living  tissue  may  be  great  or  small.  The 
question  of  an  operation,  the  character  of  the  same,  and  the  subsequent 
management  must  be  determined  in  accordance  with  the  circumstances 
of  eacli  particular  case. 

The  primary  death  of  the  parts  is  generally  due  chiefly  to  the  injury 
itself;  the  secondary,  frequently  to  bad  surgical  management.  Let  us 
now  take  a  case  in  which  the  primary  injury  has  been  severe,  greatly 
diminishing,  but  not  destroying,  the  circulation  in  the  injured  parts. 
Here  the  immediate  application  of  ice  would  be  injurious,  but  a  warm 
application  might  assist  nature.  It  is  humiliating  to  the  profession 
that  we  are  obliged  even  at  this  date  to  admit  that  the'  treatment  of 
septicamia  is  largely  symptomatic.  The  profuse  choleraic  diarrhoea 
which  generally  accompanies  this  disease  may  be  regarded  as  an  effort 
of  nature  to  eliminate  the  septic  poison ;  but,  nevertheless,  it  is  so  pros- 
trating in  its  effects  that  it  requires  to  be  controlled  with  properly  selected 
astringents,  and  these  remedies  may  be  still  further  aided  by  the  use 
of  stimulants  and  tonics. 

The  treatment  of  septicaemia  may  be  summarized  as  follows :  (1)  A  strict 
adherence  to  the  five  rules  given  under  the  head  of  the  prophylactic  treat- 
ment of  pyaemia.  (2)  The  avoidance  of  all  putrefaction  in  contact  with  the 
wound,  especially  prior  to  the  development  of  sufficient  granulations  to 
completely  cover  its  surface.  This  object  is  to  be  accomplished  by 
the  removal  of  all  necrotic  tissues,  the  avoidance  of  putrescent  fluids 
by  cleanliness,  and  the  proper  use  of  antiseptic  agents.  (3)  Free  use  of 
the  alkaline  sulphites  and  hyposulphites.  These  drugs  should  be  used  in 
all  cases  where  there  is  reason  to  anticipate  the  development  of  septic 
diseases,  as  soon  after  the  receipt  of  the  injury  as  practicable,  but  should 
not  be  neglected  even  after  the  disease  has  become  fully  developed.  (4) 
Sulphate  of  quinia  should  be  used  in  all  cases  where  the  temperature  is 
above  100°  F.,  and  its  persistent  use  in  large  doses  may  be  necessary  to 
prevent  the  fever  from  rising  still  higher.  It  will  be  remembered  in  this 
connection  that  experience  has  taught  us  that  "  a  temperature  of  108.5° 
F.  is  the  limit  beyond  which  life  can  no  longer  exist," 1  and  even  a  much 
lower  temperature  is  not  without  dangers.  "The  essential  danger  of 
fever  in  acute  diseases  consists,  then,  in  the  deleterious  influence  of  a 
high  temperature  on  the  tissues."  2 

The  treatment  of  puerperal  septicffimia,  although  requiring  the  appli- 
cation of  the  same  principles  as  any  other  form  of  this  disease,  may  be 
briefly  described  as  follows :  The  womb  should  be  maintained  in  a 
firmly-contracted  state  by  the  proper  use  of  ergot,  even  as  a  prophylactic 
measure,  and  also  during  the  whole  course  of  the  disease ;  the  uterus  and 
vagina  should  be  kept  in  an  aseptic  condition  by  the  efficient  use  of  anti- 
septics ;  sulphate  of  quinia  should  be  given  in  large  doses,  and  repeated 
as  often  as  may  be  necessary  in  order  to  lower  the  temperature ;  and 
morphia  or  some  form  of  opium  should  be  employed  for  the  relief  of 
the  pain. 

1  Liebermeister,  New  Sydenham  Soc.  Trans.,  vol.  Ixvi.  p.  278.  *  Ibid.,  p.  280. 


PUERPERAL   FEVER. 

BY  WILLIAM  T.  LUSK,  M.D. 


DEFINITION. — Puerperal  fever  is  an  infectious  disease,  due,  as  a  rule, 
to  the  septic  inoculation  of  the  wounds  which  result  from  the  separation 
of  the  decidua  and  the  passage  of  the  child  through  the  genital  canal  in 
the  act  of  parturition. 

To  maintain  this  definition  it  is,  however,  necessary  to  group  by  them- 
selves cases  of  childbed  fever  dependent  upon  causes  which  are  operative 
in  the  non-puerperal  condition,  though  the  latter  imparts  to  these  causes 
oftentimes  an  exceptional  activity  and  virulence.  In  this  category  are  to 
be  placed  especially  scarlatina,  typhus,  typhoid,  and  malarial  fevers.  It 
is  to  be  borne  in  mind  that  the  zymotic  fevers  may  provoke  in  the  puer- 
peral woman  the  same  inflammatory  lesions  commonly  associated  with 
puerperal  fever.1  This  is  in  accordance  with  the  well-known  surgical 
experience  that  a  febrile  paroxysm  from  any  cause  exerts  an  unfavorable 
influence  upon  a  wounded  surface. 

Like  all  brief  statements,  the  writer  is  well  aware  that  the  foregoing 
definition  is  necessarily  imperfect,  and  stands  in  need  of  further  limita- 
tions to  meet  the  requirements  of  exactness.  Exceptions,  however,  either 
apparent  or  real,  wrill  be  noted  hereafter  in  their  proper  connections. 

FREQUENCY. — In  a  careful  search  through  the  records  preserved  by 
the  Health  Department  of  New  York  City,  I  found  that  from  1868  to 
1875  inclusive  the  total  number  of  deaths  for  nine  years  was  248,533. 
Of  these,  3342  were  from  diseases  complicating  pregnancy,  from  the  acci- 
dents of  child-bearing,  or  from  diseases  of  the  puerperal  state;  or,  in  other 
words,  1  :  75  of  all  the  deaths  occurring  during  that  period  was  the 
result  of  the  performance  of  what  we  are  in  the  habit  of  regarding  as  a 
physiological  function. 

The  deaths  from  miscarriage,  from  shock,  from  prolonged  labor,  from 
instrumental  delivery,  from  convulsions,  from  hemorrhage,  from  rupture 
of  the  uterus,  and  from  extra-uterine  pregnancy,  and  deaths  from  eruptive 
fevers,  from  phthisis,  and  from  inflammatory  non-puerperal  affections  com- 
plicating childbirth,  made  a  total  of  1395,  or  about  42  per  cent.of  the  entire 
number.  The  remaining  1947  cases,  variously  reported  as  puerperal  fever, 
puerperal  peritonitis,  metro-peritonitis,  phlebitis,  phlegmasia  doleus,  pyae- 
mia, and  septica3mia,  represent  the  very  serious  sacrifice  of  life  resulting  from 
inflammatory  processes  which  have  their  starting-point  in  the  generative 
apparatus.  If  we  apply  the  general  term,  puerperal  fever,  to  this  class 
of  cases,  it  will  be  seen  that  the  malady  is  the  cause  of  nearly  one  one- 
1  Hervieux,  Traite  clinique  et  pratique  des  maladies  puerperales,  pp.  1073  el  seq. 
984 


MORBID  ANATOMY.  935 

hundred-and-twenty-seventh  of  all  the  deaths  occurring  in  the  city. 
The  actual  number  of  births  for  the  nine  years  in  question  was  roughly 
estimated  at  284,000 '—an  estimate  erring  upon  the  side  of  liberality.  The 
total  number  of  deaths  to  the  entire  number  of  confinements  was,  then 
at  least  in  the  proportion  of  1  :  85,  or,  from  puerperal  fever  alone/in  the 
proportion  of  1  :  146.  Garrigues2  examined  the  records  of  the  various 
city  institutions  during  the  period  in  question,  and  from  them  estimated 
the  number  of  births  which  took  place  in  hospitals  at  10,572.  The 
recorded  deaths  were  420.  Deducting  these  from  the  totals  given  above, 
the  general  death-rate  in  civil  practice  from  puerperal  causes  in  New 
York  City  was  in  the  proportion  of  1  :  94.  Max  Boehr3  in  his  now- 
famous  statistics  reckons  that  one-thirtieth  of  all  married  women  in 
Prussia  die  in  childbed.  The  Puerperal  Fever  Commission4  appointed 
by  the  Berlin  Society  of  Obstetrics  and  Gynaecology  arrived  at  the  con- 
clusion that  from  10-15  per  cent,  of  the  deaths  occurring  in  women 
during  the  period  of  sexual  activity  were  due  to  childbed  fever,  and  that 
this  disease  destroyed  nearly  as  many  lives  as  small-pox  or  cholera.  But 
puerperal  fever  differs  from  either  small-pox  or  cholera  in  that  the  latter 
presses  largely  upon  the  aged  and  the  very  young,  while  the  former 
gathers  its  victims  exclusively  from  a  selected  class — viz.  from  women  in 
adult  life,  the  mothers  of  families,  whose  loss,  as  a  rule,  is  a  public  as 
well  as  a  private  calamity. 

For  those  who  regard  statistics  with  habitual  distrust  it  may  perhaps 
be  well  to  state  that  the  foregoing  frightful  picture  is  no  exaggeration, 
but  is  less  sombre  than  the  actual  truth. 

Before  proceeding  to  consider  the  nature  of  puerperal  fever  it  is 
desirable  to  first  recall  the  anatomical  lesions  with  which  it  is  associated. 
These,  it  will  be  found,  are  for  the  most  part  inflammatory  processes 
having  their  starting-point  in  injuries  of  the  genital  passage  produced  by 
parturition,  complicated  in  many  cases  by  septic  changes  in  the  blood,  by 
secondary  degeneration  of  parenchymatous  organs,  and  at  times  by 
phlegmonous  and  erysipelatous  affections  in  remote  as  well  as  in  the 
adjacent  serous  and  cutaneous  tissues. 

MORBID  ANATOMY. — The  primary  lesions  connected  with  puer- 
peral fever  are  so  various  that  the  student  will  find  it  conve- 
nient to  classify  them  according  as  they  are  situated  in  the  mucous 
membrane  of  the  utero-vaginal  canal,  the  parenchyma  of  the  uterus, 
the  pelvic  cellular  tissue,  the  peritoneum,  the  lymphatics,  or  the 
veins.  Not,  indeed,  that  such  an  arrangement  is  strictly  in  accord- 
ance with  clinical  experience — as  a  rule,  the  inflammatory  processes  are 
rarely  limited  to  a  single  tissue — but  because  the  prognosis  and  treatment 

1  This  estimate  was  based  upon  the  assumption  that  the  natural  birth-rate  is  33  to  the 
1000 — a  proportion  believed  by  the  statisticians  of  the  Board  of  Health  to  be  approxi- 
matively  correct,  though  probably  somewhat  in  excess  of  the  reality.     P.  Osterloh  has 
recently  stated  that  my  statistics  were  computed  in  so  arbitrary  a  manner  as  to  render 
deductions  from  them  valueless.     In  this,  however,  he  is  mistaken.     The  most  conscien- 
tious care  was  taken  in  their  preparation;  wherever  the  possibility  of  error  existed  the 
fact  was  distinctly  indicated,  and  all  calculations  were  made  in  such  a  way  that  whatever 
corrections  might  be  required  would  strengthen  the  conclusions. 

2  "On  Lying-in  Institutions,"  Trans.  Am.  Gyn.  Soc..  vol.  ii.,  1878. 

s  "  Untersuchungen   iiber  die  Haiifigkeit  des  Todes  im  "VVochenbett  in   Preussen," 
ZtitRchr.  f.  Geburtsk.  und  Gynaek.,  vol.  iii.  p.  82. 
4  Zeitschr.  /.  Geburtsk.  und  Gynaek.,  vol.  iii.  p.  1. 


986  PUERPERAL  FEVER. 

are  determined  in  great  measure  by  the  tissue-system  which  is  predomi- 
nantly affected.  The  significance  of  puerperal  inflammations,  wherever 
seated,  likewise  depends  upon  whether  they  are  local  and  circumscribed 
or  whether  they  present  a  spreading  character. 

Personally,  I  have  found  the  following  classification  of  Spiegelberg J 
of  great  utility  as  a  means  of  keeping  in  mind  the  principal  points  to 
which  inquiry  should  be  directed  in  estimating  the  significance  of  the 
febrile  conditions  of  childbed : 

1.  Inflammation  of  the  Genital  Mucous  Membrane. — Endocolpitis  and 
endometritis. 

a.  Superficial. 

b.  Ulcerative  (diphtheritic). 

2.  Inflammation  of  the  Uterine  Parenchyma,  and  of  the  Subserous  and 
Pelvic  Cellular  Tissue. 

a.  Exudation  circumscribed. 

6.  Phlegmonous,  diffused ;  with  lymphangitis  and  pyamia  (lymphatic 
form  of  peritonitis). 

3.  Inflammation   of  the   Peritoneum   covering  the  Uterus   and    its 
Appendages. — Pelvic  peritonitis  and  diffused  peritonitis. 

4.  Phlebitis  Uteriua  and  Para-uteriua,  with  formation  of  thrombi, 
embolism,  and  pyaemia. 

5.  Pure  Septicaemia. — Putrid  absorption. 

EXDOCOLPITIS  AND  ExcoMETRiTis. — In  the  superficial,  catarrhal  form 
of  inflammation  the  mucous  membrane  of  the  vagina  is  swollen  and  hyper- 
aernic,  the  papillae  are  enlarged,  and  the  discharge  is  profuse  ;  in  the  vagi- 
nal portion  of  the  cervix  the  labia  uterina  are  oedematous  and  covered 
with  granulations  which  bleed  at  the  slightest  touch  •  in  the  cavity  of  the 
body  there  are  increased  transudatioii  of  serum  and  abundant  pus-forma- 
tion. The  deep  structures  of  the  uterus  are  usually  not  affected.  Some- 
times the  inflammation  extends  to  the  tubes— salpingitis — or,  passing 
outward  through  the  fimbriated  extremities,  it  may  spread  over  the  adja- 
cent peritoneum. 

The  small  wounds  at  the  vaginal  orifice  are  at  times  converted  into 
ulcers  with  tumefied  borders.  These  so-called  puerperal  ulcers  are  covered 
with  a  greenish-yellow  layer.  They  are  associated  usually  with  redema- 
tous  swelling  of  the  labia.  Under  favorable  sanitary  conditions  the 
deposit,  which  consists  in  the  main  of  pus-cells,  clears  away  and  the  sur- 
face heals  by  granulation.  The  ulcerative  form  of  inflammation  is  very 
rare  outside  of  crowded  hospitals. 

Diphtheritic  ulcers  are  situated  with  greatest  frequency  in  the  neigh- 
borhood of  the  posterior  commissure  or  around  the  vaginal  orifice.  In 
rarer  instances  they  are  found  upon  the  anterior  wall  and  in  the  fornix  of 
the  vagina,  in  the  cervix,  and  upon  the  site  of  the  placenta.  The  borders 
are  red  and  jagged;  the  base  is  covered  with  a  yellowish-gray,  shreddy 
membrane;  the  secretion  is  purulent,  alkaline,  and  fetid;  and  the  adja- 
cent tissues  are  cedematous.  From  the  vulva  they  may  extend  to  the 
perineum  or  pursue  a  serpiginous  course  down  the  thighs.  In  the  uterus 
and  about  the  cervix  they  vary  as  regards  size,  and  are  either  of  a  rounded 
shape  or  form  narrow  bands.  The  intervening  portions  of  tissue  which 
have  not  undergone  destructive  changes  swell  and  stand  out  in  strong 
1 "  Ueber  das  Wesen  des  Puerperalfiebers,"  Volkmann's  Samml.  klin.  Vortr.,  No.  3. 


METRITIS  AND  PAEAMETEITIS.  987 

relief.  Where  the  entire  inner  surface  has  become  necrosed,  it  is  often 
covered  with  a  smeary,  chocolate-brown  mass  which,  when  washed  awav 
with  a  stream  of  water,  leaves  exposed  either  the  deepest  layer  of  the 
mucous  membrane  or  the  underlying  muscular  structures. 

The  difference  between  the  superficial  ulcerations  of  the  genital  canal 
and  the  diphtheritic  form  involving  destruction  of  the  deeper  tissues  is 
due  to  the  presence  in  the  latter  of  minute  organisms  termed  micrococci 
the  relations  of  which  to  puerperal  infection  will  be  considered  in  a  sub- 
sequent division. 

METRITIS  AND  PARAMETEITIS. — In  ulcerative  endometritis,  and  even 
in  the  extreme  catarrhal  form,  the  parenchyma  of  the  uterus  likewise  be- 
comes involved.  The  changes  which  are  designated  under  the  term  metritis 
consist  in  the  first  place  of  oedematous  infiltration  of  the  tissues.  As  a 
consequence,  the  organ  contracts  imperfectly  and  becomes  soft  and  flabby, 
so  that  sometimes,  upon  post-mortem  examination,  it  bears  the  imprint 
of  the  intestines. 

In  diphtheritic  endometritis  the  gangrenous  process  may  attack  the 
muscular  tissue,  and  give  rise  to  losses  of  muscular  substance — a  condi- 
tion known  as  necrotic  eudometritis  or  putrescence  of  the  uterus. 

Inflammatory  changes  are  rarely  lacking  in  the  intermuscular  connec- 
tive tissue,  which  exhibits  in  places  serous  or  gelatinous  infiltration,  with 
afterward  pus  formation,  and  with  here  and  there  small  abscesses.  The 
sero-puruleut  infiltration  of  the  connective  tissue  is  specially  marked 
beneath  the  peritoneal  covering  of  the  uterus  either  behind  or  along  the 
sides  at  the  attachment  of  the  broad  ligaments.  In  the  same  situations 
the  lymphatics,  which  normally  are  barely  perceptible  to  the  naked  eye, 
are  ^  sometimes  enlarged  to  the  si/e  of  a  quill,  and  are  characterized  by 
varicose  dilatations  occurring  singly  or  presenting  a  beaded  arrangement. 
In  the  substance  of  the  uterus  the  dilated  vessels  are  liable  to  be  mistaken 
for  small  abscesses.  The  pus-like  substance  contained  in  the  lymphatics 
is  composed  of  pus-cells  and  of  micrococci.  From  the  cellular  tissue 
surrounding  the  vagina,  or  that  beneath  the  peritoneal  covering  of  the 
uterus,  the  inflammation  may  spread  by  contiguity  of  tissue  between  the 
folds  of  the  broad  ligament,  and  thence  pass  upward  to  the  iliac  fossae. 
Usually  the  process  is  unilateral.  After  the  inflammation  has  crossed  the 
liuea  termiualis  it  may  take  a  forward  direction  above  the  sheath  of  the 
ilio-psoas  muscle  to  Poupart's  ligament,  or  it  may  creep  upward,  follow- 
ing the  course,  according  to  the  side  aifected,  of  the  ascending  or  descend- 
ing colon,  to  the  region  of  the  kidney.  It  is  rare  for  inflammation  of 
the  cellular  tissue  to  travel  around  the  bladder  to  the  front.  In  such 
cases  it  pursues  its  course  between  the  walls  of  the  bladder  and  the  uterus, 
and  along  the  round  ligament  to  the  inguinal  canal.  In  a  few  cases  the 
cellulitis  mounts  above  Poupart's  ligament,  between  the  peritoneum  and 
the  abdominal  wall. 

The  course  of  the  inflammation  is  not  simply  fortuitous,  but  follows 
prearranged  pathways  in  the  connective  tissue.  Konig1  and  Schlesinger* 
have  shown  that  when  air,  water,  or  liquefied  glue  is  forced  into  the  cellu- 
lar tissue  between  the  broad  ligaments  the  injected  mass  has  a  tendency 
to  invade  the  iliac  fossae.  In  Schlesinger's  experiments,  if  the  canula  of 
the  syringe  was  inserted  into  the  anterior  layer  of  the  broad  ligament, 
1  Arch,  der  Hellkunde,  3  Jahrg.,  1862.  2  Gynaekologische  Studien,  No.  1. 


988  PUERPERAL  FEVER. 

the  glue  spread  between  the  folds  to  the  abdominal  end  of  the  Fallopian 
tube;  thence,  following  the  track  of  the  vessels,  it  passed  to  the  linea 
terminalis ;  and  finally  mounted  upward  along  the  colon  or  swept  forward 
to  Poupart's  ligament  until  the  advance  was  stopped  at  the  outer  border 
of  the  round  ligament.  If  the  injection  was  made  to  the  side  of  the  cer- 
vix through  the  posterior  layer  at  the  junction  of  the  cervix  and  the 
body,  the  posterior  layer  gradually  bulged  out,  the  peritoneum  was  lifted 
from  the  side  wall  of  the  pelvis,  and  the  glue  passed  beyond  the  vessels 
to  reach  the  iliac  fossa.  If  the  injection  was  made  to  the  side  of  the  cer- 
vix through  the  anterior  layer,  the  glue  passed  between  the  bladder  and 
the  uterus,  and  forward  along  the  round  ligament  to  the  inguinal  canal, 
while  another  portion  of  the  fluid  passed  between  the  layers  of  the  broad 
ligament,  and  reached  the  peritoneal  covering  of  the  side  walls  behind 
the  round  ligament.  If  the  injection  was  made  in  the  median  line  in  a 
peritoneal  fold  of  Douglas's  cul-de-sac,  the  fluid  travelled  forward  upon 
one  side  along  the  round  ligament  and  thence  to  the  posterior  wall  of  the 
bladder. 

The  term  parametritis,  introduced  into  use  by  Virchow,  is,  properly 
speaking,  limited  to  inflammation  of  the  connective  tissue  immediately 
adjacent  to  the  uterus,  the  older  one  of  pelvic  cellulitis  furnishing  a 
more  comprehensive  designation  for  cases  where,  as  a  consequence  of  a 
progressive  advance  from  the  point  of  departure  in  the  genital  canal,  the 
remoter  regions  have  likewise  been  invaded.  Connective-tissue  inflam- 
mation presents,  as  the  first  essential  characteristic,  an  acute  03dema,  the 
fluid  which  fills  the  gaps  and  interspaces  consisting  of  transuded  serum 
rendered  opaque  by  the  presence  of  pus-cells  or  possessing  a  gelatinous 
character.  In  the  mild,  uncomplicated  cases  the  redenia  disappears  rap- 
idly. Where  the  cell-collections  are  of  moderate  extent  the  entire  pro- 
cess may  vanish  without  leaving  a  trace  of  its  existence.  If  the  cell- 
elements,  on  the  other  hand,  are  present  in  great  abundance,  they,  as  a 
rule,  first  undergo  fatty  degeneration,  and,  after  the  absorption  of  the 
fluid  portion,  form  a  hard  tumor  composed  of  a  fine  granular  detritus, 
which  under  favorable  circumstances  likewise  after  a  few  weeks  becomes 
absorbed.  In  rare  cases  abscess-formation  in  the  tumor  results. 

In  the  cellulitis  resulting  from  septic  infection,  especially  in  cases  com- 
plicated by  diphtheritis,  the  tissues  seem  as  if  soaked  with  dirty  serum, 
and  contain  scattered  yellowish  deposits,  which  soon  present,  even  to  the 
naked  eye,  the  appearance  of  pus-collections.  This  sero-purulent  oadema 
is  always  associated  with  lymphangitis,  the  lymphatic  vessels  possessing 
varicose  dilatations  and  beaded  arrangements  similar  to  those  already 
described  in  the  uterine  tissue.  The  foregoing  changes  are  most  distinct 
in  the  firm  connective  tissue  adjacent  to  the  uterus  and  at  the  hilum  of 
the  ovary,  while  they  are  less  clearly  traced  in  the  looser  structure  of  the 
broad  ligament  (Spiegel berg). 

In  favorable  cases  the  inflammation  is  circumscribed,  or  at  least  is 
limited,  by  the  nearest  lymphatic  glands.  In  cases  of  intense  infection 
it  spreads  rapidly,  and  justifies  the  title  bestowed  upon  it  by  Virchow  of 
parambtritic  malignant  erysipelas. 

PELVIC  AXD  DIFFUSED  PERITONITIS. — Inflammation  of  the  pelvic 
peritoneum  may  result  from  severe  attacks  of"  catarrhal  endometritis, 
the  inflammatory  process  either  traversing  the  uterine  tissue  or  passing 


PHLEBITIS  AND  PHLEBO-THROMBOSIS.  989 

through  the  Fallopian  tubes  to  the  adjacent  serous  membrane;  or  it 
may  proceed,  secondarily,  from  the  stretching  and  irritation  occasioned 
by  an  associated  parametritis. 

As  a  rule,  pelvic  peritonitis  is  not  attended  with  much  exudation.  The 
latter  is  situated  upon  the  folds  of  the  peritoneum  limiting  the  cul-de-sac 
of  Douglas,  upon  the  ovaries,  and  upon  the  broad  ligaments.  In  favor- 
'able  cases  it  consists  of  fibrinous  flakes  and  fluid  pus.  If  the  latter  is 
abundant,  it  may  become  encysted  by  the  formation  of  adhesions  between 
the  pelvic  organs. 

General  peritonitis  may  result  from  the  extension  of  a  pelvic  peritoni- 
tis, or  from  the  transport  of  poison  through  the  lymphatics  into  the  peri- 
toneal sac.  In  the  first  case  the  entire  peritoneum  is  injected,  and  the 
contents  of  the  abdominal  cavity  are  loosely  bound  together  by  pseudo- 
membranes,  composed  of  pus  and  coagulated  fibrine.  The  intestines  are 
at  the  same  time  distended  and  the  diaphragm  is  pushed  upward.  In 
the  so-called  peritonitis  lymphatica  the  inflammatory  symptoms  are  at  the 
outset  lacking.  The  abdominal  cavity  is  found  filled  with  a  thin,  stinking, 
greenish  or  brownish  fluid  composed  of  serum  and  micrococci.  The 
intestines  are  lax  and  redematous,  and  the  muscular  structures-are  para- 
lyzed, with  resulting  tympanitic  distension.  The  peritoneal  covering 
of  the  intestines  is  devoid  of  lustre,  and  covered  with  injected  patches, 
or  is  stained  of  a  dark-brown  color.  Death  often  ensues  before  the 
occurrence  of  exudation. 

Septic  forms  of  pelvic  inflammation  are  often  associated  with  oophori- 
tis,  the  dilated  lymphatics  either  extending  to  the  substance  of  the  ovaries, 
where  they  may  lead  to  the  production  of  small  abscesses,  or,  as  a  result 
of  blood-dissolution,  the  organs  become  soft,  pulpy,  and  infiltrated  with 
discolored  serum,  and  present  hemorrhagic  spots  distributed  over  the 
surface. 

PHLEBITIS  AND  PHLEBO-THROMBOSIS. — The  formation  of  thrombi 
in  the  uterine  and  pelvic  veins  is  sufficiently  common  during  the  puer- 
peral period.  The  coagulation  may  result  from  compression  or  from 
enfeeblement  of  the  circulation.  A  predisposition  to  its  occurrence  is 
created  by  relaxation  of  the  uterine  tissue.  A  normal  thrombus  is  in 
itself  harmless.  In  time  it  becomes  organized,  and  the  occluded  vessel 
is  converted  into  a  connective-tissue  cord,  or  a  channel  may  form  through 
it  which  permits  the  passage  of  the  blood-stream.  When,  however,  pus 
or  septic  matters  obtain  access  to  a  thrombus,  it  undergoes  rapid  disinte- 
gration, and  the  particles  get  swept  away  into  the  circulation  until  arrested 
in  the  ramifications  of  the  pulmonary  artery.  $  Wherever  these  poisoned 
emboli  happen  to  lodge  inflammation  is  set  up  in  the  adjacent  tissues,  and 
abscesses  result  (pyaemia  multiplex).  Sometimes  countless  collections  of 
pus  may  form  in  the  lungs.  Less  commonly  abscesses  are  found  in  the 
liver  or  spleen,  originating  either  from  emboli  which  have  already  made 
the  pulmonary  circuit  or  from  thrombi  in  the  pulmonary  veins. 

Inflammation  of  the  veins  (phlebitis)  sometimes  occurs  when  the 
vessels  have  to  traverse  tissues  in  or  near  the  uterus  infiltrated  with 
purulent  or  septic  materials.  The  endothelium  then  undergoes  prolif- 
eration, and  thrombosis  is  produced.  Phlebitic  thrombi  do  not  necessa- 
rily break  down,  and  may  in  that  case  act  as  a  barrier  to  the  progression 
of  septic  germs  into  the  circulation  (Spiegelberg).  As  a  rule,  however, 


990  PUERPERAL  FEVER. 

under  the  influence  of  inflammation  and  infection,  they  become  converted 
into  puriform  masses. 

The  thrombi  grow  by  accretion  in  the  direction  of  the  heart.  They 
may  extend  from  the  uterus  through  the  internal  spermatic,  or  through 
the  hypogastric  and  common  iliac  veins,  to  the  vena  cava.  Sometimes 
the  thrombus  may  be  traced  back  to  the  placental  site. 

SEPTICAEMIA. — From  these  local  conditions,  sooner  or  later,  secondary 
affections  develop  in  distant  organs.  The  general  affection  is,  in  great 
part  at  least,  likewise  of  local  origin.  Sometimes,  however,  where  the 
poison,  which  enters  the  system  through  the  lymphatics  and  veins,  is 
very  active  and  abundant,  death  may  follow  from  acute  septicaemia  before 
the  changes  in  the  sexual  organs  have  had  time  to  develop.  The  fatal 
result  in  these  cases  is  probably  due  to  paralysis  of  the  heart.  After 
death  post-mortem  decomposition  rapidly  sets  in,  the  blood  is  sticky,  and 
swelling  is  found  in  the  various  parenchymatous  organs. 

The  secondary  affections  consist  in  the  metastatic  abscesses  already 
noticed  as  produced  by  infected  emboli,  in  circumscribed  purulent  collec- 
tions due  to  the  conveyance  of  septic  materials  into  the  blood-current 
through  the  lymphatics,  in  ulcerative  endocarditis,  in  inflammations  of 
the  pleura,  the  pericardium,  and  the  meninges,  and  in  purulent  inflam- 
mation of  the  joints. 

A  study  of  the  nature  of  puerperal  fever  will  best  show  how  inti- 
mately these  seemingly  distinct  processes  are  linked  together. 

EARLIER  VIEWS  COXCERXIXG  THE  NATURE  OF  PUERPERAL  FEVER.1 
— According  to  the  teachings  of  Hippocrates,  Galen,  and  Avicenna,  of 
Ambrose  Pare",  of  Sydenham,  and  of  Smellie,  the  fevers  of  puerperal 
women  were  attributable  to  the  suppression  of  the  lochia.  For  twenty 
centuries  this  doctrine  was  accepted  almost  without  dispute,  the  best 
clinical  observers  confounding  a  symptom  which  is  often  lacking  with  the 
cause  of  the  disease  itself. 

In  1686,  Puzos2  taught  that  milk,  circulating  in  the  blood,  is  attracted 
to  the  uterus  during  pregnancy  and  to  the  breasts  after  confinement,  but 
that  milk  metastases  may  form  in  other  parts,  and  produce  the  symptoms 
of  malignant  or  intermittent  fever.  In  1746,  A.  de  Jussieu,  Col  de 
Villars,  and  Fontaine  advanced  in  support  of  this  theory  the  fact  that 
they  had  found,  on  opening  the  abdomen  in  women  who  had  died  from 
an  epidemic  which  raged  that  year  in  Paris,  a  free  lactescent  fluid  in  the 
lower  portion  of  the  abdominal  cavity  and  clotted  milk  adherent  to  the 
intestines.  This  doctrine,  which  seemed  to  be  based  upon,  and  to  accord 
with,  observation,  found  many  adherents  in  France.  It  lost  ground,  how- 
ever, when,  in  1801,  Bichat  pointed  out  the  true  nature  of  the  abdominal 
effusions  of  women  who  had  died  in  childbed,  and  demonstrated  that 
they  were  to  be  found  likewise  in  peritoneal  inflammations  occurring  in 
men  and  in  non-puerperal  women. 

While,  during  the  second  half  of  the  eighteenth  century,  the  doctrine 
of  milk  metastasis  held  full  sway  in  France,  in  England  and  Germany 
the  dominant  leaders  in  medicine  referred  the  causes  of  puerperal  fevers 
to  inflammations  of  the  womb  and  of  the  peritoneum.  With  the 
advances  made  in  pathological  anatomy  in  the  beginning  of  the  present 

1  For  data  given,  and  for  a  great  variety  of  historical  information,  vide  TTervieux,  TraitS 
clinique  et  pratique  des  maladies  puerperales.  2  Premier  Memoire  sur  les  Depots  lacleux. 


EARLIER  VIEWS  CONCERNING  PUERPERAL  FEVER.          991 

century,  France  taking  the  lead 'stress  was  likewise  laid  upon  inflam- 
mations of  the  veins  and  of  the  lymphatics.  The  vitality  of  the  doctrine 
of  local  inflammations  is  well  shown  by  the  records  kept  by  the  Health 
Board  of  this  city,  where  a  large  proportion  of  the  deaths  returned  from 
childbed  fever  are  entered  under  the  head  of  metritis,  of  peritonitis,  of 
metro-peritonitis,  and  of  puerperal  phlebitis. 

In  opposition  to  the  doctrines  of  the  so-called  localists,  the  theory  that 
puerperal  fever  is  an  essential  fever,  and  as  much  a  distinct  disease  as 
typhus  fever,  typhoid  fever,  or  relapsing  fever,  has  been  strenuously 
advocated  by  some  of  the  most  distinguished  clinical  teachers  who  have 
devoted  their  attention  to  obstetrical  science. 

Fordyce  Barker,  the  most  recent  exponent  of  the  essentiality  of 
puerperal  fever,  in  his  classical  work  upon  the  Puerperal  Diseases,  states 
the  arguments  against  the  local  origin  of  the  diseases  as  follows :  1st, 
that  puerperal  fever  has  no  characteristic  lesions ;  2d,  that  the  lesions 
which  do  exist  are  often  not  sufficient  to  influence  the  progress  of  the  dis- 
ease or  to  explain  the  cause  of  death ;  3d,  that  there  may  be  inflam- 
mation, even  to  an  intense  degree,  of  any  of  the  organs  in  which  the 
principal  lesions  of  puerperal  fever  are  found,  and  yet  the  disease  will 
lack  some  of  the  essential  characteristics  of  puerperal  fever ;  4th,  that 
the  lesions  are  essentially  different  from  spontaneous  or  idiopathic  inflam- 
mations of  the  tissues  where  these  lesions  are  found ;  5th,  that  puerperal 
fever  is  often  communicable  from  one  patient  to  another  through  the 
medium  of  a  third  party,  and  that  this  is  not  the  fact  in  regard  to  simple 
inflammations  in  puerperal  women. 

However,  neither  Barker,  nor  those  who  entertain  views  similar  to 
his,  question  the  local  origin  of  many  febrile  affections  in  childbed,  but 
claim  that  purely  local  inflammations  have  each  their  characteristic  symp- 
toms, which  differ  from  those  of  true  puerperal  fever,  that  puerperal  fever 
is  a  zymotic  disease  of  unknown  origin,  and  that  local  lesions,  where  they 
coexist,  are  not  the  primary  source  of  trouble,  but  are  secondary  to  changes 
in  the  blood. 

In  1850,  James  Y.  Simpson1  published  a  short  paper  "On  the 
Analogy  between  Puerperal  and  Surgical  Fever."  This  article  may 
well  be  regarded  as  the  foundation  of  the  modern  doctrine  coucern- 


matical  demonstration,  the  paper  furnishes  a  brilliant  example  of  the 
scientific  foresight  which  is  able  to  discern  the  truth  even  where  the  evi- 
dence lacks  completeness. 

In  1847,  Semmelweis,  who  was  at  that  time  clmical  assistant  to  the 
Lying-in  Hospital  at  Vienna,  made  the  startling  assertion  that  "  puer- 
peral patients  were  chiefly  attacked  with  puerperal  fever  when  they  had 
been  examined  by  the  physicians  who  were  fresh  from  contact  with  the 
poisons  engendered  by  cadaveric  decay  ;  that  fever  ensued  in  the  practice 
of  those  who  after  post-mortem  examination  washed  their  hands  in  the 
usual  manner,  whereas  no  fever  or  but  few  cases  of  disease  followed  when 
the  examiner  had  previously  washed  his  hands  in  a  solution  of  ^chloride 
of  lime."  In  the  face  of  insult,  ridicule,  and  abuse  Semmelweis  mam- 
1  Edinlurgh  Medical  Journal. 


992  PUERPERAL  FEVER. 

tained  this  position  for  years,  almost  unaided,  with  fanatical  persistency. 
It  was  easy  for  his  opponents,  for  the  most  part  managers  of  the  great 
lying-in  asylums,  to  show  from  clinical  experiences  the  weakness  of  so 
one-sided  a  theory.  But  the  employment  of  the  equivocal  demonstration 
falsus  in  uno,  falsus  in  omnibus,  served  only  as  a  temporary  defence 
against  the  laxity  which  prevailed  in  hospital  management  only  a  quarter 
of  a  century  ago.  Though  Semmelweis  died  with  no  other  reward  than 
the  scorn  of  his  contemporaries,  it  is  impossible  at  the  present  day  to  so 
much  as  contemplate  the  abuses  he  attacked  without  a  shudder. 

In  1860,  Semmelweis  published  the  result  of  his  ripened  experience  in 
a  treatise  entitled  Die  Aetioloyie  der  Begriff  und  die  Prophylaxis  des  Kind- 
bettfiebers,  in  which,  abandoning  his  earlier  exclusive  position,  he  main- 
tained that  puerperal  fever  arises  from  the  absorption  of  putrid  animal 
substances,  which  produce  first  alterations  in  the  blood,  and  secondly 
exudations.  He  distinguished  between  cases  in  which  the  infection  was 
introduced  from  some  external  source,  and  which  he  believed  to  be  the 
most  frequent  variety,  and  those  where  the  poison  was  generated  in  the 
system.  The  sources  from  which  the  infection  is  derived  he  believed  to 
be — 1st,  from  the  dead  body,  regardless  of  age,  sex,  or  disease,  no  matter 
whether  the  latter  is  of  puerperal  or  non-puerperal  origin,  the  virulence 
depending  upon  the  stage  of  decomposition ;  2d,  diseased  persons,  whose 
malady  is  associated  with  decomposition  of  animal  tissue,  no  matter 
whether  the  affected  person  suffers  from  childbed  fever  or  not,  the 
decomposing  matter  alone  furnishing  the  product  from  which  infection 
is  derived ;  3d,  physiological  animal  substances  in  the  process  of 
decomposition.  As  carriers,  of  infection  he  regarded  the  fingers  and 
hands  of  the  physician,  midwife,  or  nurse,  sponges,  instruments,  soiled 
clothing,  the  atmosphere,  and,  in  brief,  anything  which,  after  being  defiled 
with  decomposing  animal  matter,  was  brought  into  contact  with  the  geni- 
tals of  a  woman  during  or  subsequent  to  parturition.  Absorption  takes 
place  from  the  inner  surface  of  the  uterus  or  from  traumata  in  the  genital 
canal.  Infection  seldom  occurs  in  pregnancy,  because  of  the  closure  of 
the  os  iuternum,  the  absence  of  wounded  surfaces,  and  because  of  the 
rarity  with  which  examinations  are  made  ;  during  dilatation  infection  is 
common,  but  exceptional  daring  the  period  of  expulsion,  because  the 
inner  uterine  surface  is  at  that  time  rendered  inaccessible  by  the  advance 
of  the  child  ;  in  the  placental  and  puerperal  period  infection  occurs  from 
utensils  and  instruments,  but  chiefly  through  the  access  of  atmospheric 
air  when  the  latter  is  loaded  with  decomposing  organic  matter.  In  rare 
instances  auto-infection  may  result  from  spontaneous  decomposition  of 
the  lochia,  of  bits  of  decidua,  of  coagula  of  blood,  of  necrosed  tissue,  or 
in  consequence  of  severe  instrumental  labors.  In  a  word,  puerperal 
fever  was  according  to  Semmelweis  no  new  specific  disease,  but  a  variety 
of  pyaemia. 

I  have  been  thus  particular  in  giving  prominence  to  the  labors  of 
Semmelweis  partly  from  justice  to  a  man  who  was  hated  and  despised 
in  his  lifetime,  and  partly  because  I  believe  that  few  outside  of  Germany 
are  really  cognizant  of  the  immense  service  he  rendered  to  humanity,  or 
that  to  him  is  really  due  a  large  part  of  what  is  now  current  doctrine 
concerning  the  nature  and  prophylaxis  of  puerperal  fever. 

THE  NATURE  OF  PUERPERAL   FEVER  AS   REGARDED   FROM  THE 


PUERPERAL  FEVER  FROM  THE  MODERN  STANDPOINT.     993 

STANDPOINT  OF  MODERN  INVESTIGATION. — The  older  beliefs  in  the 
suppression  of  the  lochia  and  the  metastases  of  milk  have  long  since 
been  relegated  to  the  domain  of  old  nurses'  lore,  and  do  not  call  for 
serious  discussion.  The  localist  theory,  that  puerperal  fever  is  a  metritis, 
a  peritonitis,  a  phlebitis,  or  an  inflammation  of  the  lymphatics,  is,  as 
mortuary  records  show,  still  adhered  to  by  many  practitioners,  and,  as 
we  have  seen,  is  justified  by  the  fact  that  puerperal  fever  is,  with  rare 
exceptions,  associated  at  some  period  of  its  progress  with  certain  inflam- 
matory processes  which  have  their  starting-point  in  the  generative  appa- 
ratus. But  the  localist  theory  leaves  out  of  view  the  existence  of  blood- 
poisoning,  and  yet  the  coexistence  of  a  blood-poison  with  the  local  lesions 
is  an  essential  feature  of  puerperal  fever.  It  was  this  defect  which  gave 
to  the  advocates  of  the  specificity  of  puerperal  fever  their  real  importance. 
The  outcome  of  modern  investigation  tends,  however,  to  prove  that  the 
puerperal  poison  is  of  a  septic  nature,  and  that  the  usual  points  of  intro- 
duction of  the  poison  are  the  lesions  of  the  parturient  canal.  This  does  not, 
indeed,  exclude  other  points  of  entry,  for  clinical  experience  renders  it 
probable  that,  under  certain  conditions,  the  poison  may  be  primarily 
introduced  into  the  blood  through  the  respiratory  and  digestive  organs. 
Puerperal  fever  is  really  a  surgical  fever,  modified,  however,  by  the 
peculiar  physiological  conditions  which  belong  to  the  puerperal  state. 
The  argument  against  its  septic  origin  is  based  chiefly  upon  mistaken 
ideas  concerning  the  nature  of  septicaemia.  So  long  as  the  symptoms  of 
the  latter  were  derived  for  the  most  part  from  the  effects  observed  as  a 
consequence  of  injecting  putrid  materials  into  the  veins  of  dogs,  a  con- 
fusion arose  from  the  fact  that  the  results  obtained  were  commonly  those 
of  putrid  intoxication,  and  not  those  of  true  septicaemia.  Under  such 
circumstances  it  was  not  difficult  to  formulate  definitions  of  septicsemia 
which  could  be  showTn  to  be  at  variance  with  the  phenomena  which  ordi- 
narily exist  in  puerperal  fever. 

The  argument  that  the  infectious  diseases  of  childbed  are  of  a  septic 
nature  can  best  be  understood  by  presenting  the  proofs  in  their  orderly 
sequence. 

1st.  It  is  demonstrable  that  septic  poisons  are  capable  of  producing 
the  lesions  ordinarily  associated  with  puerperal  fever.  Thus,  it  is  a 
matter  of  ordinary  experience  that  the  retention  of  a  small  bit  of  the 
membranes  within  the  uterus  will  produce  fetid  lochia,  and,  as  the  result 
of  infection,  a  febrile  condition,  which,  as  a  rule,  subsides  with  the  expul- 
sion of  the  offending  body  and  the  use  of  disinfectant  washes.  A  viru- 
lent form  of  fever  is  not  unfrequently  occasioned  by  retained  coagula  or 
placeutal  debris  \Yhich  have  undergone  decomposition.  I  was  once  sent 
for  to  see  a  puerperal  patient  suffering  fYom  fever  on  the  fourth  day 
following  her  confinement,  On  entering  the  room  I  found  the  stench 
intolerable ;  turning  down  the  sheets,  I  discovered  that  the  patient  was 
lying  in  a  decomposing  mass,  and  learned  that  her  doctor  had  forbidden, 
after  the  birth  of  her  child,  the  removal  of  the  soiled  linen  and  blankets. 
The  patient  died  in  the  third  week  from  pyaemia  multiplex. 

Haussmann1  reported  a  case  of  auto-infection  in  the  rabbit  which  termi- 
nated fatally.  A  portion  of  the  membrane,  retained  in  the  left  cornu, 

1 "  Entetehung  der  iibertragbaren  Krankheiten  des  Wochenbettes,"  Beitr.  sur  Geburtsk. 
und  Gynaek.,"  Bd.  iii.  Heft  3,  p.  345. 
VOL.  I.— 63 


994  PUERPERAL  FEVER. 

led  to  diphtheritic  losses  of  substance  in  the  lower  portion  of  the  vagina, 
to  hemorrhagic  enteritis,  and  to  peritonitis.  The  same  author  produced 
death  from  septicaemia  by  injecting  into  the  gravid  uterus  of  one  rabbit 
serum  from  the  abdomen  of  another  which  had  died  from  infection. 
The  post-mortem  examination  showed  the  muscles  filled  with  granules 
and  the  peritoneum  injected,  but  no  fibrino-purulent  exudation.  Injec- 
tions into  the  uterus  of  pus  from  the  abdomen  of  a  woman  who  had  died 
from  infectious  puerperal  disease  produced  no  effect  upon  rabbits  two 
weeks  gravid,  while  in  the  second  half  of  pregnancy  premature  delivery 
and  death  occurred,  in  one  case  in  one  and  a  half,  in  another  in  two  and  a 
half,  days.  In  the  animal  which  died  in  thirty-six  hours  there  was  com- 
mencing perimetritis  and  peritonitis,  while  in  the  one  that  died  after  the 
lapse  of  sixty  hours  the  abdomen  was  found  to  contain  fibriue  and  pus.1 
D'Espine  injected  into  the  uterus  of  a  rabbit  which  had  just  produced 
her  young  pus  from  the  abdomen  of  a  woman  who  had  died  from  puer- 
peral disease  two  days  before.  This  was  subsequently  followed  by  other 
injections  of  fetid  fluids  during  the  four  days  following.  On  the  twelfth 
day  the  animal  died.  The  autopsy  revealed  peritonitis,  most  marked  in 
the  pelvic  cavity,  inflammatory  alterations  in  the  vagina,  uterus,  and 
tubes,  small  abscesses  in  the  body  of  the  uterus,  softened  clots  in  the  veins 
of  the  broad  ligaments,  and  infarctions  of  the  liver.2  Sch filler  found  that 
subcutaneous  injections  of  septic  material  in  female  animals  during  preg- 
nancy produced  a  diphtheritic  ulcerative  process  on  the  uterine  surface, 
which  determined  the  separation  of  the  placenta;  diphtheritic  patches, 
likewise,  were  found  in  the  cornua  of  the  uterus.3 

Thus  we  find  that  in  the  human  subject  and  in  experiments  made  upon 
animals  septic  poisons  introduced  into  the  system  following  or  near  deliv- 
ery produce  lesions  similar  to  those  found  in  puerperal  fever.  As  a 
further  coincidence,  we  notice  that,  as  in  puerperal  fever,  the  lesions  from 
direct  septic  poisoning  have  nothing  characteristic  about  them,  producing 
in  one  case  pyaemia,  in  another  partial  peritonitis,  in  another  general  peri- 
tonitis, in  another  diphtheritis,  while  in  others  the  lesions  are  compara- 
tively trivial,  these  differences  being  due  to  variable  facta,  such  as  the 
qualities  of  the  septic  poisons,  the  points  of  entry  into  the  organism,  and 
the  resistance  offered  by  the  invaded  tissues. 

2d.  Septicaemia  is  a  disease  characterized  by  the  invariable  presence  in 
the  organism  infected  of  minute  bodies  generally  termed  bacteria* 

Until  very  recently  the  whole  subject  of  septicaemia  has  been  in  a  state 
Df  well  nigh  hopeless  confusion.  From  Gaspard  and  Panum,  through  a 
long  list  of  experimenters,  hardly  any  two  arrived  at  precisely  similar 

1  Contribution  d  F 'etude  de  la  septicemie  puerperale,  Paris,  1873,  p.  28.         *Ibid.,  p.  394. 

8  "  Experimentelle  Beitriige  zum  Studium  der  septischen  Infection,"  Deutsch.  Zeiischr. 
fiir  Chir.,  Bd.  vi.  p.  141. 

4  In  1865,  Mayrhofer  (Mnn.  Schr.  f.  Geburlsk.,  vol.  xxv.,  p.  112,  1865),  at  that  time 
clinical  assistant  to  the  Lying-in  Service  of  Brann  in  Vienna,  stimulated  by  the  researches 
of  Pasteur,  maintained  that  septic  endometritis  was  the  result  of  putrid  fermentation 
within  the  uterine  cavity,  and  drew  attention  to  the  vibrios — a  term  which  he  applied  to 
the  round  as  well  as  to  the  rod-like  bacteria — as  the  source,  and  not  the  product,  of  putre- 
faction. He  claimed  that  while  in  puerperal  processes  vibrios  are  always  present,  in 
healthy  women  they  never  occur  before  the  second,  third,  or  fourth  day,  and  not  always 
even  then.  The  chief  progress  that  has  been  made  as  regards  our  knowledge  of  puerperal 
fever  in  the  last  ten  years  has  been  in  the  direction  of  strengthening  Mayrhofer's  argu- 
ment by  careful  experiment,  and  by  defining  the  action  of  microscopic  fungi  in  the  pro- 
duction of  septic  morbid  proc  esses. 


PUERPERAL  FEVER  FROM  THE  MODERN  STANDPOINT.     995 

results.  Something  like  an  approach  to  order  has,  however,  been  pro- 
duced since  it  has  begun  to  be  understood  that  the  effects  produced  by 
septic  fluids  vary  with  the  quality  of  the  poison  and  the  method  of 
experimentation,  and  that  to  obtain  identity  in  the  result  there  must  be 
identity  in  all  the  conditions.  Thus,  Samuel  has  shown  that  the  same 
organic  substance  produces  different  effects  at  different  stages  of  decompo- 
sition; again,  that  the  enteritis  which  is  commonly  quoted  as  characteris- 
tic^of  septic  poisoning  occurs,  as  a  rule,  in  animals  when  the  septic  fluid 
is  injected  directly  into  the  blood,  and  is  rare  when  it  finds  its  way  into 
the  circulation  through  the  lymphatics,  as  is  the  case  usually  in  clinical 
experiences.1  There  is  one  experimental  point  of  extreme  practical 
importance  too  in  connection  with  puerperal  septicaemia — viz.  that  if  the 
injection  of  a  septic  fluid  be  made  directly  into  a  vessel,  toxic  effects 
speedily  follow,  but  are  transitory,  unless  the  amount  of  the  fluid  be 
large,  or  its  virulence  exceptional,  or  the  animal  very  young;2  whereas 
very  small  amounts  injected  subcutaneously,  by  developing  rapidly- 
spreading  phlegmonous  inflammation,  resembling  malignant  erysipelas  in 
man,  are  capable,  after  a  period  of  incubation,  of  producing  fatal  results ; 
or  they  may,  if  injected  into  a  shut  cavity  or  underneath  a  fascia,  lead  to 
the  development  of  an  inflammation  of  an  ichorous  character.  In  other 
words,  the  eliminating  organs  suffice,  under  ordinary  conditions,  to  remove 
from  the  blood  the  same  amount  of  septic  fluid  which  would  prove  fatal 
if  injected  into  the  tissues.3  To  produce  similar  results  the  injections 
into  the  blood  need  to  be  repeated  at  intervals.  This  experience  leads 
us  to  the  conclusion  that  in  the  tissues  septic  poison  possesses  the  ca- 
pacity of  self-multiplication,  and  that  in  the  local  inflammation  set  up  a 
reservoir  is  formed  from  which  poison  is  continuously  poured  into  the 
circulation. 

This  capacity  of  self-multiplication  which  septic  fluids  possess  has 
recently  been  found  to  be  coincident  with  the  presence  of  certain  parasitic 
bodies,  generically  termed  bacteria.  All  carefully-made  experiments  serve 
to  show  that  if  a  septic  fluid  be  deprived  of  these  organic  bodies  by  boil- 
ing or  filtration  while  it  continues  capable  of  producing  inflammation,  the 
inflammation  is  usually  of  diminished  intensity  and  remains  local  in  its 
character ; 4  whereas  the  bacteria  retained  upon  the  filter  possess  all  the 
virulent  properties  of  the  original  fluid.5  This  does  not  alone  necessarily 
prove  that  the  virus  resides  in  the  bacteria,  for  it  does  not  exclude  the 
possibility  that  both  the  virus  and  the  bacteria  remain  upon  the  filter. 

So  far,  attempts  at  isolating  the  microspores  of  septicaemia  and  culti- 
vating them  separately  in  vehicles  composed  of  water  holding  in  solution 
inorganic  constituents,  or  sterilized  fluids  containing  organic  matters,  or 
of  the  semi-solid  gelatinous  substances  recommended  by  Koch,  have  been 
only  partially  successful  in  proving  them  to  be  the  sole  source  of  infec- 

1  Loc.  dt.,  p.  349. 

s"Traube  und  Gescheidlen,  Versiiche  uber  Faiilniss  und  den  Widerstand  des  lebender 
Organisrnus,"  Settles.  Ges.f.  valerlandische  Cullur,  Feb.  13,  1874. 

3  In  some  instances  in  which  absorption  from  the  tissues  is  very  rapid  the  effects  of  sub- 
cutaneous injections  may  be  similar  to  those  produced  by  injections  made  directly  into  the 
circulation,  and  the  local  lesion  be  insignificant. 

*  In  filtration  through  porous  earthenware  cylinders  the  filtrate  possesses  no  phlogo- 
genic  properties. 

5Tiegel,  Correspondenzblatt  far  Schweizer  Aertze,  1871,  S.  1275;  Klebs,  Archiv  fur  eip. 
Pathol.  und  Pharmo.kol.,  Bd.  i.  Heft.  1,  S.  35. 


996  PUERPERAL  FEVER. 

tion.  Some  earlier  experiments  of  Tiegel  and  Klebs1  Avere  attended  with 
positive  results,  and  more  recently  confirmatory  evidence  has  been 
furnished  by  Pasteur  and  Doleris.2  Ililler,  rarely  quoted  now,  arrived 
at  different  conclusions.  He  found  that  bacteria  washed  in  pure  water 
were  innocuous.3  But  pure  water  had  long  before  been  proven  by 
observers  to  be  inimical  to  the  well-being  of  the  organisms  in  question. 
Schiiller  says  that  Killer's  experiments  prove  apparently  that  while  a 
•putrid  fluid  may  be  in  the  highest  degree  poisonous,  its  component  parts 
— viz.  either  the  fluid  or  the  bacteria  singly — are  neither  deadly  nor 
poisonous.4  The  fact  is,  that  isolation  experiments  are  subject  to  what  lias 
hitherto  been  in  most  experiments  an  unavoidable  source  of  error.  As 
Davaine  noted  early  in  his  observations,  the  physiological  action  of 
bacteria  is  very  dependent  on  the  constitution  of  the  medium  in  which 
they  are  developed,  which  is  in  entire  harmony  with  what  is  known  of 
organisms  much  higher  in  the  scale.  "  Many  plants,"  says  Burdon- 
Sanderson,5  "  containing  active  principles,  become  inert  when  transplanted 
from  an  appropriate  soil."  Bucholtz,  in  a  series  of  experiments  designed 
to  test  the  influence  of  antiseptics  upon  the  vitality  of  bacteria,  found  not 
only  a  difference  between  those  taken  directly  from  the  infusion  and  those 
cultivated  in  artificial  fluids,  but  between  bacteria  derived  from  the  same 
source  and  cultivated  in  modifications  of  the  nutrient  medium.6  Then, 
too,  it  is  not  always  safe  to  transfer  to  the  human  species  the  results  of 
experiments  made  upon  the  lower  animals.  Indeed,  among  animals,  not 
only  in  different  species,  but  in  varieties  of  the  same  species,  differences 
in  the  susceptibility  to  septicsemic  poisons  are  found  ranging  from  grada- 
tions as  to  the  intensity  of  the  effect  produced  to  absolute  immunity.  In 
anthrax,  a  disease  analogous  to  the  one  in  question,  the  bacterial  origin 
has  been  established  beyond  dispute  by  the  inoculation  of  isolated  bacilli, 
which  multiply  in  the  blood  and  permeate  in  enormous  numbers  the 
lungs,  liver,  kidneys,  spleen,  and  glandular  structures.  If  the  same 
unequivocal  testimony  has  as  yet  not  been  obtained  from  isolation  experi- 
ments as  regards  septicaemia,  it  is  reasonable  to  suppose  that  this  is  due  to 
the  defects  in  the  technique,  for  which  it  is  presumable  the  ingenuity  of 
investigators  will  in  future  find  the  remedy. 

It  is,  however,  from  the  constant  presence  of  the  bacteria  in  infected 
wounds,  and  their  distribution  through  the  tissues,  that  the  argument  in 
favor  of  connecting  septic  symptoms  with  the  bacteria  has  been  mainly 
deduced.  Here  the  ground  is  sufficiently  solid,  and,  judged  by  ordinary 
laws. of  scientific  evidence,  the  pathological  importance  of  the  microspores 

1  Archw.  filr  exp.  Pathologie  und  Pharmakoloyie,  "  Beitriige  znr  Kenntniss  der  Pathogenen 
Schistomyceten,"  Band  iv.  Heft  3,  S.  241  und  ff. ;  Tiegel,  loc.  cit. 

2  In  this  connection  may  be  mentioned  some  very  interesting  experiments  by  Dr.  George 
Gafi'ky  (Experimentellen  Erzengte  Septiccem.ie,   Mittheilungen  awt  den  Kaiserlich,   Oesundh. 
Amle),  in  which  micrococci  from  the  blood  of  septicsemic  mice  were  succcessfully  cultivated 
in  a  gelatine  preparation,  and  produced,  when  inoculated  in  small  quantities,  the  symp- 
toms identical  with  those  obtained  by  inoculating  the  blood  itself. 

3  "  Exp.  Beitriige  zur  Lehre  von  der  organisirte  Natur  der  Contagion  und  von  der 
Faiilniss,"  Archw.  fur  klinische  Chirurgie,  Bd.  xvii.  Heft  4,  S.  669  u.  ff. 

*  "  Exp.  Beitriige  zum  Studium  der  septischen  Infection,"  Deutsche  Zeitschrift  filr  Chi- 
rurgie, Bd.  vi.  S.  162. 

1 "  Lectures  on  the  Relations  of  Bacteria  to  Disease,"  British  Mfd.  Journal,  March  27, 
1875.  See  also  Klebs,  "  Beitriige  zur  Kenntniss  der  Pathogenen  Schistomyceten,"  Arch, 
fur  Pathol.  und  Pharmakol.,  Bd.  iii.  S.  321. 

'  "  Antiseptica  und  Bacterien,"  Arch.f.  e.cp.  Pathol.  und  Pharmakol.,  Bd.  iv.,  Heft  1  und  2. 


PUERPERAL  FEVER  FROM  THE  MODERN  STANDPOINT.      997 

may  be  regarded  as  established.  To  be  sure,  we  find  them  in  tongue- 
scrapings  of  healthy  individuals,  but  tongue-scrapings  are  poisonous  if 
injected^  into  the  tissues.  That  they  do  not  ordinarily  prove  so  in  the 
mouth  is  no  more  singular  than  that  woorari  can  be  swallowed  with 
impunity.  Tiegel l  has  endeavored  to  show  that  round  bacteria  are  found 
normally  in  the  internal  organs  of  the  body ;  but  Koch 2  states  that  he 
has  on  many  occasions  examined  normal  blood  and  normal  tissues  by 
means  which  prevented  the  possibility  of  overlooking  bacteria,  or  of  con- 
founding them  with  granular  masses  of  equal  size,  and  that  he  has  never 
in  a  single  instance  found  organisms. 

It  is  stated  that  bacteria  are  sometimes  absent  from  the  blood  with- 
drawn during  life  in  septic  diseases.  As,  however,  their  constant  presence 
has  been  confirmed  in  the  vessels  and  glomeruli  of  the  kidneys,  it  is  fair 
to  assume  that  those  organs,  acting  as  filters,  must  have  received  the 
colonies  observed  in  them  from  the  general  circulation. 

The  difficulty  of  obtaining  bacteria  from  the  blood  in  many  cases  dur- 
ing life  in  septic  diseases  does  not,  however,  as  was  once  supposed,  invali- 
date the  theory  of  their  pathogenic  importance.  Septicaemia  is  at  present 
employed  as  a  collective  term  for  a  number  of  processes  which  may  occur 
singly  or  in  combination  with  one  another.  When  a  relatively  large 
quantity  of  a  putrid  fluid  is  injected  into  the  veins  of  an  animal,  death 
follows  from  the  action  of  a  chemical  poison  (sepsin).  The  blood  during 
life  rarely  displays  the  presence  of  bacteria,  the  latter  disappearing  in  the 
circulation.  In  animals  thus  poisoned  blood  does  not  possess  infectious 
properties.  This  form  is  termed  putrid  intoxication.  That  the  poison  in 
these  cases  is,  however,  produced  by  the  bacteria  is  shown  by  experiments 
of  Gutmauu,3  who  demonstrated  that  bacteria  from  a  drop  of  putrid 
blood  cultivated  in  Cohn's  solution  developed  in  the  fluid  a  poison  which, 
when  injected  into  the  veins  of  dogs,  occasioned  death  with  all  the  symp- 
toms of  putrid  intoxication.  Still  more  conclusive  were  the  experiments  of 
Koch.  This  observer  injected  four  drops  of  putrid  blood  beneath  the  skin 
of  mice.  The  latter  died  in  from  four  to  eight  hours.  There  were  no 
bacteria  in  the  blood,  and  the  blood  was  not  infectious.  When,  however, 
a  single  drop  was  injected,  the  mice  often  remained  unaffected,  but  in  a 
third  of  the  cases  they  became  ill  after  twenty-four  hours,  death  occurring 
in  from  forty  to  sixty  hours.  The  blood  during  life  communicated  the 
same  disease  to  other  mice,  and  bacilli  were  always  present  in  large  num- 
bers. In  these  cases  the  dissolved  poison  in  the  fluid  injected  was  too 
small  in  amount  to  destroy  life,  and  death  resulted  only  after  a  period 
of  incubation  as  a  consequence  of  the  multiplication  of  bacilli  in  the 
blood  and  in  the  tissues. 

In  another  class  of  cases  Koch  experimented,  not  with  putrid  blood, 
but  with  a  fluid  produced  by  macerating  a  piece  of  mouse-skin  in  dis- 
tilled water.  Of  this  he  injected  a  syringeful  into  the  back  of  a  rabbit. 
The  result  was  peritonitis,  swelling  of  the  spleen,  gray  wedge-shaped 
patches  in  the  liver,  and  in  the  lungs  were  found  dark-red  patches  the 
size  of  a  pea,  devoid  of  air — all  appearances  in  harmony  with  what  is 
designated  as  pyasmia.  Oval  micrococci  were  found  in  great  numbers 

1  Arch.  f.  Path.  Anat.  u.  Physiol.  u.f.  klin.  Med.,  vol.  Ix.  p.  453. 

•2  On  Traumatic  Infective,  Diseases,  iSew  Sydenham  Soc.  publication  p.  15. 

8  Vide  Semmer,  "'Putride  Intoxication,"  etc.,  VirchouSs  Arch.,  vol.  Ixxxi.  p.  109. 


998  PUERPERAL  FEVER. 

everywhere  throughout  the  body.  But  the  point  of  special  interest  in 
the  present  connection  is  the  fact  that  wherever  these  micrococci  come  in 
contact  with  the  red  blood-corpuscles  the  latter  stick  together  and  become 
arrested  in  the  minute  capillary  network.  The  thrombi  thus  formed 
are  further  enlarged  by  the  deposition  of  micrococci,  which  multiply, 
block  up  individual  capillary  loops,  and  invade  contiguous  tissues.  In 
the  blood-current  itself,  however,  the  micrococci  do  not  increase  in  num- 
bers, and  cannot  always  be  found  in  the  circulation  upon  a  single  exam- 
ination, but  Doleris1  assures  us  that  in  puerperal  fever  by  repeated 
trials,  especially  after  a  chill,  he  has  never  failed  to  demonstrate  their 
presence. 

As  to  the  exact  manner  in  which  these  minute  bodies  exercise  their 
pernicious  influence,  whether  they  operate  mechanically,  or  whether  they 
produce  a  virus  in  the  process  of  nutritive  activity,  or  whether,  as  is 
probable,  both  suppositions  are  correct,  must  be  decided  by  future  inves- 
tigations. It  is  enough  for  us  to  note  that  the  connection  between  sepsis 
and  bacteria  is  intimate  and  vital. 

3d.  Pathogenic  bacteria  are  invariably  associated  with  puerperal  fever, 
and  to  them  the  infectious  qualities  of  the  disease  are  due.  I  have  been 
explicit  regarding  the  evidence  concerning  bacteria  in  septic  diseases, 
because  it  places  the  question  of  the  infectious  group  of  puerperal  fever 
cases  in  the  following  position:  Experiences  occurring  clinically,  as  well 
as  those  produced  upon  animals,  teach  us  that  certain  lesions  and  symp- 
toms, similar  to  those  we  are  accustomed  to  regard  as  characteristic  of 
puerperal  fever,  results  from  septic  poisoning.  In  a  large  class  of  cases, 
however,  the  connection  between  childbed  fever  and  sepsis  has  been 
deduced  rather  from  analogy  than  direct  proof.  For  those  who  chose  to 
regard  such  as  due  to  a  specific  poison  peculiar  to  the  puerperal  state 
there  was  really  no  objection.  If,  however,  bacteria  are  characteristic  of 
septic  poisoning,  the  question  presents  itself  in  a  different  light,  and  we 
have  to  inquire  whether,  in  the  less  obvious  cases,  bacteria  are  present  in 
puerperal  fever  in  the  proportions  and  groupings  that  we  find  them  in 
other  diseases  due  to  putrid  infection.  Now,  it  is  precisely  proof  of  this 
nature  that  has  recently  been  abundantly  rendered. 

Waldeyer,2  Orth,3  Heiberg,4  and  Von  Reeklinghausen 5  found  the 
tissues  and  lymphatics  of  the  parametria  filled  with  pus-like  masses, 
which  consisted,  in  addition  to  pus-cells,  chiefly  of  bacteria.  Bacteria 
swarmed  in  the  fluid  of  the  peritoneal  cavity.  In  one  case  examined  by 
Waldeyer  six  hours  after  death,  while  the  body  was  still  warm,  the  peri- 
toneal exudation  was  like  an  emulsion,  and  furnished  an  abundant  deposit 
which  consisted  almost  entirely  of  bacteria.  Orth  injected  ten  minims 
of  peritoneal  fluid  from  a  woman  dead  of  puerperal  fever  into  the  abdo- 
men of  a  rabbit.  As  the  animal  was  dying  he  broke  up  the  medulla 
oblongata,  and  found  in  the  peritoneal  fluid  enormous  quantities  of  these 

1  La  Fievre  Puerperale,  etc.,  p.  120. 

2  "Ueber  das  Verkommen  von  Bacterien  bei  dcr  diphtheritischen  Form  des  puerperal 
Fiebers,"  Archivfiir  Oynaekoloffie,  vol.  iii.  p.  293. 

3  *'  Untersuchungen  iiber  puerperal  Fieber."  Virchoufs  Archiv,  vol.  Iviii.  p.  437. 

4  Die  puerperalen  und  pycemischen  Processe.  Leipzig,  1873. 

5  For  the  views  of  Von  Recklinghausen  I  am  indebted  to  his  pupil  Steurer.     Vide  the 
•writer's  paper  on  " The  Nature,  Origin,  and  Prevention  of  Puerperal  Fever,"  Trans,  of 
tlie  International  J/ec/.  Conyr&te,  Phila.,  1876. 


999 

organisms.  In  puerperal  fever  round  bacteria  have  been  likewise  found 
though  in  less  quantities,  in  the  lymphatics  of  the  diaphragm  and  in  the 
fluids  of  the  pleura,  the  pericardium,  and  the  ventricles  of  the  brain.  In 
post-mortem  examinations  of  fresh  subjects  the  serous  fluids,  withdrawn 
under  proper  precautions,  do  not  contain  round  bacteria  except  in  cases 
of  septic  infection.1  Orth  found  in  the  purulent  contents  of  the  vessels 
of  the  funis,  in  children  who  died  of  sepsis,  precisely  the  same  formations 
as  existed  in  the  exudations  of  the  mother. 

Dpleris,  in  a  remarkable  essay  already  referred  to,  published  in  1S80,2 
furnishes  not  only  conclusive  evidence  of  the  presence  of  bacteria  in  the 
various  tissues  and  serous  cavities  of  women  dying  of  puerperal  fever, 
but  has  added  the  evidence  of  their  pathogenic  character  by  cultivating 
them  apart  in  sterilized  fluids,  and  by  reproducing  in  anima'ls,  by  means 
of  subcutaneous  injections  of  the  isolated  bacteria,  the  infarctions,  the 
the  blood-changes,  and  the  suppurative  processes  of  the  original  disease. 

^  So  far,  the  generic  term  bacteria  has  been  employed  to  indicate  the 
disease-germs  which  are  the  active  agents  of  infection  in  puerperal  fever. 
It  is  not,  however,  intended  to  assume  that  the  germs  of  septic  processes 
are  all  identical,  or  that  they  all  produce  precisely  the  same  pathological 
conditions.  Koch,  indeed,  maintains  that  a  distinct  specific  bacterial  form 
is  found  in  such  closely-allied  affections  as  pyaemia,  septicaemia,  gangrene, 
and  erysipelas,  the  different  forms  possessing,  however,  this  link  in  com- 
mon— viz.  that  they  are  alike  generated  in  putrefying  media.  Singularly 
enough,  the  bacterium  termo  and  the  bacterium  commune — to  which  the 
fetidity  of  matters  undergoing  putrefaction  is  due — are  in  themselves 
harmless.  They  are  rapidly  destroyed  in  the  circulation,  and  are  not 
inoculable.  Fetid  discharges  from  wounds  are  not  therefore  necessarily 
dangerous.  The  putrid  odor  serves  a  useful  purpose,  as  it  gives  warning 
of  the  existence  of  conditions  which  favor  the  development  of  life-destroy- 
ing organisms ;  but  the  latter  may  develop  without  the  concurrence  of 
the  forms  which  give  rise  to  putrefaction — a  fact  of  considerable  import- 
ance in  view  of  the  common  belief  that  septic  infection  is  excluded  by 
the  absence  of  fetid  odors. 

In  puerperal  fever  Dole'ris  found  the  prevailing  pathogenic  organisms 
consisted  of  bacilli  or  rods,  and  micrococci  or  round  bacteria  in  the  vari- 
eties of  micrococci,  simple  points ;  diplococci,  double  points ;  and  chains 
or  wreaths.  The  bacilli  he  regarded  as  the  source  of  acute,  rapid  septi- 
caemia, while  pus-production  was  associated  with  the  multiplication  of  the 
round  bacteria,  and  especially  of  the  diplococci. 

4th.  The  presence  of  germs  in  puerperal  fever  serves  not  only  to  fix  cases 
hitherto  doubtful  in  the  category  of  septic  diseases,  but  affords  the  most  sat- 
isfactory explanation  of  the  protean  phenomena  of  puerperal  fever  itself. 

"We  have  seen,  from  both  Koch's  and  Gutmann's  experiments  upon 
animals,  that  death  may  occur  independently  of  bacteria  by  the  rapid 
absorption  of  a  chemical  poison  developed  in  a  putrefying  fluid.  Clinical 
experiences,  such  as  the  speedy  death  sometimes  observed  when  retained 
coagula  or  portions  of  placenta  undergo  decomposition  within  the  uterine 
cavity,  renders  it  probable  that  similar  cases  of  putrid  intoxication  are 

1  Klebs,  "  Beitrtige  zur  Kenntniss  der  Pathogenen  Schistomyceten,"  Archiv  fur  exp. 
Pathol.  und  Pharmakol.,  vol.  iv.  p.  441  et  seq. 

2  La  Fievre  Puerperale  et  les  Oryanismes  Infer ieurs. 


1000  PUERPERAL  FEVER. 

not  unknown  in  puerperal  women,  though,  so  far,  the  anatomical  demon- 
stration of  the  fact  has  not  been  furnished. 

In  cases,  however,  where  puerperal  fever  has  a  distinct  period  of  incu- 
bation, and  progresses  step  by  step  to  the  fatal  ending,  bacteria  are  always 
found  invading  the  tissues  of  the  genital  canal.  In  rare  cases  they  pass 
by  the  Fallopian  tube  to  the  peritoneal  cavity  and  excite  salpiugitis  and 
peritonitis.  More  commonly  from  local  lesions  they  enter  the  canalicular 
spaces  of  the  connective  tissue  forming  the  framework  of  the  genital 
canal,  which  is  continuous  with  the  subperitoneal  connective  tissue  of  the 
pelvis.  From  the  canalicular  space  they  enter  the  lymphatics.  Cellulitis 
is  excited  by  their  presence,  and  the  lymphatic  glands  become  inflamed 
and  enlarged.  In  pernicious  forms  they  produce  a  sero-puruleut  oedema, 
which  spreads  rapidly  with  a  wave-like  progress  after  the  manner  of 
erysipelas ;  or  in  milder  cases  the  progress  of  the  disease-germs  is  arrested 
by  the  lymphatic  glands  or  the  resistance  oifered  by  the  tissues  them- 
selves, and  the  ordinary  circumscribed  phlegmon  is  produced.  By  the 
lymphatics  which  accompany  the  vessels  of  the  Fallopian  tubes  they 
reach  the  ovaries  (puerperal  ovaritis),  and  by  the  broad  ligaments  they 
pass  to  subperitoneal  tissues  of  the  iliac  and  lumbar  regions.  Through 
the  same  system  they  are  conveyed  to  the  great  serous  cavities  of  the  body. 
In  the  peritoneum  they  give  rise,  unless  death  occurs  too  speedily,  to 
pycemic  peritonitis,  which,  unlike  the  traumatic  form,  is  attended  with 
but  little  pain,  and  for  which  the  claim  has  been  set  up  that  it  is  peculiar 
to  puerperal  fever.  The  wide  stomata  upon  the  abdominal  surface  of 
the  diaphragm  allows  the  facile  entrance  of  the  organisms  into  its  lym- 
phatics. Waldeyer  found  in  diaphragmitis  the  lymphatics  of  the  dia- 
phragm filled  with  bacteria.  And  thus,  following  the  lymphatic  system, 
if  we  only  admit  that  bacteria  are  the  active  agents  of  sepsis,  the  fre- 
quency, in  severe  types  of  puerperal  fever,  of  inflammation  of  the  serous 
membranes  of  the  peritoneum,  the  pleura?,  the  pericardium,  the  meninges, 
and  the  joints  finds  an  easy  explanation.  Nor  is  it  altogether  accident 
which  determines  in  different  cases  the  precise  serous  membranes  which 
are  affected.  The  widespread  ramifications  of  the  lymphatic  system 
would  naturally  give  rise  to  eccentric  inflammations  in  place  of  those 
following  the  apparent  continuity  of  tissues. 

The  ductus  thoracicus  is  the  principal  channel  through  which  the  bac- 
teria enter  the  blood.  It  is  possible  that  they  may  further  obtain  access 
into  the  circulation  through  the  radicles  which  furnish  the  communica- 
tions between  the  capillaries  and  the  lymphatics.  We  have  seen  that 
nacteria  are  found  with  difficulty  in  the  blood  during  life.  A  few  hours 
after  death  they  swarm  in  that  fluid.  That  they  do,  however,  enter  the 
general  circulation  during  life  is  incontestable.  Steurer  writes :  "  As  the 
kidneys  are  the  great  filters  of  the  human  system,  I  never  neglected  to 
examine  them,  and  almost  invariably  found  micrococci  filling  the  arterioles 
and  glomeruli."  This  is  in  correspondence  with  what  occurs  in  other 
septic  diseases,  and  accounts  for  the  albumiuuria  and  interstitial  nephritis 
which  often  supervene  in  the  advanced  stages. 

The  action  of  the  bacilli  upon  the  blood  differs  materially  from  that, 
of  the  round  bacteria.  So  soon  as  the  latter  come  in  contact  with  the  red 
corpuscles,  the  corpuscles  stick  together  and  form  larger  or  smaller  clots 
in  the  blood.  They  then  are  no  longer  able  to  pass  through  the  minute 


PUERPERAL  FEVER  FROM  THE  MODERN  STANDPOINT.  1001 

capillary  networks,  but  are  arrested  in  the  larger  or  smaller  vessels 
(Koch).  The  micrococci  in  the  resulting  infarctions  multiply,  and  migrate 
into  the  vessels  and  cellular  tissue  of  the  neighborhood.  Thus  fresh  foci 
of  infection  are  formed.  Or  by  their  destructive  action  they  may,  when 
situated  near  the  serous  surfaces,  penetrate  into  the  serous  cavities,  and  in 
this  way  indirectly  occasion  peritonitis,  pleurisy,  meningitis,  and  purulent 
inflammations  of  the  joints.  When  the  micrococci  enter  directly  into 
the  circulation,  they  sometimes,  in  passing  through  the  heart,  adhere  to 
the  endocardium  and  the  valves,  where  they  cause  exudation  and  ulcera- 
tion,  and  give  rise  to  the  so-called  endocarditis  ulcerosa  puerperalis.1  The 
red  globules  of  the  blood  undergo  changes  of  shape,  assume  a  stellate 
aspect,  and  rapidly  disappear.  The  white  globules  are  greatly  increased 
in  numbers,  and  the  blood  itself  becomes  nearly  colorless.  A  certain 
amount  of  light  is  thrown  upon  these  blood-changes  by  Doleris,  who 
added  micrococci  to  the  fresh  blood  of  a  frog  and  watched  the  ensuing 
changes  under  the  microscope.  The  micrococci  could  be  seen  in  the  act 
of  penetrating  the  red  globules,  which  thereupon  lost  their  color  and 
became  shrunken,  and,  following  the  discharge  of  the  organisms,  which 
meantime  had  multiplied  in  an  astonishing  manner,  little  or  nothing  of 
the  original  globules  remained. 

In  the  bacillar  form  of  septicaemia  the  blood  is  dark  and  has  a  semi- 
gelatinous  appearance,  compared  by  French  writers  to  partially-cooked 
gooseberry  jelly.  The  red  globules,  though  they  exhibit  the  various  stages 
of  deformation,  are  not  diminished  in  number.  The  disease  is  further 
characterized  by  ecchymoses  and  minute  apoplectic  eifusions,  and  by  the 
absence  of  pus-formation.  In  the  artificial  septicaemia  produced  by  Koch 
in  mice  by  means  of  bacilli  the  rod-like  organisms  were  found  to  enter 
the%  white  corpuscles  and  to  compass  their  destruction.  They  did  not 
cause  the  red  globules  to  adhere  together,  and  there  was  no  clogging  of 
the  capillary  circulation.  All  the  principal  structures  of  the  animals 
subjected  to  experiment  were  infiltrated  with  bacilli.  The  distribution  of 
the  latter  was  apparently  accomplished  by  the  blood-vessels,  and  not  by 
the  lymphatics,  the  bacilli  probably  effecting  their  entrance  into  the  ves- 
sels by  virtue  of  their  penetrative  power,  in  place  of  traversing  preformed 
pathways.  Possibly  it  is  this  action  of  the  bacilli  which  causes  the  weak- 
ening of  the  vessel-walls,  as  evidenced  by  the  large  number  of  red  cor- 
puscles which  pass  out  from  them. 

In  puerperal  fever  it  is  rare  to  find  either  round  bacteria  or  bacilli 
acting  singly  as  the  agent  of  infection.  As  a  rule,  both  forms  exist  to- 
gether in  varying  proportions,  the  predominant  form,  however,  determin- 
ing in  general  the  character  of  the  symptoms. 

Thrombosis  of  the  veins  may  be  a  physiological  phenomenon,  or  may 
be  due  to  an  alteration  of  the  blood,  to  weakness  of  the  heart,  or  to  local 
influences.  So  long  as  the  clot  remains  firm  its  influence  is  limited  to 
disturbances  of  the  circulation.  The  pysemic  symptoms — viz.  suppura- 
tion of  the  coagulum,  the  separation  of  emboli,  and  the  formation  of 
metastatic  abscesses— are  always  dependent  upon  the  presence  of  round 
bacteria.  In  phlebitis  the  latter  are  found  in  the  endothelium  and  in  the 
sheaths  of  the  veins.  The  inflammation  of  the  veins  is  followed  by 

1  Heiberg,  Die  puerperalen  und  pynmischen  Prncense,  Leipzig,  1873,  pp.  22  and  34,  with 
references  to  cases  reported  by  Wiege  and  Eberth. 


1002  PUERPERAL  FEVER. 

thrombosis.  According  to  Doleris,  micrococci  derived  from  the  blood 
are  deposited  upon  the  central  extremities  of  the  clots ;  beyond  these 
depots  a  fresh  inflammation  is  set  up,  followed  by  fibrinous  coagulation. 
Thus  the  micrococci  become  imprisoned  between  two  plugs.  The  same 
process  may  be  repeated  until  a  series  of  abscesses  are  formed.  For  a 
time  no  mischief  may  ensue.  Finally,  however,  the  resistance  of  the 
outworks  is  overcome,  an  embolus  becomes  detached,  and  an  infectious 
abscess  is  opened  into  the  blood — an  event  which  is  announced  by  an 
intense  chill  and  the  familiar  systemic  derangement. 

In  septic  diseases  death  takes  place  from  apnoea,  partly  from  the  inabil- 
ity of  the  blood-corpuscles  to  carry  oxygen  to  the  tissues,  and  partly 
from  paralysis  of  the  nerve-centres.1 

In  hospital  epidemics  of  puerperal  fever  diphtheritic  patches  situated 
upon  the  lesions  of  the  vulva  and  in  the  course  of  the  utero-vagiual 
canal  are  sometimes  observed.  Steurer  found  these  patches  were  always 
associated  with  loss  of  substance,  and  were  composed  of  disintegrated 
fibrin,  white  and  red  blood-globules,  and  colonies  of  round  bacteria  in 
great  abundance.  Morphologically,  these  so-called  diphtheritic  patches 
are  identical  with  those  which  appear  in  the  throat.  Fallen2  has 
reported  an  instance  of  the  simultaneous  occurrence  of  puerperal  diph- 
theritis  in  the  mother  and  throat  diphtheritis  in  the  two- weeks'  old 
child.  In  lying-in  hospitals  it  is  the  genital  organs,  as  the  locus  resis- 
teutice  miuoris,  and  not  the  throat,  which  are  the  usual  points  of  attack. 

The  question  as  to  the  extent  to  which  erysipelas  and  puerperal  fever 
are  cognate  diseases  is  in  a  fair  way  to  be  solved  by  recent  investigation. 
Orth  took  the  contents  of  a  vesicle  from  an  erysipelatous  patient  which 
contained  bacteria  in  great  abundance,  and  employed  the  same  for  injec- 
tions under  the  skin  of  rabbits.  In  this  way  he  succeeded  in  producing 
in  these  animals  a  species  of  erysipelas  maliguum.  In  the  subcutaneous 
cedema  and  affected  portions  of  the  skin  he  found  enormous  masses  of 
bacteria,  so  far  exceeding  in  quantity  the  amount  introduced  as  to  prove 
an  abundant  new  production.3  Samuel  produced  similar  results  by  the 
injection  of  ordinary  putrid  fluids  containing  round  bacteria.  An  affec- 
tion resembling  simple  erysipelas  he  obtained  most  frequently  by  the 
application  of  fluid  to  a  wound  torn  open  after  the  second  or  third  day.4 
Lukomski  found  that  erysipelas  could  be  produced  by  fluid  containing 
micrococci  even  when  putrefaction  did  not  exist.  The  contents  of  erysip- 
elatous vesicles  containing  no  micrococci  excited  no  morbid  manifestations. 
Where  the  erysipelatous  process  was  fresh  and  progressing  micrococci 
were  found  in  great  abundance  in  the  lymphatics  and  canalicular  spaces. 
AVhere  the  process  was  retrogressive,  there  were  no  micrococci  to  be  found, 
even  in  cases  in  which  inflammation  existed  to  an  intense  degree.5  Doleris 
submitted  to  the  culture-process  of  Pasteur  fluid  obtained  from  vesicles 
which  developed  in  the  course  of  facial  erysipelas  in  a  man  of  forty  years. 
Micrococci  in  chains  were  found  in  the  liquids  employed  identical  with 
those  he  had  discovered  in  puerperal  fever.  In  many  cases  I  have  seen 
an  erysipelatous  inflammation  start  from  a  puerperal  diphtheritic  ulcer 

1  Schiiller,  "Exp.  Beitriige  zur  Studium  der  Septischen  Infection,"  Deutsche  Zeitschr.f* 
Chir.,  vol.  vi.  p.  149  et  seq.  2  Trans.  N.  Y.  Obvt.  Soc.,  1876-78,  p.  78. 

8  Untersuchungen  iiber  Ervsipel.,"  Arch,  fur  ez/».  Puthol.  und  PharmakoL,  Bd.  i.  S.  81. 
*  Arch,  fiir  exp.  Path,  und  Pharmak.,  Bd.  i.  S.  335,  u.ff. 
6  "  Untersuchungen  iiber  Erysipel.,"  Virchow's  A  rchiv,  Bd.  Ix.  S.  430. 


PUERPERAL  FEVER  FROM  THE  MODERN  STANDPOINT.  1003 

upon  the  iutroitus  vaginae,  and  extend  outward  over  the  buttocks,  the 
thighs,  and  the  lower  portion  of  the  abdomen. 

Virchow  1  has  so  far  given  in  his  adhesion  to  the  new  school  as  to 
say  :  "  Especially  in  this  connection  are  to  be  mentioned  the  diphtheritic 
process  and  the  erysipelatous,  especially  erysipelas  maliguum.  The 
granular  deposit  in  diphtheritically  affected  tissues,  of  which  I  formerly 
spoke,  has  more  and  more  proven  to  be  of  a  parasitic  character.  What 
we  formerly  regarded  as  simple,  organic  granules,  as  infiltration  or  exu- 
dation, has  since  proven  to  be  a  dense  aggregation  of  micro-organisms 
which  penetrate  ^  into  the  tissues  and  cells  to  compass  their  destruction." 

Thus  we  find  in  surgical  fever,  in  puerperal  fever,  in  diphtheria,  and  in 
erysipelas  the  presence  of  a  common  element  which  links  them  together, 
and  which  establishes  the  relationship  which  has  long  been  recognized  as 
existing  between  these  various  processes. 

4th.  The  differences  between  surgical  and  puerperal  septicaemia  are  due 
to  differences  partly  structural  and  partly  physiological  in  the  wounded  sur- 
faces exposed  to  septic  contamination. 

A  certain  amount  of  misapprehension  has  arisen  from  the  circumstance 
that  along  with  many  coincidences  in  the  symptoms  of  puerperal  and 
surgical  fever  there  are  observable  differences  which,  from  a  purely 
clinical  point  of  view,  would  justify  a  separate  classification  of  the  two 
affections.  It  will  not  do,  however,  to  ignore  the  fact  that  the  conditions 
which  prevail  in  the  parturient  canal  subsequent  to  labor  have  no  strict 
analogue  in  the  lesions  which  the  surgeon  is  called  upon  to  treat,  and  that 
therefore  a  complete  identity  as  to  all  the  clinical  features  of  puerperal 
and  surgical  fever  would  hardly  be  within  the  range  of  possibility. 

In  the  puerperal  state  it  is  necessary  to  take  into  account  the  blood- 
changes  induced  by  pregnancy,  the  effects  of  shock  and  exhaustion  in 
protracted  labors,  the  frequency  of  hemorrhage,  the  deep  situation  of 
puerperal  \vouuds,  the  presence  of  clots,  decidua,  and  dead  tissue  in  a 
state  of  disintegration  or  decomposition,  the  ease  with  which  deleterious 
matters  are  absorbed  by  the  wide  lymphatic  interspaces,  the  serous  infil- 
tration of  the  pelvic  tissues,  the  exaggerated  size  of  the  lymphatics  and 
veins,  and  the  proximity  of  the  peritoneal  cavity. 

Samuel,2  in  speaking  of  the  immunities  and  dispositions  to  septic 
poisoning,  says  :  "  The  statistical  frequency  of  septic  puerperal  disease 
is  due  to  the  length  of  the  parturient  canal,  to  the  fact  that  through  this 
long  passage  there  must  pass  all  the  pathological  and  physiological  excre- 
tions, and  to  the  soiling  of  these  parts  with  fingers,  instruments,  and 
secretions  which  have  become  the  bearers  of  sepsis."  He  found,  on  the 
other  hand,  that  it  was  extremely  difficult  to  produce  a  progressive  ichor- 
ous  condition  by  daily  painting  an  open  stump  with  a  septic  fluid,3  though 
the  same  was  readily  obtained  when  an  infinitesimal  quantity  of  septic 
fluid  was  injected  underneath  a  fascia. 

5th.  In  the  present  state  of  our  scientific  knowledge  it  is  necessary  to 
admit  that  thew  is  a  limited  number  of  febrile  and  inflammatory  dis- 
turbances occurring  in  puerperal  ivomen,  the  bacterial  origin  of  which 
may  be  fairly  questioned.  As  illustrations  of  this  class  may  be  men- 

1  Die  Fortsehritte  der  Kriecfs  Heilkunde,  Berlin,  1874. 

2"Ueber  die  Wirkung  des  Faiilniss  Process  auf  den  lebenden  Orgamsmus,"  Arch.f. 
cxp.  Pathologic,  vol.  i.  p.  343.  8  Loc.  cit.,  p.  339. 


1004  PUERPERAL  FEVER. 

tioned :  1.  Cases  of  catarrhal  endometritis  due  to  errors  of  diet  and 
exposure.  Indeed,  I  have  frequently,  in  hospital  practice,  been  able  to 
trace  severe  cases  of  cellulitis,  pelvic  peritonitis,  and  general  peritonitis 
occurring  in  the  winter  season  to  the  patient  getting  out  of  bed  dripping 
with  perspiration,  and  clad  only  in  a  night-dress,  and  going  thus  bare- 
footed over  a  cold,  uncarpeted  floor  to  the  water-closet.  2.  Cases  of 
puerperal  disorders  proceeding  from  emotional  causes,  the  nervous  system 
furnishing  the  first  impulse  to  the  disturbed  action.  3.  Cases  of  exces- 
sive vulnerability  in  non-pregnant  women  ;  individuals  are  sometimes 
found  so  susceptible  that  a  parametritis  follows  a  simple  application  of 
the  tincture  of  iodine  to  the  cervix.  4.  Cases  of  pelvic  peritonitis  start- 
ing from  old  intra-peritoueal  adhesions.  5.  Cases  of  peritonitis  and 
retro-peritoneal  inflammations  secondary  to  ulcerative  processes  in  the 
ca3cum  or  the  descending  colon.  This  condition  is  apt  to  be  masked 
during  pregnancy,  but  starts  into  activity  during  childbed  as  a  conse- 
quence of  fecal  accumulation  or  of  excessive  purgation. 

It  is  by  no  means  easy  to  decide  as  to  the  precise  nature  of  local  inflam- 
mations following  lacerations  of  the  cervix  and  the  bruising  or  crushing 
of  the  soft  parts  in  long  or  instrumental  labors.  The  marvellous  absence 
of  heat,  pain,  redness,  and  swelling  in  wounds  treated  in  strict  accordance 
with  the  principles  of  Lister,  the  very  slight  reaction  when  the  atmo- 
sphere is  pure,  and  the  severity  of  these  symptoms  in  overcrowded  hos- 
pitals, tend  indeed  to  strengthen  the  belief  that  even  the  simplest  inflam- 
mations proceeding  from  wounds  owe  their  origin  in  great  part  to  septic 
germs.  But,  on  the  other  hand,  in  hospital  practice  it  is  not  uncommon 
to  observe  puerperal  inflammations  and  febrile  conditions  which  possess 
this  distinctive  peculiarity — that  they  in  no  wise  visibly  affect  the  health 
of  puerperal  patients  in  their  vicinity.  The  symptoms  of  blood-poison- 
ing too  are  either  absent  or  present  to  a  subordinate  extent.  Probably 
the  difficulty  is  best  solved  by  assuming  with  Genzmer  and  Volkmann1 
that  there  is  such  a  thing  as  an  aseptic  surgical  fever  due  to  the  absorp- 
tion of  the  products  of  physiological  tissue-changes  at  the  seat  of  injury. 
In  surgical  cases,  even  wrhere  the  precautions  of  Listerisui  have  been 
faultlessly  observed,  febrile  movements  of  considerable  intensity,  but  of 
no  prognostic  signification,  are  of  frequent  occurrence.  While  in  puer- 
peral women  we  can  never  exclude  the  possibility  of  the  septic  infection 
of  puerperal  wounds,  it  is  in  accordance  with  clinical  experience  to  assume 
that  a  high  fever  belonging  to  the  aseptic  class  may  coincide  with  a  septic 
process  of  insignificant  proportions. 

GENERAL  SYMPTOMS. — As  in  other  infectious  diseases,  there  is,  from 
the  time  of  the  entry  of  the  poison  into  the  system  up  to  the  outbreak 
of  fever,  a  distinct  period  of  incubation.  The  first  febrile  symptoms 
usually  occur  within  three  days  of  the  birth  of  the  child.  An  attack 
coming  on  a  few  hours  after  childbirth  is  indicative  of  infection  during 
or  previous  to  labor.  The  third  day  is  the  one  upon  which  ordinarily 
the  beginning  of  the  fever  is  to  be  anticipated.  After  the  fifth  day  an 
attack  is  rare,  and  at  the  end  of  a  week  patients  may  be  regarded  as 
having  reached  the  point  of  safety.  Apparent  exceptions  to  this  rule 
are  probably  referable  to  cases  of  mild  parametritis,  in  which  the  initial 

1  Genzmer  and  Volkmann,  "  Ueber  septisches  und  aseptiscbes  Wundfieber,"  SammJ, 
klin.  Vortrdge,  No.  121. 


GENERAL  SYMPTOMS.  1005 

fever  and  the  pain  were  insufficient  to  attract  attention  to  the  existence 
of  local  inflammation. 

The  symptoms  of  puerperal  fever  vary  with  the  character  of  the  local 
affections  and  with  the  extent  to  which  the  general  system  participates  in 
the  disturbed  action.  The  different  groups  of  puerperal  processes  possess 
the  following  pathognomonic  symptoms — viz.  increased  temperature, 
enlargement  of  the  spleen,  disturbed  involution,  and  sensitiveness  of  the 
uterus  upon  pressure  (Braun). 

In  most  cases  the  fever  is  ushered  in  by  chilly  sensations  or  by  a  well- 
defined  chill.  This  symptom,  however,  does  not  possess  much  prognos- 
tic importance.  A  chill  is  significant  of  a  sudden  change  between  the 
temperature  of  the  skin  and  that  of  the  surrounding  medium.  It  may, 
therefore,  be  absent  in  pernicious  forms  of  fever,  provided  only  that  the 
temperature  changes  are  inaugurated  slowly,  whereas  it  may  follow  a 
trifling  increase  of  the  body-heat  if,  as  sometimes  happens  in  sleep,  the 
moist  skin  is  exposed  to  cool  currents  of  air.  Repeated  chills  indicate 
phlebitis  and  pyamia. 

In  order  to  grasp  the  many  symptoms  of  puerperal  fever,  it  is  neces- 
sary to  keep  separately  in  mind  the  clinical  features  of  each  of  the  lo^al 
processes,  although  in  fact  the  latter  rarely  occur  singly,  but  to  a  greater 
or  less  extent  in  combination  with  others. 

The  symptoms  of  ENDOMETRITIS  AND  ENDOCOLPITIS. — The  uncom- 
plicated catarrhal  inflammation  of  the  uterus  and  vagina  is  the  most  fre- 
quent and  the  mildest  of  the  diseases  of  childbed.  In  endometritis  the 
uterus  is  large,  flabby,  and  sensitive  upon  pressure ;  the  after-pains  are 
often  unusually  severe,  involution  is  retarded,  and  the  lochia  become  fetid, 
remain  sanguiuolent  for  a  longer  period  than  usual,  and  at  the  outset  may 
be  temporarily  suspended.  Sometimes  the  large  intestine  is  distended 
with  flatus.  In  endocolpitis  the  vaginal  discharge  is  thin  and  purulent, 
the  patient  experiences  pain  and  burning  in  the  acts  of  defecation  and 
urination,  and,  where  the  wounds  of  the  vulva  and  vagina  assume  an 
ulcerative  character,  there  is  often  found  at  the  same  time  inflammatory 
cedema  of  the  labia. 

The  fever  iu  these  cases  is  ushered  in  frequently,  but  not  always,  by 
chilly  feelings,  and  the  temperature  reaches  its  height  usually  upon  the . 
evening  of  the  third  or  fourth  day,  is  remittent,  almost  intermittent  in 
character,  and  rarely  exceeds  102°  to  103°  F.  In  mild  forms  the  occur- 
rence of  the  fever  is  often  overlooked  or  is  referred  to  disturbance  pro- 
duced by  the  secretion  of  the  milk.  In  severer  attacks  the  febrile  symp- 
toms may  continue  from  three  to  seven  days.  At  the  end  of  a  week  the 
swelling  of  the  labia  subsides,  the  discharge  becomes  thick,  and  ulcers,  if 
present,  begin  to  assume  a  healthy  granulating  appearance. 

In  diphtheritic  ulcerations,  and -in  endometritis  due  to  decomposing 
remains  of  the  ovum,  the  load  condition  is  often  complicated  by  the 
invasion  of  the  neighboring  tissues. 

The  symptoms  of  PARAMETRITIS  and  PERIMETRITIS  (Pelvic  perito- 
nitis ]). — The  symptoms  of  these  two  affections,  as  would  be  naturally 

1  The  following  clinical  history,  together  with  the  statistical  details,  is  borrowed  in 
great  part  from  the  description  of  Olshausen  ("  Ueber  puerperale  Parametritis  und  Peri- 
raetritis,"  Volkmann's  Samml.  klin.  Vortr.,  No.  28),  the  exactitude  of  which  I  have  had 
abundant  opportunity  to  verify. 


1006  PUERPERAL  FEVER. 

expected  from  the  proximity  of  the  peritoneum  to  the  pelvic  connective 
tissue,  for  the  most  part  overlap.  It  must  be  very  rare  for  one  form  to 
occur  entirely  independent  of  the  other.  For  this  reason  it  will  be  found 
convenient  to  consider  first  the  symptoms  common  to  both  morbid  pro- 
cesses, and  subsequently  to  direct  -attention  to  what  are  believed  to  be 
points  of  distinction  between  them. 

During  the  period  of  incubation  there  are  usually  no  prodromic  symp- 
toms. Elevations  of  temperature  in  the  course  of  the  first  twelve  hours 
following  labor  are  equally  frequent  under  perfectly  normal  conditions. 
Suspicious  symptoms  are  disturbed  sleep,  excessively  painful  after-pains, 
and  a  pulse  of  80  to  90. 

The  beginning  of  the  fever  occurs  in  90  per  cent,  within  the  first  four 
days  of  childbed ;  most  frequently  upon  the  second  or  third  day,  and 
taking  place  upon  the  fourth  day  in  scarcely  12  to  15  per  cent,  of  the 
cases.  If  five  days  have  elapsed  without  fever,  the  period  of  danger, 
with  very  rare  exceptions,  may  be  regarded  as  having  passed. 

At  the  outset  the  fever,  especially  in  perimetritis,  is  ushered  in  by 
chilly  sensations  or  by  an  intense  chill.  The  temperature  rises  rapidly, 
though  the  highest  point  is  usually  not  readied  before  the  second,  and  in 
rare  cases  not  before  the  third,  day.  In  most  cases  the  heat  in  the  axilla 
exceeds  103°,  and  may  even  mount  up  to  105°.  The  decline  occurs 
gradually,  the  fever  ending  in  70  per  cent,  in  the  course  of  a  week,  in 
20  per  cent,  in  two  weeks,  and  only  in  10  per  cent,  extending  beyond  that 
period.  Protracted  cases  indicate  abscess  formation. 

The  fever  does  not,  however,  always  pursue  a  regular  course.  In  place 
of  progressively  declining  until  the  termination  is  reached,  the  high  tem- 
perature of  the  second  day  may  be  attained  upon  one  or  more  occasions. 
The  morning  remissions  are  at  first  slight,  but  become  marked  as  the 
disease  approaches  its  close.  In  cases  of  long  duration  the  morning 
hours  are  often  free  from  fever,  a  circumstance  calculated  to  mislead  a 
physician  who  sees  his  patient  but  once  a  day.  A  pulse  of  80  to  90  beats, 
a  disturbed  sleep,  lack  of  appetite,  and  sensitiveness  to  pressure  upon  the 
sides  of  the  uterus  are,  however,  symptoms  which  should  serve  as  a  warn- 
ing of  some  disturbing  cause,  and  should  lead  the  physician  to  renew  his 
visit  in  the  latter  part  of  the  day. 

If,  from  a  mistaken  notion  that  the  morbid  process  has  come  to  an  end, 
the  patient  is  allowed  prematurely  to  resume  her  household  duties,  the 
pains  across  the  abdomen  and  along  the  hip  and  thigh  return,  and  an 
examination  reveals  the  existence  of  exudation  in  the  pelvic  cavity  or 
upon  an  iliac  fossa. 

Errors  of  this  kind  are  most  frequent  in  cases  of  parametritis  associated 
with  slight  peritoneal  inflammation,  as  the  local  pain  is  then  insignificant, 
and  the  initial  chill,  happening  on  the  third  or  fourth  day,  is  apt  to  be 
ascribed  to  engorgement  of  the  breasts. 

Relapses  after  the  complete  disappearance  of  febrile  disturbance  occur 
in  15  to  20  per  cent.  They  are  usually  shorter,  but  sometimes  more 
obstinate,  than  the  original  attack.  As  a  rare  exception  may  be  men- 
tioned cases  with  evening  remissions  and  morning  exacerbations. 

In  circumscribed  pelvic  inflammations  the  pulse  rarely  exceeds  120 
beats  to  the  minute.  A  pulse  of  140,  of  more  than  half  a  day's  duration, 
betokens  severe  septic  complications,  and  is  therefore  of  evil  omen.  In 


GENERAL  SYMPTOMS.  1007 

some  cases  the  slow  pulse  observed  after  labor  makes  its  influence  felt  in 
the  first  day  or  two  of  the  fever,  so  that  the  curious  phenomenon  may 
be  witnessed  of  a  temperature  of  104°  coinciding  for  a  time  with  a  pulse 
ranging  between  50  and  70  beats  to  the  minute. 

As  regards  other  symptoms,  headache  and  sleeplessness  are  rarely 
absent  Profuse  sweating  follows  the  first  febrile  attack,  and  frequently 
recurs  during  the  course  of  the  disease.  J 

Pain  is  present  at  the  onset  in  the  majority  of  cases,  and  is  then 
usually  most  violent.  The  spontaneous  pain,  which  is  due  to  the  affec- 
tion of  the  peritoneum,  subsides  in  great  part  in  the  course  of  one  or  two 
days,  but  the  sides  of  the  uterus  remain  sensitive  to  pressure  In  the 
rare  cases  of  pure  parametritis,  however,  this  symptom  may  be  absent 
altogether.  The  pain,  like  that  from  the  inflammation  of  serous  mem- 
branes, is  of  a  lancinating  character.  Sometimes  it  is  associated  only  with 
the  contractions  of  the  uterus.  After-pains  occurring  under  unusual  cir- 
cumstances, as  in  primipara  or  after  the  third  day,  are  to  be  regarded 
with  suspicion. 

Vomiting  occurs  occasionally,  but  is  comparatively  rare  unless  the 
peritonitis_  becomes  diffused  and  spreads  to  the  region  of  the  stomach. 
The  appetite  is  lost,  and  only  returns,  as  a  rule,  with  the  departure  of  the 
fever.  The  tongue  is  coated  and  moist,  and  constipation  is  common.  In 
other  cases  there  is  diarrhoea  with  rumbling  in  the  bowels,  but  without 
pain  or  ^tenesmus.  The  urinary  secretion  is  rarely  interfered  with,  and 
when  this  is  the  case  it  indicates  the  extension  of  the  inflammation  to  the 
peritoneum  covering  the  bladder. 

Most  cases  of  perimetritis  and  parametritis  terminate  in  five  or  ten 
days,  the  fever  and  other  symptoms  gradually  subsiding.     When,  as  may 
happen  in  exceptional  instances,  the  temperature  falls  suddenly  from  a  high 
degree  to  one  below  the  normal  level,  the  body  grows  icy  cold,  the  pulse 
becomes  small  and  irregular,  and  symptoms  of  collapse  develop.     But  in 
twelve  to  twenty-four  hours  the  symptoms  of  collapse  subside,  and  the  dis- 
ease reaches  its  end  with  a  disappearance  of  the  alarming  manifestations. 
If  the  fever  subsides  within  a  week  exudation  is  somewhat  rare.     Its 
continuance  beyond  that  date  should  lead  to  a  careful  exploration  of  the 
pelvic  organs.     The  exudation  is  usually  demonstrable  in  the  course  of 
the  second  week  or  at  the  beginning  of  the  third  week.     It  is  recognized, 
according  to  its  location,  by  external   or  by  internal  examination,  or, 
where  the  deposit  is  considerable,  by  both  methods.     In  most  cases  the 
deposit  is  extra-peritoneal,  and  is  situated  between  the  folds  of  the  broad 
ligament,  above  and  to  the  sides  of  the  vaginal  cul-de-sac.     It  has  gener- 
ally a  rounded  form,  though  with  less  convexity  than  fibrous  and  ovarian 
tumors.     Sometimes,  however,  the  tumor  is  flat  below,  like  a  board.     It 
seldom  exceeds  in  size  that  of  a  large  apple.     In  fresh  exudations  the 
sensation  produced  is  often  that  of  a  hard  tumor  surrounded  by  a  softer 
layer,  due  to  continued  succulence  of  the  soft  parts.     In  a  few  weeks  they 
may  reach  or  exceed  the  hardness  of  a  fibroid  tumor.     The  older  the 
tumor,  unless  suppuration  sets  in,  the  less  sensitive  it  becomes.     Often 
the  exudation  extends  to  the  pelvic  walls.     The  uterus,  as  a  rule,  is  fixed, 
and  in  cases  of  large  tumors  becomes  pushed  toward  the  opposite  side, 
while  as  a  consequence  of  later  shrinkage  the  fundus  may  be  drawn  per- 
manently toward  the  affected  side. 


1008  PUERPERAL  FEVER. 

The  cul-de-sac  of  the  vagina  is  rendered  broader  and  flatter  by  the 
pressure  of  the  deposit,  or,  when  the  tumor  is  deep  enough,  the  vaginal 
surface  may  be  rendered  convex.  Behind  the  uterus  the  exudation  is  as 
it  were  flattened  antero-postcriorly,  and  in  some  cases  it  may  be  felt  in 
the  form  of  rigid  bauds  betMreen  the  posterior  ligaments  which  enclose  the 
cul-de-sac  of  Douglas.  The  ante-uterine  tumors  have  a  spherical  shape 
and  depress  the  vagina  anteriorly. 

Tumors  situated  in  the  iliac  fossa  have  a  more  or  less  convex  form,  and 
may  be  of  such  considerable  size  that  the  swelling  may  be  recognized  by 
the  eye  through  the  abdominal  walls.  As  the  exudation  between  the 
broad  ligaments  may  in  these  cases  have  been  slight  from  the  beginning, 
or  may  have  subsequently  disappeared  by  absorption,  the  iliac  tumors 
have  often  apparently  a  spontaneous  origin. 

Sometimes  the  uterus  is  surrounded  by  exudation,  and  the  entire  pelvis 
appears  as  though  it  were  a  mould  filled  with  a  solid  mass.  The  fornix 
is  then  often  pressed  downward,  and  irregular  rounded  masses  are  to  be 
felt  through  the  vaginal  walls. 

The  recognition  of  paranietritic  tumors  through  the  abdominal  cover- 
ings is  possible  when  they  are  situated  above  Poupart's  ligament,  in  the 
upper  portion  of  the  broad  ligaments,  aud  in  the  iliac  fossae. 

The  pain  and  the  functional  disturbances  in  the  pelvic  organs  depend 
upon  the  size  and  situation  of  these  inflammatory  deposits.  Of  the  func- 
tional troubles  may  be  mentioned  frequent  and  painful  micturition,  obsti- 
nate constipation  and  difficult  defecation,  contractures  of  the  ilio-psoas 
muscles  when  the  exudation  is  seated  beneath  the  sheath  or  between  the 
muscle  and  the  pelvic  bones,  disturbances  of  motility  in  the  abductor 
muscles,  paresis  of  the  lower  extremities,  and  radiating  pains  in  the  upper 
portion  of  the  thigh  and  in  the  renal  and  lumbar  regions,  produced  by 
pressure  upon  the  obturator,  the  crural,  the  cutaneous,  and  the  sciatic 
nerves. 

So  long  as  fever  is  present  the  exudation  rarely  diminishes.  If  absorp- 
tion takes  place  in  one  point,  growth  almost  certainly  follows  in 
some  other  direction.  When,  however,  the  apyretic  period  is  reached,  the 
exudation,  as  a  rule,  disappears  rapidly,  so  that  often  in  the  course  of  six 
weeks  no  trace  of  its  existence  remains.  In  a  smaller  number  the  solid 
mass  may  persist  for  months  or  even  years. 

After  the  fever  has  departed  the  patient  usually  feels  well.  The  sleep 
and  appetite  return,  the  night-sweats  disappear,  the  pulse  often  falls  to  50 
or  60  beats,  and  the  temperature  is  in  many  cases  for  a  time  subnormal 
in  character. 

Where  the  fever  persists  for  from  five  to  six  weeks  there  is  always  a  sus- 
picion of  abscess  formation.  With  the  exception  of  afternoon  fever  and 
night-sweats  the  patient  may  feel  very  comfortable.  Then  the  exudation 
becomes  sensitive,  the  spontaneous  pains  recur,  sleep  is  lost,  and  locomo- 
tion, defecation,  and  urination  occasion  acute  suffering.  The  fever  becomes 
violent,  chills  announce  the  presence  of  pus,  and  finally,  about  the  seven- 
tieth or  eightieth  day,  perforation  of  the  abscess  takes  place.  The  usual 
seat  at  which  the  pus  is  discharged  is  just  above  Poupart's  ligament; 
next  in  frequency  perforation  takes  place  into  the  colon,  and  in  rare 
instances  into  the  bladder,  the  uterus,  and  vagina.  Fortunately,  of  very 
rare  occurrence  is  the  discharge  of  pus  into  the  peritoneal  cavity,  which  is 


GENERAL  SYMPTOMS.  1009 

naturally  followed  by  acute  peritonitis.  Another  likewise  unfrequent  but 
most  dangerous  accident  is  the  septic  infection  of  the  abscess — an  occur- 
rence referred  to  by  Olshausen  to  the  diffusion  of  intestinal  gases  through 
the  walls  of  the  tumor. 

In  suppuration  of  parametritic  exudations  the  pus  commonly  forms  in 
small  scattered  collections,  and  rarely  gives  rise  to  large  abscesses. 

Although  parametritis  and  perimetritis  are  usually  found  associated 
together,  there  are  always  cases  in  which  the  one  form  of  inflammation  so 
far  predominates  over  the  other  as  to  justify  an  attempt  to  establish  a 
clinical  distinction  betAveen  them. 

^  In  the  beginning  of  the  attack,  sharp  pain,  high  fever,  and  tympanitic 
distension  of  the  lower  abdomen  are  symptomatic  of  inflammation  in  the 
pelvic  peritoneum.  Whether  the  cellular  tissue  is  simultaneously  impli- 
cated can  only  be  determined  by  a  digital  examination  after  the  abdomi- 
nal sensitiveness  has  subsided.  The  absence  of  the  objective  signs  of 
cellulitis  would  then  contribute  to  prove  that  the  case  had  been  one  in 
which  the  peritoneum  had  been  in  the  main  affected.  On  the  other  hand, 
moderate  fever,  pain  elicited  only  on  pressure,  and  tympanitic  distension 
confined  to  the  colon,  coinciding  with  exudation  between  the  folds  of  the 
broad  ligament,  would  be  indicative  of  a  nearly  pure  cellulitis. 

A  palpable  exudation  is  by  no  means  the  necessary  product  of  peritoneal 
inflammation.  Indeed,  in  many  cases,  the  distinctive  symptoms  of  the 
latter  may  be  present  for  from  four  to  eight  days,  and  may  then  subside 
without  leaving  a  trace  of  its  existence  at  the  pelvic  brim. 

The  demonstration  of  a  fluid  effusion  by  noting  the  change  of  level 
upon  shifting  the  position  of  the  patient  is  rarely  possible,  either  because 
the  quantity  is  too  small  or  because  it  quickly  becomes  confined  by  pseudo- 
membranous  adhesions  between  the  intestines. 

Bandl1  mentions  as  a  sign  of  local  peritonitis,  sometimes  noticeable,  a 
number  of  resistant  points  or  tumors  near  the  pelvic  brim  or  above  one 
of  the  iliac  fossa?,  due  to  a  matting  together  of  the  intestines  or  to  their 
adhesion  to  the  uterine  appendages.  They  are  distinguished  from  solid 
tumors  by  their  emitting  a  tympauitic  sound  upon  percussion  and  by  their 
changing  position  in  consequence  of  an  accumulation  of  urine  in  the  blad- 
der or  of  feces  or  gases  in  the  bowels.  Again,  all  tumors  may  be  reck- 
oned as  intra-peritoneal  which  very  rapidly  form  behind  or  to  the  side  of 
the  uterus  from  enclosed  exudation-products,  and  which  at  the  same  time 
rise  far  above  the  level  of  the  pelvic  brim.  If,  however,  they  start  from 
the  cul-de-sac  of  Douglas,  and  do  not  much  exceed  the  linea  terminalis, 
or  if  they  occupy  an  iliac  fossa,  it  becomes  very  difficult  to  decide  whether 
they  are  of  intra-  or  extra-peritoneal  origin.  The  peritoneal  exudation, 
however,  long  remains  soft  and  fluctuating.  It  arises,  as  a  rule,  behind 
the  uterus,  and  does  not  exhibit  a  tendency  to  spread  to  the  sides  or  to 
the  anterior  or  posterior  pelvic  walls. 

Still  more  difficult  is  it  to  decide  as  to  the  seat  of  exudations  met  with 
beneath  the  abdominal  walls.     When  diffused  and  continuous  with  a  pel- 
vic deposit  the  diagnosis  is  uncertain.    'It  is  only  safe  to  assume  the  peri- 
toneal origin  of  extravasations  of  a  rounded  form,  of  a  fluctuating  con- 
sistence, and  when  they  are  situated  high  up  and  are  disconnected  from 
exudation  at  the  pelvic  brim.     An  opening  of  the  abscess  through  the 
lHandbuch  der  Frauenkrankheiten,  red.  Von  Billroth,  5te  Absohnitt,  p.  — . 
VOL.  I.— 64 


1010  PUERPERAL  FEVER. 

navel  would  indicate  a  peritoneal  source,  while  the  discharge  through  the 
abdominal  parietes  would  point  to  a  seat  in  the  connective  tissue. 

After  the  perforation  of  an  abscess  the  fever  and  pain  subside;  the 
wound,  if  external,  either  closes  in  the  course  of  one  or  two  weeks,  or 
fistulas  form  which  become  the  source  of  protracted  suppuration. 

In  psoas  abscesses  the  exudation  extends  beneath  the  sheath  of  the 
muscle  or  between  the  iliacus  and  the  bone.  In  puerperal  patients  they 
proceed  from  an  inflammation  originating  in  the  broad  ligament.  They 
are  situated  too  deep  to  be  easily  palpated.  The  pains  they  occasion  are 
referred  rather  to  the  hip  or  knee  than  to  the  abdomen.  The  contracture 
of  the  psoas  muscle  furnishes  a  diagnostic  sign  which  distinguishes  this 
form  from  the  superficial  abscesses  of  the  iliac  fossae.  The  pus  eventually 
is  discharged  beneath  Poupart's  ligament,  in  the  lower  portion  of  the 
inguinal  fossa,  at  some  point  upon  the  crest  of  the  ilium,  or  exceptionally 
along  the  thigh.  Often  the  discharge  is  maintained  for  months. 

The  symptoms  of  GENERAL  PERITONITIS. — This  form  generally  begins 
with  the  usual  symptoms  of  pelvic  inflammation,  but  the  tenderness,  which 
at  first  was  limited  to  the  side  of  the  uterus,  gradually  spreads  over  the 
entire  abdomen.  The  abdominal  pain  is  of  a  tearing,  lancinating,  some- 
times colicky  character.  It  is  increased  by  the  slightest  bodily  move- 
ment, by  jarring  of  the  bed,  or  even  by  the  weight  of  the  bed-clothes. 

As  a  consequence  of  the  peritoneal  inflammation  and  of  the  accom- 
panying exudation,  the  muscular  walls  of  the  bowels  become  paralyzed, 
and  tympanitic  distension  results  from  the  accumulation  of  gases.  In  the 
dependent  portions  of  the  peritoneal  cavity  it  is  often  possible  to  demon- 
strate by  percussion  the  presence  of  fluid  exudation,  though  distinct 
fluctuation  is  rarely  to  be  made  out.  The  size  of  the  abdomen  is  due 
much  more  to  the  tympanites  than  to  the  amount  of  effusion.  Sometimes 
the  liver,  with  the  diaphragm,  is  pushed  by  the  swollen  bowels  to  the 
level  of  the  fourth  or  third  rib,  and  exercises  such  a  degree  of  compres- 
sion upon  the  posterior  portion  of  the  lungs  as  to  place  the  patient  in 
danger  of  suffocation.  The  respirations  are  jerky  and  attended  with  a 
moaning  sound. 

The  loss  of  muscular  power  in  the  intestines  permits  the  contents  of  the 
middle  portion  to  pass  unchecked  toward  the  duodenum,  and  thence,  upon 
accidental  contractions  of  the  abdomen,  they  may  pass  to  the  stomach  and 
be  ejected  by  vomiting.  The  first  vomited  matter  has  a  dark -green  color, 
and  that  ejected  afterward  presents  the  color  of  intestinal  matter.  Con- 
stipation at  the  outset  may  be  subsequently  followed  by  colliquative 
diarrhoea. 

The  fever  begins,  as  a  rule,  though  not  always,  with  an  intense  chill, 
the  temperature  rises  to  104°,  and  the  pulse  becomes  small,  hard,  and 
resistant.  Its  frequency  rapidly  increases,  varying  from  120  to  160  beats 
to  the  minute.  The  skin  is  sometimes  dry,  sometimes  dripping  with  per- 
spiration. In  fatal  cases,  as  the  end  approaches,  the  temperature  fre- 
quently falls,  while  the  pulse  becomes  more  rapid,  the  face  assumes  a 
pinched,  anxious  expression,  sweat  gathers  upon  the  forehead,  the  extrem- 
ities grow  icy  cold,  and  the  patient  dies  in  collapse.  The  duration  of 
peritonitis  averages  not  more  than  from  four  to  six  day?. 

In  cases  of  recovery  the  pulse  improves,  the  vomiting  ceases,  and  the 
tympanites  disappears.  The  diffuse  exudation  then  becomes  converted 


GENERAL  SYMPTOMS.  ]Q11 

into  circumscribed  tumors,  which  on  palpation  are  felt  on  the  side  of  the 
pelvis  and  extending  upward  to  the  level  of  the  umbilicus.  Upon  internal 
examination  the  uterus  is  often  found  depressed  by  the  weight  of  the 
fluid,  which  likewise  may  bulge  the  cul-de-sac  of  Douglas  into  "the  pelvic 
cavity.  Sometimes  the  exudation  may  become  encysted  above  the  pelvis 
and  leave  the  contents  of  the  latter  free.  In  still  other  cases  the  uterus 
may  become  attached  high  up  to  the  abdominal  walls,  so  that  the  vaginal 
portion  disappears  and  the  os  is  reached  with  difficulty. 

The  peritoneal  exudation  may,  as  in  pelvic  inflammations,  become 
absorbed  and  disappear.  When,  however,  it  is  surrounded  by  loops  of 
intestines  it  is  apt  to  undergo  purulent  and  septic  changes,  and  the 
abscesses  may  then  become  discolored  and  filled  with  stinking  gases.  The 
patient,  whose  previous  improvement  has  been  watched  with  delight,  now 
loses  appetite,  the  pulse  becomes  frequent,  the  strength  fails,  and  death 
may  follow  from  septic  fever  or  from  rupture  of  abscess  into  the  abdom- 
inal cavity. 

In  the  pyaemia  form — a  still  more  deadly  variety  of  peritonitis — the 
symptoms  differ  materially  from  those  which  have  been  recounted.  As, 
however,  it  constitutes  only  a  single  one  of  the  pathological  changes  con- 
nected with  the  poisoning  of  the  blood  through  the  lymphatic  system,  its 
consideration  belongs  properly  to  the  study  of  the  septic  infection. 

The  symptoms  of  SEPTICAEMIA  LYMPHATICA. — The  symptoms  of 
blood-poisoning  in  the  infectious  diseases  of  childbed  vary  to  a  consid- 
erable extent  according  to  the  channel  through  which  the  septic  germs 
enter  the  general  circulation.  In  the  murderous  epidemics  which  prevail 
in  lying-in  hospitals  the  lymphatics  are,  as  a  rule,  the  vessels  primarily 
invaded.  It  is  to  this  form  that  the  cases  already  described  belong,  where, 
with  diphtheritic  patches  upon  the  utero-vaginal  canal  and  sero-purulent 
oedema  of  the  parametrium,  there  are  associated  pysemic  peritonitis  and 
deformation  of  the  blood-corpuscles ;  or  where,  following  the  migrations  of 
the  round  bacteria,  the  serous  cavities  become  successively  involved,  septic 
vegetations  gather  upon  the  heart,  and  the  glomeruli  of  the  kidneys  be- 
come choked  with  micrococci.  The  lymphatic  form  of  septicaemia  develops 
soon  after  labor,  and  is  always  ushered  in  by  a  chill.  The  temperature 
rises  to  104°  or  even  higher,  and  the  pulse  is  thin  and  frequent.  The 
abdomen  swells  rapidly,  without'  being  especially  painful.  Indeed,  pain- 
less distension  of  the  intestines  is  one  of  the  characteristics  of  an  acute 
invasion  of  the  lymphatics.  Peritoneal  effusion  is  absent  in  cases  which 
run  a  rapid  course,  and  is  distinctly  recognizable  only  in  a  peritonitis  of 
long  continuance.  The  effusion  is  not  so  much  due  to  exudation  as  to  a 
transudation  of  serum  with  which  micrococci  are  commingled.  At  the 
same  time  the  tongue  is  moist,  but  slightly  coated,  and  at  times  quite 
clean.  Sometimes  there  is  diarrhoea  due  to  catarrh  or  to  a  diphtheritic 
affection  of  the  colon.  When  the  bowels  have  been  constipated  the 
administration  of  a  purgative  may  provoke  discharges  which  it  may  be 
found  difficult  to  arrest.  The  skin  is  bathed  in  perspiration.  At  the 
beginning  and  during  the  course  of  the  disease  bleeding  at  the  nose  is  of 
not  infrequent  occurrence. 

Toward  the  end  the  pulse  runs  up  to  140  to  160  beats,  while  in  many 
cases  the  temperature  falls.  Immediately  after  death  the  heat  of  the  body 
may  for  a  short  time  exceed  the  highest  point  reached  during  life.  The 


1012  PUERPERAL  FEVER. 

respirations  are  superficial  and  jerky.  In  many  instances  the  face,  the 
neck,  and  the  fingers  are  blue  from  defective  oxygenation  of  the  blood. 
At  the  same  time  the  skin  becomes  clammy  and  the  extremities  cold. 

The  sensorium,  in  cases  which  run  a  rapid  course,  is  usually  affected  at 
an  early  period.  The  patients  appear  somnolent,  are  restless  in  bed,  have 
light  delirium,  and  respond  only  when  spoken  to  loudly.  As  a  rule,  they 
make  but  little  complaint,  and,  were  it  not  for  the  dyspnoea,  would  have 
nothing  to  disturb  their  sense  of  comfort.  Very  few,  even  as  death 
approaches,  have  any  idea  of  the  danger  that  threatens  them.  Now  and 
then,  in  place  of  stupor,  great  restlessness,  and  even  a  maniacal  condition, 
is  developed.  Albumen  is  usually  .found  in  the  urine. 

Pleurisy,  so  frequently  associated  with  lymphatic  septicaemia,  is  fre- 
quently double,  more  rarely  single,  and  begins,  as  a  rule,  with  sharp  pain 
in  the  side  and  an  aggravation  of  the  previous  dyspnoea.  Pericarditis  is 
less  frequent,  and  occurs  usually  without  symptoms  toward  the  close  of 
life.  The  joint  affections  are  characterized  by  redness  and  swelling,  and 
by  pain,  which  is  sometimes  so  great  that  touching  the  inflamed  part 
suffices  to  arouse  the  patient  from  sopor.  Sometimes  fluctuation  is  felt, 
but  death  occurs  before  perforation  and  discharge  of  the  pus. 

The  most  frequent  ending  is  death,  which  follows  in  from  two  to 
twenty-one  days,  and,  as  a  rule,  between  four  and  seven  days.  Recovery 
is,  however,  possible. 

The  symptoms  of  SEPTICAEMIA  VEXOSA  (phlebitis  uteri na,  pyaemia 
metastatica). — The  putrid  infection  of  a  thrombus  at  the  placental  site  may 
take  place  within  twenty-four  to  forty-eight  hours  after  labor.  Usually, 
however,  the  approach  is  insidious,  and  the  disease  develops  from  an  appar- 
ently insignificant  endometritis  or  parametritis ;  or  the  patient,  with  the 
exception  perhaps  of  a  tired  feeling,  of  slight  chilly  sensations,  and  of  pro- 
fuse perspiration,  may  not  have  been  conscious  of  any  indisposition  for 
days  preceding  the  attack,  or  even  until  the  first  getting  up  from  childbed. 
The  initial  chill  in  typical  cases  is  characterized  by  its  violence  and  dura- 
tion. In  some  cases  it  may  last  for  hours.  It  is  accompanied  and  fol- 
lowed by  high  temperature,  the  febrile  attack  ending  with  profuse  perspi- 
ration as  in  intermittent  fever,  with  which  it  is  apt  to  be  confounded.  The 
fall  in  temperature  often  assumes  the  form  of  a  prolonged  remission. 

In  many  cases  the  pulse  rises  and  falls  with  the  variations  in  the  body 
heat,  while  in  others  it  remains  permanently  above  the  average.  A  fre- 
quent pulse  is  always  a  suspicious  symptom  in  childbed,  even  where  the 
other  symptoms  are  apparently  normal. 

Erratic  chills  announce  the  lodgment  of  emboli  in  distant  organs. 
With  the  formation  of  metastatic  abscesses  in  the  lungs  and  other  paren- 
chymatous  organs  the  typical  character  of  the  disease  changes.  In  place 
of  chills  occurring  at  irregular  intervals,  followed  by  remissions  and 
periods  of  apparent  improvement,  the  fever  is  continuous,  the  pulse 
becomes  small  and  rapid,  while  sopor,  slight  delirium,  a  dry  skin,  a  dry, 
brown,  cracked  tongue,  and  a  moderately  tympanitic  abdomen,  give  the 
case  the  appearance  of  one  of  typhus  fever. 

Peritonitis  is  present  in  hardly  one-third  of  the  cases.  The  abdomen 
is  therefore  flat  and  soft,  and  often  is  not  sensitive  upon  pressure.  Icterus, 
due  to  disintegration  of  the  blood-corpuscles,  is  an  ominous  symptom. 

Death  usually  occurs  in  the  second  or  third  week.     In  the  typhus- 


CAUSES.  1013 

like  cases,  however,  it  may  follow  the  first  attack  speedily.  Recovery 
is  possible  where  the  organs  secondarily  affected  are  not  of  too  great 
importance. 

A  combination  of  the  lymphatic  and  venous  forms  of  septicaemia  is 
not  uncommon  .in  cases  running  a  protracted  course. 

The  symptoms  of  PUHE  SEPTICAEMIA.— Under  the  title  of  pure  septi- 
caemia should  be  placed  cases  in  which  the  absorption  of  putrid  materials 
into  the  blood  gives  rise  to  symptoms  of  intense  blood-poisoning  without 
the  development  of  local  lesions.  A  common  example  of  this  form  is  met 
with  in  the  fever  which  results  from  the  presence  in  the  uterus  of  decom- 
posing coagula  or  portions  of  retained  ovum,  the  fever  subsiding  with 
the  removal  of  the  disturbing  cause.  In  like  manner  we  sometimes 
meet  with  cases  of  intense  septic  poisoning  followed  by  speedy  death,  in 
which  the  post-mortem  examination  reveals  only  changes  in  the  blood 
and  softening  of  the  parenchymatous  organs.  The  symptoms  are  often 
similar  to  those  produced  by  the  injection  of  putrid  materials  containing 
rod-like  bacteria  into  the  vessels  of  animals.  As  the  long  bacteria  do 
not  possess  the  capacity  of  self-reproduction  in  the  blood,  to  produce  fatal 
results  the  quantity  of  putrid  fluid  injected  must  be  large  or  be  frequently 
repeated.  This  form  is  said  not  to  be  inoculable. 

CAUSES. — The  effects  of  a  poisoned  state  of  the  atmosphere  as  a  cause 
of  puerperal  fever  is  best  observed  in  the  so-called  uosocomial  malaria  of 
hospitals.  In  days  gone  by,  before  I  had  learned  by  experience  that  the 
safe  conduct  of  a  lying-in  service  depends  upon  the  fastidious  exclusion  of 
every  source  of  contamination,  I  had  frequent  occasion  to  witness  febrile 
outbreaks  among  puerperal  women  in  the  Bellevue  Hospital,  which  were 
instantly  arrested  by  the  simple  transfer  of  the  inmates  of  the  affected  ward 
to  a  wholesome  locality,  though  no  changes  were  simultaneously  made  in 
either  the  personnel  or  the  utensils  of  the  service.  In  these  instances  it 
seems  fair  to  assume  that  the  previous  unhealthy  condition  was  not  due 
to  the  direct  transfer  of  an  inoculable  matter  from  patient  to  patient  by 
the  attendants,  but  by  something  residing  in  the  air  of  the  vacated  apart- 
ment. In  the  inquiry  as  to  the  production  of  this  condition  it  can  be 
assumed  that  it  is  not  caused  by  aggregation  alone.  The  medical  wards 
of  Bellevue,  always  crowded,  have  often  furnished  in  times  of  need  safe 
receptacles  for  puerperal  patients.  It  is  certainly  not  due  to  the  presence 
of  the  ordinary  constituents  of  the  atmosphere.  We  must  therefore 
look  for  some  additional  element  capable  of  unfavorably  affecting  the 
economy.  What  this  element  really  is,  is  demonstrated  by  a  familiar 
clinical  experience.  When  the  disturbance  produced  by  nosocomial 
malaria  is  not  at  an  early  stage  arrested  by  change  of  locality,  the  secre- 
tions of  patients  affected  become  iuoculable.  Then  the  epidemic  spreads 
rapidly,  and  assumes  continuously  a  more  and  more  severe  type.  If 
during  an  epidemic  the  external  genitals  be  carefully  watched,  now  and 
then  diphtheritic  patches  will  be  noticed  to  form  upon  them.  At  first 
these  patches  may  disappear  or  yield  readily  to  treatment.  When  an 
epidemic  has  assumed  a  pestilential  form  the  patches,  which  may  in 
isolated  cases  make  their  appearance  at  any  time  in  a  hospital,  are  rarely 
absent  in  fatal  cases.  The  composition  of  the  patches  tells  the  tale  of 
what  it  is  in  the  atmosphere  which  accomplishes  the  charnel-house  work. 
Favoring  conditions  have  led  to  the  multiplication  of  disease-germs 


1014  PUERPERAL  FEVER. 

in  the  air,  and  have  fitted  them  to  become  the  active  producers  of 
disease. 

In  a  patient  dying  in  the  early  stages  of  an  epidemic  there  may  be  no 
diphtheritic  manifestations,  though  the  tissues  and  secretions  are  filled 
with  bacteria.  As,  however,  the  epidemic  gains  headway,  the  lesions  of 
the  generative  apparatus,  and  especially  of  the  external  organs,  which  are 
most  exposed  to  air,  become  covered  with  patches  which  swarm  with 
micrococci.  Under  the  conditions  named  it  is  certainly  more  in  accord 
with  ordinary  scientific  reasoning  to  conclude  that  the  micrococci  play  an 
important  part  in  the  production  of  puerperal  fever  than  that  the  puerperal 
fever  produces  the  micrococci. 

To  be  sure,  bacteria  or  their  spores  are  always  present  in  the  air,  and  it 
may  be  fairly  asked  how  patients  are  ever  spared  from  their  perverse 
industry.  The  answer  is,  that  the  eifect  produced  by  the  atmosphere  of 
a  hospital  is  dependent  partly  upon  the  quantity,  and  partly  upon  the 
quality,  of  the  suspended  germs.  Floating  spores,  when  sparsely  distrib- 
uted, rarely  possess  the  power  of  invading  a  healthy  organism.  In  the 
inauguration  of  an  epidemic  the  first  patient  severely  attacked  is  usually 
one  whose  powers  of  resistance  are  broken  down  by  prolonged  labor,  by 
hemorrhage,  by  poverty,  or  some  other  condition  leading  to  impaired 
vitality. 

Puerperal-fever  epidemics  due  to  contamination  of  the  atmosphere, 
and  not  to  direct  contagion,  do  not  at  once  reach  the  maximum  of  inten- 
sity. At  first  the  temperature  tables  indicate  the  prevalence  of  milk 
fever;  next  follow  cases  closely  resembling  those  of  mild  paludal  poison- 
ing; and,  finally,  if  these  warnings  are  unheeded  and  reliance  is  placed 
upon  autiperiodic  remedies  rather  than  upon  prompt  closure  of  the  threat- 
ened ward,  the  pestilence  develops.  In  the  conduct  of  lying-in  hospitals 
it  should  never  be  forgotten  that  with  the  multiplication  of  the  septic 
germs  the  danger  increases. 

At  the  same  time,  the  quality  of  the  agents  which  pervade  the  air 
where  hospital  patients  are  confined  is  an  important  element  in  the  genesis 
of  febrile  outbreaks.  The  bacterium  termo,  which  causes  putrefaction,  is 
not  in  itself,  as  we  have  already  mentioned,  a  source  of  danger.  A  stink- 
ing odor  is  not  necessarily  incompatible  with  a  low  mortality-rate.  The 
importance  of  the  common  forms  of  bacteria,  according  to  Pasteur,  results 
from  the  fact  that  by  their  power  to  consume  oxygen  they  pave  the  way 
for  the  active  development  of  the  pernicious  germs,  nearly  all  of  which 
thrive  only  in  media  in  which  that  element  has  been  materially  dimin- 
ished. Again,  there  is  reason  to  believe  that  the  same  germs  are  not1 
always  equally  active  for  evil.  Gravitz  claims  that  the  ordinary  varieties 
of  aspergillus  and  penicillium  found  everywhere  on  the  surface  of  the 
ground,  on  moistened  walls,  on  food  of  every  variety,  on  decaying  leaves 
and  fruit,  and  whose  spores  are  universally  present  in  the  purest  air,  can 
by  a  succession  of  cultures  be  gradually  brought  to  flourish  in  a  warm 
alkaline  fluid,  and  that  they  then  acquire  the  capacity  to  penetrate  living 
tissues,  to  proliferate  in  them,  to  excite  local  necroses,  and  to  cause  death 
in  the  course  of  three  days.  The  insistence  of  micrococci  to  carbolic  and 
salicylic  acids  is  found  experimentally  to  depend  in  a  measure  upon  the 

1  Gravitz,  "  Ueber  Schimmel  vegetationen  im  thierischen  organismus,"  Virch.  Arch.,  voL 
Ixxxi,  p.  355. 


CAUSES.  1015 

nature  of  the  vehicle  in  which  they  are  cultivated  (Buchholz).  The 
action  of  sept]C  fluids  varies  too  with  the  age  of  the  infusions,  with  the 
materials  employed,  and  with  the  conditions  under  which  the  poison- 
germs  are  generated. 

Micrococci  multiply  in  hospitals  when  organic  materials  favorable  to 
their  growth  are  present  in  sufficient  quantities.  Perrin,  Quenquand 
and  others  have  shown  that  the  hospital  wards  in  Paris,  especially  those 
upon  the  surgical  and  maternity  divisions,  contain  an  infinite  number  of 
vibrios,  bacteria,  and  all  the  coccus  forms  (Charpentier).  Robin1  has 
demonstrated  the  existence  of  albuminoid  matters  iu  water  condensed 
upon  vessels  containing  freezing  mixtures  and  placed  in  overcrowded  wards 
of  hospitals.  When  the  results  of  crowding  become  manifest,  these  albu- 
minoid matters  not  only  impart  a  fetid  odor  and  putrefy  with  great  rapid- 
ity, but  rapidly  impart  putrefaction  to  healthy  muscle  and  normal  blood 
with  which  they  are  brought  into  contact.  Pasteur  was  able  by  the  micro- 
scopic examination  of  the  lochia  from  patients  in  the  services  of  Hervieux 
and  Lucas-Champonniere  to  predict,  from  the  character  of  the  contained 
organisms,  an  impending  attack  of  fever  in  advance  of  the  slightest  symp- 
tom betokening  danger. 

It  is  unquestionably  the  lochial  discharge  which  makes  it  such  a  diffi- 
cult task  to  keep  a  maternity  ward  in  a  healthful  condition.  Putrid 
blood  has  been  found  to  be  the  most  favorable  material  for  septic  experi- 
ments. It  was  noticeable  in  Bellevue  Hospital  that  febrile  outbreaks 
always  arose  in,  and  were  usually  confined  to,  the  ward  in  the  hospital 
which,  by  a  bad  arrangement,  was  assigned  to  patients  for  the  first  four 
or  five  days  following  confinement — i.  e.  during  the  period  of  the  lochia 
cruenta.  As  puerperal  fever  is  rare  after  the  fifth  day,  this  at  first  sight 
would  seem  natural.  But  if  a  patient  was  transferred  directly  after  con- 
finement, during  one  of  these  unhealthy  periods,  to  the  ward  containing 
the  patients  who  had  passed  the  first  five  days,  but  had  not  completed  the 
ten  days,  she  would  escape  the  fever.  It  was  always  the  same  ward  that 
required  to  be  disinfected.  In  a  communicating  apartment  ail  the  con- 
finements took  place,  and  at  all  times,  therefore,  the  conditions  were  pres- 
ent for  loading  the  atmosphere  with  the  products  of  decomposing  blood. 
In  the  summer  months,  so  long  as  the  windows  were  open  and  the  air  was 
diluted  by  the  continuous  passage  of  fresh  currents,  the  patients  enjoyed 
immunity  from  nosocomial  malaria.  In  the  autumn,  so  soon  as  it 
became  necessary  to  close  the  windows  partially  on  account  of  the  cool 
nights,  it  was  not  uncommon  for  the  more  trivial  disturbances,  such  as  so- 
called  milk  fever,  the  hospital  pulse,  and  catarrhal  affections  of  the  geni- 
talia,  to  manifest  themselves.  Through  the  months  of  February,  March, 
and  April  the  mortality  was  usually  greatest.  During  the  winter  months 
there  was,  as  a  rule,  crowding  of  patients,  insufficient  ventilation,  stagna- 
tion of  the  air,  and  the  rapid  accumulation  of  disease-germs.  That  the 
later  winter  months  should  prove  the  most  perilous  is  in  accordance  not 
only  with  the  theory  of  continuous  accumulation,  but  with  the  experi- 
mental fact  that  weeks  sometimes  elapse  before  a  decomposing  substance 
acquires  the  highest  degree  of  virulence. 

Apart  from  the  nosocomial  malaria  of  hospitals,  there  is  reason  to 
believe  in  the  influence  at  times  of  certain  general  widespiead  atmospheric 
1  Lemons  sur  les  Humeurs,  Paris,  1867,  p.  195. 


1016  PUERPERAL  FEVER. 

states  which  affect  the  entire  community.  In  the  year  1871  the  mortality 
from  childbed  in  New  York  was  399 ;  in  1872,  503 ;  in  1873,  431 ;  in 
1874,  439 ;  and  in  1875,  420.  Now,  the  excess  in  the  deaths  for  1872 
was  due  wholly  to  an  increase  in  the  cases  of  metria,  those  from  ordinary 
accidents  remaining  nearly  the  same  as  in  the  preceding  years.  The  dis- 
ease certainly  did  not  extend  into  the  city  from  the  hospitals  serving  as 
foci,  for  the  mortality  at  Bellevue  Hospital  was  hardly  more  than  half 
the  usual  average.  There  was  no  especial  mortality  that  year  from  either 
diphtheria,  erysipelas,  or  scarlatina,  but  the  aggregate  mortality  was  the 
largest  known  in  the  history  of  the  city.  There  are  no  positive  data  con- 
necting the  civil  deaths  from  puerperal  fever  in  1872  with  parasiticisni, 
but  the  prevalence  of  epizo5tics,  of  epidemic  cartarrhal  aifections,  of 
peculiarly  fatal  forms  of  pueumonia  and  other  diseases  which  are  now 
attributed  to  the  presence  of  minute  organisms  in  the  atmosphere,  renders 
such  a  source  highly  probable. 

It  is  proper  to  say  here  that,  though  the  argument  is  very  strong  in 
favor  of  regarding  the  genitalia  of  puerperal  women  as  the  exclusive 
point  of  entry  of  infectious  materials  into  the  system,  it  seems  impos- 
sible at  the  present  time  to  make  all  the  facts  coincide  with  such  a  theory. 
I  have  the  records  of  a  number  of  cases  occurring  during  an  epidemic  of 
puerperal  fever  in  which  patients  were  either  attacked  with  fever  previous 
to  parturition,  or  in  whose  cases  the  unusual  length  of  labor,  the  fre- 
quency of  post-partum  hemorrhage,  and  the  imperfect  contraction  of  the 
uterus  immediately  after  confinement  were  signs  of  some  abnormal  influ- 
ence exercised  upon  the  economy  at  an  early  period  of  labor  previous  to 
the  existence  of  traumatism.  That  deleterious  materials  may  find  other 
channels  for  entering  the  system  than  a  wounded  surface  is  evidenced  by 
the  cachectic  condition  not  unfrequeutly  produced  in  physicians  by  too 
assiduous  attendance  in  dissecting-rooms  and  places  in  which  post-mortem 
examinations  are  conducted.  One  severe  and  rapidly  fatal  case  of  puer- 
peral fever  which  occurred  in  Bellevue  Hospital  I  find  it  impossible  to 
attribute  to  any  other  cause  than  that  the  woman  for  five  mouths  pre- 
vious to  her  confinement  served  as  a  helper  in  a  lying-in  ward.  The 
post-mortem  examination  disclosed  no  special  local  lesions,  but  her  symp- 
toms were  those  of  intense  septicaemia.  French  writers  report  instances 
of  toxsemic  conditions  developing  in  young  midwives  during  puerperal- 
fever  epidemics.  "While  we  are  not  prepared  to  go  as  far  as  Taruier, 
who  says,  "  It  is  probable  that  the  lungs,  by  their  extent  and  activity, 
offer  conditions  most  favorable  to  absorption,  and  that  often,  if  not 
always,  it  is  by  them  that  poisoning  occurs,"  it  does  not  yet  seem  time  to 
give  up  the  idea  that  under  exceptional  circumstances  the  respiratory  and 
the  digestive  tracts  may  allow  the  passage  of  materials  of  a  septic  cha- 
racter. 

Another  and  frequent  source  of  puerperal  fever  is  by  direct  inoculation. 
Any  material  of  a  septic  character,  introduced  into  the  genital  passages 
of  a  woman  during  or  after  confinement,  may  produce  a  general  infection 
of  the  system.  But  the  point  upon  which  I  wish  especially  to  dwell  is 
that  it  is  possible  to  trace  epidemics  of  puerperal  fever  directly  to  the  i^arry- 
ing  of  puerperal  poison  from  patient  to  patient  through  the  medium  of 
attendants.  In  such  cases  changes  in  wards  and  the  most  rigid  sanitary 
precautions  avail  but  little,  so  long  as  the  affected  personnel  is  continued 


CAUSES.  1017 

in  charge.  Unless  this  fact  is  fully  recognized,  all  the  cleverest  devices 
in  hospital  construction  will  fail  to  prevent  the  occurrence  of  disasters. 
In  theory,  the  doctrine  of  the  contagiousness  of  puerperal  fever  has  ceased 
to  be  the  subject  of  dispute ;  and  yet  no  longer  than  thirty  years  ago  it 
was  combated  as  a  pernicious  heresy  by  both  Meigs  and  Hodge  of  Phila- 
delphia, at  that  time  regarded  as  the  best  authorities  upon  obstetrical  ques- 
tions in  this  country.  Hodge,  addressing  his  students,  said :  "  The  result  of 
the  whole  discussion  will,  I  trust,  serve  not  only  to  exalt  your  views  of 
the  value  and  dignity  of  our  profession,  but  to  divest  your  minds  of  the 
overpowering  dread  that  you  can  ever  become,  especially  in  women  under 
the  extremely  interesting  circumstances  of  gestation  and  parturition,  the 
ministers  of  evil — that  you  can  ever  convey,  in  any  possible  manner,  a 
horrible  virus  so  destructive  in  its  effects  and  so  mysterious  in  its  opera- 
tions as  that  attributed  to  puerperal  fever ;"  and  Meigs,  in  his  letters  to 
students,  writes  :  "  I  prefer  to  attribute  them  to  accident  or  to  Providence, 
of  which  I  can  form  a  conception,  rather  than  to  a  contagion  of  which  I 
cannot  form  any  clear  idea,  at  least  as  to  this  particular  malady."  Con- 
trasted with  these  rhetorical  utterances,  in  an  essay  published  in  1843 
by  Prof.  Oliver  Wendell  Holmes,  entitled  Puerperal  Fever  as  a  Private 
Pestilence,  the  opposing  testimony  in  favor  of  contagion  was  presented 
with  equal  literary  and  scientific  skill.  The  evidence  was  complete  and 
conclusive,  and  has  exercised  a  most  beneficial  influence  upon  the  practice 
of  midwifery  in  America.  With  his  many  claims  to  our  admiration  and 
esteem  there  is  probably  no  title  which  Prof.  Holmes  "wears  with  greater 
pride  than  that  of  pioneer  in  a  movement  that  has  done  so  much  to  pre- 
vent the  slaughter  of  innocent  women  and  the  wrecking  of  happy  homes. 
Thanks  to  changed  theoretical  views,  physicians  seem  now  rarely  to  be 
the  carriers  of  contagion.  At  least,  in  studying  the  records  of  New  York 
City  for  nine  years,  I  find  that  the  occurrence  of  two  deaths  from  puer- 
peral disease,  following  one  another  so  closely  as  to  lead  to  the  suspicion 
of  inoculation,  occurred  to  thirty  physicians ;  a  sequence  of  three  cases 
occurred  in  the  practice  of  three  physicians :  one  physician  lost  three 
cases,  and  afterward  two,  in  succession ;  one  physician  had  once  two 
deaths,  once  three  deaths,  and  twice  four  deaths,  following  one  another ; 
finally,  a  physician  reported  once  a  loss  of  two  cases  near  together,  then 
of  six  patients  in  six  months  and  then  of  six  patients  in  six  weeks. 
Thus  in  the  practice  of  more  than  twelve  hundred  physicians  in  nine 
years  I  find,  excluding  cases  occurring  in  hospitals,  that  the  experience 
of  thirty-six  only  lends  color  to  the  idea  that  puerperal  fever  is  due  to 
criminal  neglect  on  the  part  of  the  medical  profession.  Undoubtedly  in 
many  of  these  cases,  too,  the  responsibility  is  only  apparent,  as  when  a 
practitioner  has,  for  example,  had  the  misfortune  to  lose  in  one  week  a 
woman  from  puerperal  convulsions,  and  another  in  the  following  week 
from  placental  hemorrhage.  Singularly  enough,  not  one  of  the  sequences 
mentioned  occurred  in  the  practice  of  a  physician  connected  with  a  lying- 
in  hospital.  In  face  of  the  charge  that  the  physicians  holding  obstetrical 
appointments  in  public  institutions  are  active  disseminators  of  puerperal 
fever  through  populous  communities,  I  find  that  the  total  loss  from  all 
puerperal  causes,  occurring  in  the  private  practice  of  ten  physicians  inti- 
mately associated  with  such  institutions,  numbered  during  the  nine  years 
but  twenty-one  cases.  Of  these,  thirteen  were  the  result  of  ordinary  acci- 


1018  PUERPERAL  FEVER. 

dents,  and  only  eight  cases  of  metria  proper,  of  which  one  was  developed 
before  the  physician  was  called  in  attendance ;  whereas  a  single  physician, 
holding  no  hospital  appointment,  lost  during  the  same  time  twenty-seven 
cases,  of  which  twenty-one  were  cases  of  metria. 

There  is,  however,  a  survival  of  the  older  ideas,  chiefly  to  be  seen 
among  the  laity,  in  propositions  to  secure  absolute  immunity  from  puer- 
peral fever  in  hospital  patients  by  confining  them  in  wooden  structures 
or  by  conducting  births  under  carbolic  acid  spray. 

I  have  been  interested  in  endeavoring  to  ascertain  how  far  experience 
corresponds  with  Semmelweis's  oi'iginal  theory  that  puerperal  fever  owes 
its  origin  to  poisonous  materials  obtained  from  dissecting-rooms  and 
introduced  into  the  genital  canal  by  the  hands  of  physicians  attending 
cases  of  labor.  With  this  view  I  have  made  personal  application  to  a 
number  of  gentlemen  who  have  engaged  in  midwifery  practice  while 
performing  the  functions  of  demonstrators  of  anatomy  in  our  medical 
schools.  H.  B.  Sands,  of  the  College  of  Physicians  and  Surgeons, 
reports  that  in  the  five  years  during  which  he  held  the  office  of  demon- 
strator he  attended  about  sixty  cases  of  labor.  All  did  well.  He  lost 
his  first  patient,  from  childbed,  a  short  time  after  he  had  resigned  his 
position  in  the  dissecting-room.  J.  W.  Wright,  the  present  professor 
of  surgery  in  the  Medical  Department  of  the  New  York  University,  who 
held  for  one  year  the  position  of  demonstrator  in  the  Woman's  College, 
writes  me  that  "during  the  year  I  attended  one  hundred  and  four  cases, 
including  twenty-two  forceps  cases,  two  of  craniotomy,  two  of  podalic 
version,  and  four  of  breech  presentation.  Of  this  number  I  lost  two 
cases,  one  from  phlegmasia  dolens  complicating  uraemia,  from  both  of 
which  troubles  the  patient  had  suffered  during  her  previous  labor,  and 
one  from  double  pneumonia,  the  result  of  unusual  exposure  following 
confinement.  Out  of  these  one  hundred  and  four  cases  I  can  recall  but 
three  or  four  cases  of  metritis,  and  those  of  a  mild  character ;  I  have 
never  thought  they  had  any  special  connection  with  my  duties  in  the 
dissecting-room.  1  may  add  that  for  ten  years  I  have  attended  a  pretty 
large  number  of  confinements  each  year,  and  that  during  the  whole  of 
this  time  I  have  been  in  the  habit  of  making  autopsies  as  occasion  has 
offered,  and  of  handling  and  examining  pathological  specimens  both  in 
and  out  of  the  dissecting-room,  notwithstanding  which  my  death-rec- 
ord among  this  class  of  cases  has  been  unusually  low."  Samuel  B. 
Ward,  formerly  demonstrator  at  the  Woman's  College,  at  present  pro- 
fessor of  surgery  in  the  Medical  School  at  Albany,  writes :  "  While  I 
was  daily  in  the  dissecting-room  during  the  winter  sessions  of  the  school 
from  1868  to  1872,  I  attended  thirty-two  confinements,  of  which  I  have 
notes.  All  of  the  patients  recovered,  nor  did  any  of  thern^  suffer  from 
any  complication  that  could  be  traced  to  infection."  It  is  familiarly 
known  that  after  Semrnelweis  had  introduced  the  practice,  among  the 
physicians  attending  patients  at  the  large  lying-in  hospital  in  Vienna,  of 
washing  the  hands  in  a  solution  of  chloride  of  lime,  there  was  a  great 
diminution  in  the  mortality  which  prevailed,  notwithstanding  which  G. 
Braun  reports,  however,  that  in  1857,  in  the  month  of  July,  in  two 
hundred  and  forty-five  deliveries  there  were  seventeen  deaths.  The 
following  month  Klein  gave  orders  to  suspend  the  use  of  disinfect- 
ants. By  chance,  in  August  there  were  only  six  deaths  out  of  two  him- 


CAUSES.  1019 

clred  and  fifty  confinements,  and  in  September,  of  two  hundred  and 
seventy-five  patients,  none  died.  From  1857  to  1860  the  mortality  was 
slight,  though  disinfectants  were  not  used,  while  during  the  three  follow- 
ing years,  in  spite  of  the  systematic'  and  persistent  employment  of  these 
agents,  the  death-rate  once  more  assumed  formidable  proportions.1 

Of  course  I  do  not  wish  to  underrate  the  importance  of  Semmelweis's 
labors.  There  is  no  question  but  that  it  is  a  perilous  experiment  to  pass 
from  the  dissecting-room  to  a  patient  in  labor  without  employing  rigorous 
measures  to  disinfect  the  hands  and  all  parts  of  the  person  brought  into 
contact  with  the  dead  body.  But  it  is  well  to  call  attention  to  the  fact 
that  puerperal  fever  is  not  due  to  any  single,  simple  cause,  nor  can  be 
effectually  guarded  against  by  a  single  precaution ;  and,  again,  that  an 
infectious  poison  does  not  of  necessity  exist  in  every  cadaver  examined. 
Hausmann  found  that  injections  into  the  vagina  of  gravid  rabbits,  in  the 
latter  half  of  pregnancy,  of  serum  from  the  corpse  of  a  person  who  had 
not  died  of  septicaemia  produced  no  fatal  results,  while  rapid  death 
resulted  from  injections,  under  the  same  conditions,  of  pus  from  the 
abdomen  of  a  woman  who  had  died  from  puerperal  infectious  disease.2 
Barues  and  other  English  writers  lay  considerable  stress  upon  cases 
of  puerperal  fever  due  neither  to  contagion  nor  to  atmospheric  con- 
ditions, but  to  the  poisoning  of  the  patient  by  her  own  secretions. 
There  is  justification  for  this  view  in  the  fact  that  even  normal  lochia 
contain  bacteria,  and  when  inoculated  into  animals  produce  in  them 
affections  of  an  ichorrhsemic  and  scpticasmic  nature.  When  death  takes 
place  the  tissues  of  animals  thus  treated  are  found  to  be  filled  with  round 
bacteria.  Furthermore,  the  disease  artificially  produced  is  in  itself  infec- 
tious, and  can  be  continuously  propagated  in  other  animals.  But  it  may 
be  asked,  "Does  not  this  admission  cut  both  ways?  How  is  it  possible, 
if  even  normal  lochia  possess  virulent  qualities,  that  childbed  is  ever 
unattended  by  accessions  of  fever?"  To  this  we  can  only  answer  that 
the  reasons  for  immunity  in  ordinary  cases  are  only  known  in  part. 
Karewski3  and  other  experimental  investigators  have  shown  that  the 
virulence  of  the  lochia  increases  proportionately  to  the  number  of  days 
that  have  transpired  since  the  birth  of  the  child,  and  that  during  the 
first  three  days  the  lochia  are  comparatively  harmless.  Meantime,  the 
retraction  of  the  uterus,  the  closure  of  the  sinuses,  and  the  formation 
upon  the  wounded  surfaces  of  protecting  granulations,  all  act  as  natural 
barriers  to  the  penetration  of  poison-germs.  But,  aside  from  these 
reasons,  there  is  undoubtedly  an  unknown  quantity  calling  for  further 
investigation,  which,  in  the  absence  of  positive  knowledge,  ^ye  are  con- 
tent to  term  the  predisposition  of  the  individual  patient.  The  vagina 
after  childbirth  possesses  all  the  conditions  most  favorable  for  the  pro- 
duction of  putrefaction — viz.  the  access  of  air,  fostering  warmth,  and 
stagnating  fluids  charged  with  dead  tissue.  It  is  probable  that  the  first 
of  Ihcse  needful  conditions  is,  in  normal  labors,  happily  wanting  in  the 
uterine  cavity.  In  these  days  of  intra-uterine  medication  it  is  well  to 
1  Brann,  Hiic.kbllcke  auf  die  Gesundheits  Verhiilhwse  unter  den  Wochnerlnnen,  u.  s.  w., 
S.  32,  33. 


den 


1020  PUERPERAL  FEVER. 

bear  in  niiud  the  relatively  greater  frequency  of  infection  through  vaginal 
and  cervical  wounds,  as  compared  with  that  which  takes  place  through 
the  denuded  intra-uteriue  surface.  The  term  auto-infection  may,  with 
propriety,  be  employed  as  a  distinctive  appellation  to  designate  those 
attacks  of  fever  which,  in  the  absence  of  any  demonstrable  cause,  occur 
in  the  early  days  of  childbed,  and  which  there,  quoad  vitam,  pursue  a 
favorable  course,  and  to  cases  of  so-called  late  infection — i.  e.  where, 
after  the  fifth  day,  the  accidental  opening  of  a  healing  wound  permits 
the  tardy  absorption  of  poisonous  secretions ;  but  with  the  reserve  that 
the  primary  cause  is,  in  point  of  fact,  atmospheric,  and  the  predisposing 
condition  the  susceptibility  of  the  individual.  Cases  of  auto-infection 
are  in  this  country  extremely  rare,  if  not  unknown  altogether,  in  salu- 
brious or  rural  districts. 

On  another  occasion  I  have  shown  that  in  New  York  City  the  death- 
rate  from  puerperal  fever  is  nearly  twice  as  great  during  the  six  months 
from  December  to  May,  inclusive,  as  from  June  to  November.  The 
greatest  mortality  occurred  in  February  and  March,  comprising  rather 
more  than  one-fourth  the  entire  amount.  The  smallest  number  of  deaths 
occurred  in  September  and  October,  in  which  mouths  but  one-thirteenth 
of  the  entire  number  took  place. 

That  puerperal  fever,  in  its  harvest  of  death,  does  not  spare  the 
wealthy  and  well-to-do  classes  is  too  familiar  a  truth  to  be  worthy  of 
discussion.  That,  however,  the  wealthy  do  enjoy  special  immunities 
as  compared  with  the  less-favored  members  of  society,  I  have  shown 
by  comparisons  made  between  sections  of  the  city  which,  though  lying 
side  by  side,  exhibit  in  a  marked  degree  the  two  extremes  of  wealth 
and  poverty.  Thus,  the  mortality  among  the  representatives  of  the 
lower  social  strata,  in  proportion  to  population,  was  from  three  to  six 
times  as  great  as  that  among  the  more  fortunate  classes. 

RELATIONS  TO  ZYMOTIC  DISEASES. — In  investigating,  some  years  ago, 
the  nature,  causes,  and  prevention  of  puerperal  fever,1  I  prepared,  from 
the  statistics  of  the  Health  Board  of  New  York  City,  tables  extending 
over  a  period  of  nine  years  to  answer  the  inquiry  as  to  whether  there  was 
any  relation  between  the  frequency  of  deaths  from  scarlatina,  diphtheria, 
and  erysipelas  and  those  from  metria.  Previous  to  their  publication  I 
was  anticipated  in  my  deductions  by  a  paper  upon  the  same  subject  by 
Matthews  Duncan.2  Neither  Duncan  nor  myself  found  any  such  re- 
lation existing  between  the  statistical  frequency  of  puerperal  fever  and 
the  zymotic  diseases  mentioned.  There  was,  however,  nothing  in  our 
investigations  to  invalidate  any  direct  testimony  which  tends  to  show  that, 
in  individual  cases,  a  real  connection  between  puerperal  fever  and  the 
zymotic  diseases  may  exist.  Indeed,  it  seems  to  me  to  be  fairly  estab- 
lished that  a  poison  may  be  conveyed  from  patients  suffering  from  either 
of  the  foregoing  morbid  processes  which  may  be  absorbed  by  the  puer- 
peral woman,  and  may  in  her  give  rise  to  an  infectious  fever  possessing 
an  intense  degree  of  virulence.  My  friend  Prof.  Barker  has  recently 
drawn  attention  to  the  important  relations  of  intermittent  fever  to  the 
puerperal  state.  I  have  not,  however,  thought  it  advisable  to  complicate 

1  Tr«n*.  of  tie  International  Med.  Congress,  Philadelphia,  1876. 

2  'On  the  Alleged  Occasional  Epidemic  Prevalence  of  Puerperal  Pvspmia,  or  Puerpe- 
ral Fever  and  Erysipelas,"  Edinburgh  Med.  Journal,  March,  1876,  p.  774. 


PREVENTION.  1021 

the  present  discussion  with  any  extended  notice  of  his  very  valuable 
observations.  So  far  as  malarial  fever  occurs  unequivocally  as  such  in 
puerperal  women,  there  is  no  more  reason  for  establishing  a  special  cate- 
gory for  puerperal  malaria  than  for  puerperal  typhoid  or  puerperal  small- 
pox. In  the  class  of  cases  characterized  by  sharp  chills,  intense  fever, 
irregular  remissions,  and  profuse  perspiration,  which  pursue  a  pernicious 
course  unaffected  by  antiperiodic  remedies,  the  nature  is  extremely 
dubious.  The  same  symptoms  are  likewise  characteristic  of  certain 
forms  of  pyaemia,  and  I  cannot  learn  that  such  cases  are  familiar  in  the 
practice  of  those  of  our  physicians  who  practise  outside  of  cities  in  dis- 
tricts where  malarial  affections  are  most  prevalent. 

PREVENTION. — Of  the  3342  deaths  from  puerperal  causes  in  New 
York  City  from  1868  to  1875,  inclusive,  420  occurred  in  hospital,  or 
one-eighth  of  the  entire  number.  Of  the  1947  cases  of  metria,  about 
300,  or  not  quite  one-sixth,  were  contributed  by  the  hospitals.  After 
such  a  showing  the  first  impulse  would  be  to  cry  out  loudly  for  the 
suppression  of  the  maternities.  But  a  wiser  policy  suggests  an  inquiry 
as  to  whether  the  large  mortality  mentioned  is  an  evil  necessity.  The 
following  reports  will  show  how  much  may  be  done  in  the  present 
state  of  our  scientific  knowledge  to  so  control  the  conditions  which 
favor  the  generation  of  puerperal  diseases  in  large  hospitals  as  to  make 
them  safe  asylums  for  the  needy. 

Goodell l  has  stated  that  at  the  Preston  Retreat  in  756  cases  of  labor 
there  have  been  but  2  deaths  from  septic  disease.  Winckel2  of  the 
Lying-in  Institution  in  Dresden  reported,  in  1873, 18  deaths  from  metria, 
or  1.8  per  cent.,  but  from  the  10th  of  January  to  the  7th  of  July  in  570 
births  there  was  but  1  case  of  septic  disease ;  in  the  year  1872  the 
death-rate  exceeded  5  per  cent.  The  reduction  in  mortality  was  no  for- 
tuitous circumstance,  but  was  due  to  rigid  measures  for  the  prevention 
of  disease.  Stadfeldt 3  reduced  the  mortality  from  puerperal  fever  in  the 
Maternity  Hospital  of  Copenhagen  from  1  to  37,  the  proportion  between 
the  years  1865  and  1869,  to  1  in  87  between  the  years  1870-74. 
Johnston 4  reports,  in  the  Rotunda  Hospital  of  Dublin,  during  the  seven 
years  of  his  mastership,  7860  births  with  169  deaths,  of  which  85,  or  1 
in  91,  were  from  metria.  Braun  von  Fernwald 5  in  sixteen  years  reports 
61,949  confinements  in  the  vast  Maternity  Hospital  of  Vienna,  with  825 
deaths  from  puerperal  fever,  or  1.3  per  cent.  In  a  visit  made  by  me  to 
the  Vienna  Maternity  in  1883,  I  was  informed  that  the  recent  mortality, 
including  difficult  operations,  had  been  reduced  to  one-half  of  1  per  cent. 
Spiegelberg6  lost,  in  901  confinements  at  Breslau,  only  5  cases  of  puer- 
peral fever.  Beurmann 7  reports  that  in  the  Hdpital  Lariboisiere,  under 
the  administration  of  M.  Siredey,  the  death-rate  in  1877  was  1  in  145, 
and  in  1878,  1  in  199,  confinements;'  in  the  Hopital  Cochin,  under  the 
charge  of  M.  Polaillon,  the  total  mortality  from  1873  to  1877  was  1  to 
108.7.  In  1877  there  was  but  1  death  from  puerperal  causes  in  807 
confinements.  Upon  Prof.  Streng's  division  of  the  magnificent  mater- 

1  On  the  Mean*  employed  at  the  Preston  Retreat  for  the  Prevention  and  Treatment  of  Puer- 
peral  Diseases,  p.  13.  2  Berichte  und  Studien,  Leipsic,  1874,  S.  183. 

3  Lea  maternites,  leur  organwa.tion  et  administration,  Copenhagen,  1876. 

4  Clinical  Reports,  from  1870  to  1876,  inclusive. 

6  Lehrbuch  der  gesammien  GynaeMorjie,  S.  885.  _      wt&i  »•  748. 

7  Rccherches  sur  la  mortality  desfemmes  en  couches  dans  lea  h6pitaux,  Paris,  18/9. 


1022  PUERPERAL  FEVER. 

nity  in  Prague,  I  was  told  that,  in  1882—83,  in  over  1100  confinements 
there  had  been  no  death  from  septic  causes. 

When  the  maternity  service  was  transferred  in  1872  from  Bellevue 
Hospital  to  BlackwelPs  Island,  it  became  necessary  to  make  some  pro- 
vision for  so-called  street-cases — i.  e.  women  taken  suddenly  in  labor 
without  homes,  and  representing  the  extremes  of  penury  and  want. 
At  first  they  were  received,  in  part,  by  the  various  private  institutions 
of  charity  in  New  York  City,  but  these  in  1877  decided  to  exclude  them 
thenceforth,  on  the  ground  that  their  condition  at  the  time  of  their  recep- 
tion was  such  as  to  endanger  the  lives  of  the  inmates  for  whom  the 
charities  were  specially  provided.  An  old  engine-house  was  then  put  in 
readiness  by  the  city,  and  under  the  name  of  the  Emergency  Hospital 
was  placed  under  the  charge  of  Henry  F.  Walker1  and  myself.  The 
number  of  confinements  in  the  Emergency  has  averaged  220  annually. 
The  death-rate  from  all  causes  has  been  2  per  cent.,  which,  though  large, 
is  not  an  unfavorable  showing  when  we  remember  that  the  patients  all 
belong  to  the  homeless  class,  that  all  were  taken  in  labor  before  their 
entrance,  and  that  many  of  them  were  in  a  deplorable  condition  at  the 
time  of  their  admission.  The  hospital,  too,  receives  a  considerable  num- 
ber of  patients  annually  who  are  sent  there  only  after  protracted,  and 
often  severe,  operative  measures  have  been  fruitlessly  attempted  outside 
its  walls.2  The  building  possesses,  for  maternity  purposes,  two  fairly 
ventilated  rooms.  Excellent  nurses  are  furnished  by  the  New  York 
Training  School  for  Nurses.  Mr.  Osborn,  a  liberal  private  citizen,  has 
had  constructed  in  the  rear,  but  detached  from  the  main  house,  a  small 
pavilion,  modelled  after  that  of  Tarnier,  for  the  reception  of  infectious 
cases.  The  Commissioners  of  Charities  have  promptly  responded  to  every 
call  made  upon  them  to  extend  the  facilities  for  the  care  of  patients. 

Surely  these  results  do  not  support  the  idea  that  it  is  better  for  a 
woman  to  be  confined  in  a  street-gutter  than  to  enter  the  portals  of 
a  lying-in  asylum.  Goodell's  experience  shows  that  a  hospital  for 
respectable  married  women  may  be  so  conducted  that  its  inmates  may 
enjoy  absolutely  a  greater  degree  of  safety  than  do  women  in  their  homes 
surrounded  by  all  the  aids  that  wealth  can  command.  Equally  good 
results  are  not  to  be  obtained  in  hospitals  which  are  open  to  unfortunates 
of  every  class.  But  there  is  much  misapprehension  and  confusion  of 
ideas  respecting  the  fate  of  these  women  when  no  charitable  provision  is 
made  for  them.  In  Copenhagen  the  Maternity  Hospital  is  closed  for 
from  six  to  eight  weeks  in  the  summer-time.  During  this  period  unmar- 
ried parturient  women  receive  pecuniary  assistance  from  the  hospital  to 
enable  them  to  obtain  a  place  in  which  to  be  confined.  Now,  Stadfeldt 
reports  a  larger  mortality  among  this  class  than  among  those  delivered  in 
the  hospital.  Yet  they  are  confined  at  a  favorable  season  of  the  year, 
without  any  communication  with  the  furniture,  the  sage-femmes,  or  the 

'  Dr.  Walker  lias  since  resigned,  and  my  present  colleague  is  Prof.  Win.  M.  Polk. 

2  From  Oct.,  1883,  to  Aug.,  1884,  there  have  been  confined  168  women  in  the  hospital. 
Twenty  were  brought  in  from  the  street  just  after  the  birth  of  the  child.  Of  these 
188,  not  one  suffered  from  any  puerperal  affection.  There  were  2  deaths — 1  from  intes- 
tinal ulcerations,  possibly  the  result  of  the  corrosive  sublimate  irrigations,  and  1  from 
exhaustion.  This  latter  patient  had  been  thirty-six  hours  in  labor  before  she  was 
brought  to  the  hospital,  and  died  four  hours  after  admission.  Under  the  admirable 
management  of  Miss  Hart,  the  matron,  in  addition  to  the  slight  mortality,  there  haa 
likewise  been  almost  complete  absence  of  even  trivial  temperature  elevations. 


PREVENTION.  1023 

physicians  of  the  hospital.  As  they  fortunately  receive  nothing  but 
money,  that  can  hardly  be  suspected  of  communicating  contagion.  What 
their  fate  would  be  in  New  York  City  perhaps  may  be  judged  from  the 
following  facts :  Excluding  cases  confined  in  hospitals,  nearly  one-thirtieth 
of  all  the  deaths  and  one-twenty-fourth  of  the  cases  of  metria  between 
1867  and  1875  are  reported  by  four  practitioners.  Ten  practitioners  out 
of  twelve  hundred  signed  the  death-certificates  of  one-fifteenth  of  the 
women  dying  from  puerperal  causes,  and  one-tenth  of  the  cases  of 
metria.  .  But  it  is  not  to  be  supposed  that  these  deaths  were  all  the  result 
of  malpractice  and  incompetence.  The  true  history  of  most  of  them 
probably  was  that  the  doctor  was  engaged  to  attend  the  case  of  confine- 
ment for  a  small  fee,  with  the  understanding  that  he  should  make  no 
calls  subsequently,  unless  specially  summoned  by  the  friends  of  the 
patient.  The  latter,  left  to  ignorant  care  or  perhaps  without  any  assist- 
ance whatever,  and  exposed  to  all  the  pernicious  influences  bred  by 
poverty,  when  illness  supervened  probably  did  not  call  the  physician  to 
her  aid  until  the  time  for  help  had  passed,  so  that  in  the  end  his  profes- 
sional functions  were  confined  to  procuring  the  requisite  permit  for  burial. 

Humanity  demands  that  charity  should  furnish  places  of  refuge  in 
which  poor  outcasts  can  receive  assistance  during  the  perils  of  child- 
bearing.  If  we  must,  then,  have  maternities,  we  should  make  them 
safe,  and  this  can  be  in  great  measure  accomplished  by  remembering 
the  twofold  source  of  danger  arising  from  a  poisoned  atmosphere  and 
direct  inoculation.  A  hospital  must  be  clean,  spacious,  and  well-venti- 
lated, or  its  atmosphere  will  become  charged  with  the  spores  of  septic 
fungi  and  produce  nosocomial  malaria.  The  most  rigid  sanitary  pre- 
cautions observed  by  the  attendants  will  not  prevent  a  badly-ventilated 
ward  from  becoming  unwholesome,  unless  unoccupied  wards  are  kept  to 
which  patients  can  be  transferred  upon  the  first  admonition  of  danger. 
Goodell  states  that  at  the  Preston  Retreat  the  wards  are  used  invariably 
in  rotation.  In  connection  with  the  Maternity  at  Copenhagen  there  are 
a  number  of  small  supplementary  hospitals  scattered  through  the  city, 
which  serve  as  safety-valves  for  the  central  institution.  Artificial 
methods  of  ventilation  render  the  task  of  keeping  the  wards  wholesome 
comparatively  easy.  They  do  not  need,  however,  to  be  complicated  and 
expensive.  The  good  repute  of  the  Rotunda  Hospital,  it  seems  to  me, 
is  in  large  measure  due  to  the  natural  ventilation  afforded  by  open 
fireplaces. 

In  the  Vienna  Clinic,  according  to  C.  Braun,  the  mortality  between 
1834  and  1862  averaged  6  per  cent.,  and  in  1842  the  enormous  total  of 
521  deaths  to  3067  confinements  was  reached.  With  the  introduction  in 

1862  of  what  is  known  as  Bohm's  heating  and  ventilation  system  an 
immediate  improvement  was  experienced.     In  the  sixteen   years   from 

1863  to  1878,  inclusive,  the  total  mortality  has  been  1.6  per  cent.,  though 
in  that  time  5464  practitioners  have  received  an  obstetrical  training  in  its 
wards.     In  commenting  upon  this  change,  Braun  says :  "  I  have  now 
from  practical  experience  arrived  at  the  knowledge  of  the  fact  that^  the 
rapid  and  thorough  prevention  of  putridity  by  adequate  ventilation  is  to 
be  regarded  as  a  good  preventive  measure  against  puerperal  fever ;  that 
it  is  not  the  number  of  patients  in  a  lying-in  hospital,  nor  yet  the  number 
of  patients  in  a  single  room,  but  the  deficient  circulation  of  air— a  fault 


1024  PUERPERAL  FEVER. 

•which  may  inhere  to  separate  compartments  in  the  smallest  maternities 
— which  is  the  important  feature  in  the  spread  of  puerperal  fever ;  that 
puerperal  women  are  to  be  protected  from  childbed  diseases  not  by 
isolated  buildings  and  gardens,  nor  by  walls,  but  by  the  permanent 
introduction  of  great  quantities  of  pure,  warm  air."  He  then  adds, 
what  is  in  thorough  accord  with  my  own  experience,  "  Before  new 
institutions  are  built  greater  attention  than  heretofore  should  be  paid 
to  the  ventilation  of  the  old  structures,  and,  where  this  is  found  defec- 
tive, a  system  should  be  substituted  corresponding  to  the  scientific 
requirements." 

In  the  year  1872  puerperal  fever  destroyed  28  women  of  156  who 
were  confined  in  the  Bellevue  Hospital.  The  service  was  then  broken 
up,  and  a  great  outcry  arose  against  "tainted  hospitals."  Wooden 
pavilions  were  accordingly  erected  on  Blackwell's  Island  for  the  recep- 
tion of  lying-in  women.  These  buildings  were  constructed  upon  what 
is  known  as  the  cottage  plan.  They  were  favorably  situated  in  an  airy 
location  remote  from  the  general  hospital.  They  were,  however,  heated 
by  large  iron  stoves,  and  no  means  of  ventilating  the  wards  was  pro- 
vided, except  by  lowering  the  windows.  In  less  than  three  months  from 
their  occupancy  an  epidemic  of  puerperal  fever  made  it  necessary  to 
remove  the  service  for  a  time  to  the  Charity  Hospital.  The  same  result 
followed  every  subsequent  attempt  to  utilize  them  for  maternity  purposes, 
until,  after  three  years'  trial,  it  was  found  necessary  to  abandon  them 
altogether. 

In  private  practice  it  is  likewise  important  that  the  lying-in  room 
should  be  provided  with  plenty  of  light  and  air.  The  physician  should 
insist  upon  the  value  of  ventilation  as  a  means  of  contributing  to  the 
speedy  recovery  of  childbed  women.  By  hermetically  sealing  the  win- 
dows, through  false  fears  of  his  patient's  taking  cold,  he  exposes  her  to 
the  risk  of  becoming  poisoned  with  her  own  exhalations. 

But  the  early  experiences  of  the  Hdpital  Cochin  and  the  Hopital  Lari- 
boisi£re,  costly,  palace-like  structures,  with  every  appliance  of  art,  prove 
that  fresh  air  alone  does  not  protect  patients  from  the  consequences  of 
inoculation. 

The  great  improvement  in  the  condition  of  maternity  patients  in  recent 
years  has  been  due  to  the  application  of  Lister's  principles  to  obstetric 
practice.  Complete  antisepsis  in  the  surgical  sense  is,  of  course,  imprac- 
ticable. Adequate  antisepsis  has,  however,  been  proved  to  result  from 
the  observance  of  a  variety  of  precautions  which  have  been  the  slow  out- 
come of  experience.  These,  in  brief,  in  hospitals,  consist  in  protecting 
the  patient  from  every  known  form  of  contamination,  and  in  the  prompt 
removal  and  isolation  of  every  puerperal  woman  who  manifests  febrile 
symptoms. 

In  citing  the  examples  of  the  Hopital  Cochin  and  the  Hdpital  Lari- 
boisidre,  I  was  led  to  the  selection  because  these  hospitals  most  strikingly 
illustrate  the  extent  of  the  triumph  of  the  new  doctrines.  Whereas  at 
the  Lariboisiere  the  mortality  in  1854,  the  year  of  its  opening,  exceeded 
10  per  cent.,  as  a  result  of  the  prophylactic  measures  adopted  by  M. 
Siredey  the  mortality  was  1  to  145  in  1877,  and  1  to  199  in  1878.  And 
at  the  H6pital  Cochin,  in  1878,  Lucas-ChamponnieTe,  with  770  confine- 
ments, was  able  to  report  but  2  deaths  from  puerperal  causes. 


PREVENTION.  1025 

As  regards  details,  the  bedsteads  should  be  of  iron  and  should  be  fre- 
quently scrubbed  with  a  carbolic  solution ;  after  each  confinement  the 
palliasse  upon  which  the  woman  lay  should  be  washed  in  boiling  water 
and  the  straw  should  be  burned ;  in  place  of  the  usual  rubber  covering  to 
the  bed,  Tarnier  recommends  tarred  paper,  which  is  antiseptic,  and  costs 
so  little  that  it  need  be  used  in  but  a  single  case ;  all  soiled  linen  should 
be  instantly  removed  from  the  ward,  either  to  be  burned  or  disinfected  by 
prolonged  boiling;  sponges  should  be  banished,  as,  when  they  have  once 
been  soaked  with  blood,  not  even  carbolic  acid  can  make  them  safe ; 
nurses  employed  in  the  puerperal  wards  ought  not  to  have  access  to  cases 
of  labor,  as  D'Espine  and  Karewski1  have  shown  that  the  lochia  of  even 
a  healthy  person  on  the  third  day  will  poison  a  rabbit;  a  patient  attacked 
with  fever  should  be  immediately  removed,  and  the  nurse  in  attendance 
should  go  with  her.  At  the  Emergency  Hospital,  with  the  first  appear- 
ance of  catarrhal  affection  of  the  genital  organs  or  of  so-called  milk 
fever,  the  wards  are  immediately  emptied  and  fumigated  with  sulphur- 
ous acid.  In  spite  of  recent  scepticism  regarding  the  value  of  the  fumes 
of  sulphurous  acid  as  a  germicide  and  disinfectant,  I  do  not  hesitate  to 
express,  after  long  experience,  my  firm  conviction  as  to  their  efficacy. 

Doleris2  formulates  the  indications  for  effective  prophylaxis  as  follows: 
1,  prevent  the  introduction  of  germs  (antisepsis  before  confinement) ;  2, 
paralyze  their  action  (antisepsis  after  confinement) ;  3,  shut  up  the  doors 
— veins,  lymphatics,  and  Fallopian  tubes  (employment  of  means  which 
promote  uterine  contraction). 

The  first  duty  of  the  physician  is  to  refrain  from  attending  a  case  of 
labor  when  fresh  from  the  presence  of  contagious  diseases  or  from  contact 
with  septic  materials,  whether  derived  from  the  dissecting-room  or  the 
clinic.  Scepticism  regarding  these  sources  of  danger  is  sure  in  the  long 
run  to  be  severely  punished.  In  a  doubtful  case  the  least  concession 
should  consist  in  a  full  bath  and  a  complete  change  of  clothing.  A  special 
coat  for  confinement  purposes,  stained  with  blood  and  amniotic  fluid,  is 
liable  to  convey  infection.  In  every  case  of  labor,  whether  in  hospital  or 
private  practice,  the  hands  and  forearms  should  be  freely  bathed  in  a  car- 
bolic solution  before  making  a  vaginal  examination.  A  nail-brush  should 
form  a  part  of  the  ordinary  obstetric  equipment.  Frequent  examinations 
during  labor  should  be  avoided.  All  instruments  employed  during  or 
subsequent  to  confinement  should  be  carefully  disinfected.  In  prolonged 
labors,  after  operation,  in  cases  of  dystocia,  or  where  the  membranes 
have  ruptured  prematurely  and  the  foetus  is  dead,  it  is  a  useful  precaution 
after  delivery  to  wash  both  uterus  and  vagina  with  warm  carbolized  water 
or  solution  of  corrosive  sublimate  (1  :  2000).  In  Vienna  both  Spaeth 
and  Brauii  after  difficult  labors  introduce  a  suppository  of  iodoform,  2 
to  2|  inches  in  length,  into  the  uterine  cavity.  The  formula  recom- 
mended consists  of — 

^.  Iodoform  i,  20  grammes ; 

Gummi  Arabici, 

Glycerine, 

Amyli  puri,  da.  2  grammes ; 

Ft.  Bacilli,  No.  iij. 

:  D'Espine,  "  Contribution*  d  ? etude  de  la  septicemie  puerperde,"  p.  18 ;  Karewski,  loc.  dt. 
*Lafievre  puerperde,  1880,  p.  303. 
VOL.  I.— 65 


1026  PUERPERAL  FEVER. 

In  their  introduction  the  half-hand  (left)  should  be  passed  to  the  cervix ; 
the  iodoform  bacillus  should  be  seized  by  a  pair  of  polypus  forceps  and 
pushed  into  the  cervical  canal.  The  hand  in  the  vagina  should  then  be 
used  to  shove  the  suppository  upward  past  the  internal  os.  No  symptoms 
of  poisoning  from  the  iodoform  have  been  observed.  The  disinfection 
is  complete  and  prolonged.  In  hospitals  the  woman  should  be  bathed 
before  entering  the  lying-in  ward,  and  the  vagina  should  in  all  cases 
be  disinfected  writh  carbolic  acid  or  corrosive  sublimate  both  before  and 
immediately  after  labor.  The  conduct  of  labor  under  carbolic  acid  spray 
is  commended  by  Fancourt  Barnes.  Dole"ris  advises  the  application  of 
a  compress  soaked  in  carbolic  fluid  to  the  external  genitals  during  the 
progress  of  labor.  Tarnier  advises  dressing  the  vulva,  so  soon  as  the 
head  begins  to  emerge,  with  a  pledget  soaked  in  carbolized  oil  (1  :  10). 
With  the  recession  of  the  head  during  the  interval  between  pains  a  por- 
tion of  the  oil  is  carried  upward  into  the  vagina. 

In  the  puerperal  period  the  warm  carbolized  douche  stimulates  uterine 
retraction  and  promotes  the  rapid  healing  of  wounds  in  the  vaginal  canal ; 
in  hospital  practice  it  possesses  the  additional  advantage  of  preventing  the 
accumulation  of  putrid  albuminoid  matters  in  the  air.  In  private  prac- 
tice the  patient  should  employ  a  new  syringe ;  in  hospitals  every  woman 
should  be  supplied  with  a  glass  tube  to  be  attached  to  the  irrigator. 
When  not  in  use  these  tubes  should  be  immersed  in  carbolic  acid.  The 
stream  injected  into  the  vagina  should  be  continuous,  like  that  furnished 
by  the  fountain  syringe.  With  my  hospital  patients,  in  place  of  cloths 
to  the  vulva  I  have  been  in  the  habit  of  using  oakum.  By  soaking  the 
latter  in  a  solution  of  carbolic  acid  the  vulva  is  surrounded  by  an  anti- 
septic atmosphere.1 

Pedantic  as  these  directions  may  seem,  they  are  justified  by  experience, 
and  the  carrying  out  of  the  details  given  easily  becomes  a  matter  of  habit. 
That  by  such  precautions  puerperal  fever  is  destined  to  be  erased  from  the 
list  of  dangerous  diseases  attacking  the  woman  in  childbed  is  saying  more 
than  is  warranted.  Nevertheless,  it  is  true  that  a  physician  ought  never 
to  lose  the  sense  of  personal  responsibility  for  its  occurrence.  Indeed, 
puerperal  fever  ought  to  be  regarded  as  a  preventable  disease,  and  an 
attack  as  the  evidence  that  some  source  of  danger  has  been  overlooked, 
though,  owing  to  the  imperfection  of  our  knowledge,  it  may  easily  happen 
that  even  with  the  keenest  scrutiny  the  precise  cause  in  an  individual  case 
may  escape  detection.2 

1  I  know  that  of  late  there  has  been  a  strong  reaction  against  the  use  of  vaginal  injec- 
tions in  normal  childbed,  but  personally  I  have  experienced  none  of  the  disagreeable 
effects  ascribed  to  them.     Indeed,  both  my  hospital  and  private  patients  alike  speak  of 
them  as  soothing  and  grateful.    I  therefore  have  had  no  ground  to  discontinue  them.    That 
they  are  indispensable  I  do  not  claim.     They  are  no  longer  used  in  Vienna,  in  Prague, 
nor  in  the  New  York  Maternity,  and  yet,  none  the  less,  their  results  have  since  been  in 
the  highest  degree  satisfactory.     At  these  institutions,  however,  vaginal  disinfection  is 
vigorously  resorted  to  during  and  immediately  subsequent  to  labor,  and  during  childbed 
some  form  of  antiseptic  pad  over  the  vulva  is  employed. 

2  Since  the  above  was  written  Dr.  Garrigues  has  furnished  a  most  extraordinary  exam- 
ple of  the  efficacy  of  the  antiseptic  treatment  at  the  New  York  Maternity  Hospital. 
From  the  years  1875  to  1882,  inclusive,  the  number  of  confinements  was  2827 ;  the  deaths 
116,  or  a  little  over  4  per  cent.     The  highest  percentage  was  reached  in  1877 — viz.  6.67  ; 
the  lowest  in  1881,  when  it  fell  to  2.36.     In  1883,  of  345  women  confined,  30  died.     In 
September  of  that  year  there  were  9  deaths,  and  of  5  puerperre  who  were  seriously  ill, 
1  died  later.     At  this  time  he  introduced  a  series  of  reforms  of  which  the  following, 


PREVENTION.  ]Q27 

Before  terminating  this  section  upon  the  prophylaxis  of  puerperal  fever 
1  take  great  satisfaction  in  furnishing  from  Taruier's  recent  treatise  the 
Allowing  description,  by  Pinard,  of  the  ingenious  pavilion  designed  by 
larmer  to  make  it  possible  to  secure  for  hospital  patients,  at  the  mini- 
mum expense,  the  benefits  of  isolation,  and  to  provide  for  each  room  in 
the  pavilion  all  the  conditions  favorable  to  rapid  and  complete  disin- 
fection. 

The  pavilions  are  two-storied  and  of  a  rectangular  shape,  twenty-four 
feet  m  width  by  forty-six  feet  in  length.  The  front  and  rear  face  to  the 
north  and  south,  the  ends  to  the  east  and  west.  Two  main  partitions 
divide  the  interior  into  three  divisions.  Each  end  division  is  subdivided 
by  a  central  partition  into  two  chambers,  so  that  each  story  has  five  com- 
partments— a  central  one  for  the  attendants,  and  four  at  the  four  corners 
destined  for  the  reception  of  patients.  On  the  ground  floor  the  central 
compartment  consists  of  a  vestibule  facing  to  the  north,  and  an  office 
facing  to  the  south.  On  the  former  are  placed  the  staircase,  the  water- 
closet^  and  a  reception-closet.  In  addition  to  the  main  entrance  there  are 
three  interior  doors — one  leading  to  the  water-closet,  one  to  the  closet,  and 
one  to  the  office.  The  latter,  for  the  occupation  of  the  person  on  dutv, 
contains  a  heater,  a  portable  bath,  a  table,  chairs,  and  wardrobe.  T^'o 
windows  face  the  south.  The  office  has  two  doors,  one  opening  into  the 
vestibule,  and  the  other,  in  the  opposite  side,  opens  directly  outward. 
The  four  corner  rooms  for  patients  have  each  a  door  and  a  window,  the 
latter  looking  from  the  end  of  the  partition  and  reaching  to  the  floor,  and 
the  former  opening  out  from  the  fa9ade.  These  four  rooms  are  therefore 
not  only  independent  of  one  another,  but  have  no  communication  with 
the  vestibule  or  the  central  office.  On  the  second  floor  the  arrangement 
is  similar,  except  that  the  rooms  open  upon  a  balcony,  by  means  of  which 
communication  from  the  outside  is  rendered  possible.  Upon  each  fa§ade 
a  glazed  screen  furnishes  shelter  in  rainy  weather.  The  screen  extends 
to  the  roof,  but  is  not  in  direct  contact  with  the  walls,  a  space  being 
left  for  a  current  of  air.  The  eight  rooms  for  patients,  four  on  each 
story,  are  severally  fourteen  feet  long,  eleven  and  a  half  feet  wide,  and  ten 
feet  high.  Below,  the  floors  are  of  asphaltum ;  above,  of  flags  or  slates. 
The  walls  and  ceilings  are  stuccoed  and  covered  with  oil  paint.  The 
corners  are  rounded  to  prevent  the  accumulation  of  dust.  To  facilitate 

omitting  details,  gives  the  essentials:  "Wards  fumigated  with  sulphurous  acid  fumes,  and 
the  floors  and  furniture  washed  with  a  solution  of  corrosive  sublimate  (1  :  1000).  Every 
patient,  on  entering  the  lying-in  ward  after  the  bath,  had  her  abdomen,  buttocks,  genitals, 
and  thighs  washed  with  sublimate  solution  (1  :  2000).  During  labor  vagina  irrigated 
with  latter  solution.  In  prolonged  labors  irrigation  repeated  every  three  hours.  Great 
care  of  hands  on  part  of  doctor  and  nurses.  Glycerine  and  corrosive  sublimate  (1 : 1000) 
used  for  lubricating  fingers  before  making  internal  examinations.  Antiseptic  pad  applied 
to  the  head  during  its  egress,  and  to  the  vulva  until  the  secondines  had  been  expelled. 
Absorbent  cotton  covered  with  netting  soaked  in  corrosive  sublimate  solution  applied  to 
external  genitals  during  childbed  period.  This  latter  applied  and  removed  with  the 
same  care  as  in  dressing  a  wound  after  a  capital  operation.  Irrigation,  first  of  the  vagina 
and  afterward  of  the  uterus,  immediately  after  labor  in  cases  where  the  hand  or  instru- 
ments had  been  passed  into  the  uterine  cavity. 

When  the  details  of  this  treatment  were  first  published  by  Garrigues,  many  took  a 
humorous  view  of  it,  but  mark  the  result:  In  the  following  162  confinements  there  were 
no  deaths,  and  from  October  to  July,  inclusive,  of  the  present  year,  of  409  patients  con- 
fined, though  many  operations  were  performed,  5  died ;  but  of  these,  3  only  were  from 
septic  causes,  and  they,  Garrigues  believes,  were  the  result  of  the  neglect  of  certain  of 
the  prescribed  details. 


1028  PUERPERAL  FEVER. 

washing,  the  floors  slant  toward  a  gutter  communicating  by  means  of 
a  pipe  with  the  sewer.  In  each  room  panes  of  glass  enable  patients  and 
the  office  attendant  to  see  one  another,  so  that  surveillance  is  secured  with- 
out sacrificing  the  principle  of  isolation.  The  furniture  of  the  rooms 
consists  of  an  iron  bedstead  with  metallic  springs.  The  pillow,  bolster, 
and  palliasse  are  stuffed  with  straw.  In  addition,  each  room  is  provided 
with  a  night  table,  a  round  table,  a  chair,  a  stool,  and  a  crib — all  of  iron. 
A  bell-rope  at  the  bedside,  the  wire  of  which  passes  to  the  office  by  the 
outside  of  the  building,  enables  the  patient  to  summon  assistance.  Each 
room  likewise  contains  a  washstand,  with  faucets  for  hot  and  cold  water, 
the  latter  supplied  from  a  cistern  on  the  roof,  the  former  from  the  office 
heater.  The  patients  remain  in  the  rooms  where  they  are  confined  until 
they  are  discharged.  When  this  takes  place  the  chamber  is  aired,  the 
furniture  is  removed  and  washed  with  care,  the  straw  is  burned,  and  the 
walls  are  washed  with  an  abundant  supply  of  water.  If  a  patient  is 
taken  ill,  she  is  carefully  isolated,  and  has  assigned  to  her  her  own 
especial  attendant  and  physician,  who  do  not  come  into  contact  with  other 
puerperal  patients. 

That  the  plans  of  construction  in  the  Tarnier  pavilions  would  require 
some  modification  to  adapt  them  to  the  rigor  of  our  winters  seems  prob- 
able, but  the  principles  which  they  illustrate  are  sufficiently  vindicated  by 
the  results  so  far  reported — viz.  6  deaths  in  1062  confinements,  whereas 
in  the  old  Maternity  the  death-rate,  formerly  amounting  to  5  per  cent., 
still  aggregates  2  to  the  100. 

TREATMENT. — When  the  septic  germs  characteristic  of  putrid  infec- 
tion have  once  entered  the  blood,  they  are  beyond  the  reach  of 
the  physician.  Except,  however,  in  cases  of  acute  septicaemia,  where 
the  quantity  of  poison  introduced  at  the  outset  is  excessive,  the 
patient  rallies  from  the  immediate  shock,  and,  provided  no  fresh  pyro- 
genic  material  finds  its  way  into  the  system,  recovery  is  to  be  antici- 
pated. The  indications  for  treatment  are,  therefore,  to  neutralize 
the  puerperal  poison  at  the  point  of  production,  in  order  to  prevent  its 
causing  further  mischief,  and  to  adopt  measures  calculated  to  enable  the 
patient  to  tolerate  its  presence,  when  once  absorbed,  until  it  is  either 
eliminated  or  loses  its  harmful  properties. 

Toward  the  fulfilment  of  the  first  indication  it  is  to  be  recom- 
mended that  in  every  case  of  fever  of  puerperal  origin  the  vagina 
be  cleansed  with  a  2  to  3  per  cent,  solution  of  carbolic  acid  or 
corrosive  sublimate  (1  :  3000)  every  four  to  six  hours.  The  douche 
in  itself  is  absolutely  harmless.  In  most  cases  the  infection  starts 
from  the  wounds  of  the  vagina  and  of  the  cervix.  Then,  too,  the  tend- 
ency of  the  secretions  to  stagnate  in  the  vaginal  cul-de-sac,  bathing  as 
they  do  the  cervical  portion,  is  a  prolific  source  of  septic  trouble.  In  all 
but  the  mildest  cases  the  vaginal  orifice  should  be  examined  with  refer- 
ence to  the  existence  of  puerperal  ulcers.  All  necrotic  patches  should  be 
touched  with  hydrochloric  acid,  with  a  10  per  cent,  solution  of  carbolic 
acid,  with  iodoform,  or,  what  I  personally  prefer,  a  mixture  composed  of 
equal  parts  of  the  solution  of  the  persulphate  of  iron  and  the  compound 
tincture  of  iodine.  The  latter  acts  as  a  powerful  antiseptic,  while  the 
former,  by  corrugating  the  tissues,  closes  the  lymphatics  and  shuts  up 
the  portals  through  which  the  septic  germs  penetrate  into  the  system. 


TREATMENT.  1029 

Infra-uterine  injections  should  be  resorted  to  with  extreme  circum- 
spection. They  are  not  indicated  by  a  simple  rise  of  temperature.  A 
very  large  proportion  of  the  febrile  attacks  which  occur  in  childbed  run 
an  absolutely  favorable  course.  Unless  the  infection — and  this  is  not  the 
rule,  but  the  exception — proceeds  from  the  uterine  cavity,  they  are 
unnecessary.  In  circumscribed  inflammations,  where  the  morbific  poison 
loses  its  virulence  at  a  short  distance  from  the  puerperal  lesion,  they  are 
often  injurious.  It  is  difficult,  if  not  impossible,  to  so  conduct  them  as 
to  avoid  opening  up  afresh  recent  granulating  wounds.  Yet  the  practice 
of  local  disinfection  is  warmly  advocated  by  Fritsch,  Schiiller,  Langen- 
buch,  and  Schroeder  as  a  prophylatic  against  puerperal  affections.  On  the 
other  hand,  Braun  von  Fernwald,  with  his  vast  opportunities  for  judg- 
ing obstetrical  questions,  writes  with  reference  to  this :  "  We  must  pro- 
test against  injections  made  by  physicians  into  the  uterine  cavity.  Such 
meddlesomeness  is  more  likely  to  do  harm  than  good."  This  corresponds 
with  my  own  experience.  In  theory,  the  proposition  to  treat  the  uterus 
as  one  would  any  other  pus-secreting  cavity  seems  rational,  but  I  have 
found  that  every  attempt  to  carry  the  theory  to  its  logical  conclusion  in 
hospital  practice  has  been  followed  by  a  rise  in  the  puerperal  death-rate. 
Ruuge  reports  an  epidemic  of  puerperal  fever  in  Gusserrow's  clinic  brought 
about  by  the  employment  of  mtra-uterme  irrigations,  during  which  the 
mortality  rose  to  3.8  per  cent.  With  the  abolition  of  the  irrigations  the 
mortality  sank  to  .39  per  cent.  In  1880,  Fischel 1  introduced  the  so-called 
permanent  irrigations  into  the  Prague  maternity.  Of  880  patients,  9 
died  of  sepsis.  The  irrigations  were  then  prohibited.  The  following 
year,  of  933  patients,  only  2  died  from  the  same  cause,  and  in  1882,  of 
521  patients,  there  were  no  deaths  from  sepsis.  Fehling,  who  limited 
the  use  of  intra-uterine  injections  to  special  momentary  indications, 
reported,  in  1880,  415  confinements  without  a  single  death. 

Among  the  accidents  which  have  been  referred  to  the  use  of  injections 
are  convulsions,  shock,  and  carbolic-acid  or  corrosive-sublimate  poison- 
ing; but  the  chief  danger  lies  in  the  possibility  of  conveying  the  infec- 
tious materials,  from  the  vagina  to  the  previously  normal  uterus.  There 
seems  to  be  no  question  as  to  the  superior  effectiveness  of  corrosive  sub- 
limate as  a  germicide.  It  not  only  acts  more  rapidly  than  carbolic  acid, 
but  its  action  is  more  permanent.  In  the  usual  proportion  of  1  :  2000  it 
is  apt,  when  repeated  frequently  as  a  vaginal  douche,  to  corrugate  the 
vagina  and  cervix.  When  used  for  intra-uterine  irrigation  great  pains 
should  be  taken  that  no  portion  of  the  fluid  remain  behind  in  the  uterine 
cavity.  Since  its  introduction  into  the  Emergency  Hospital  there  has 
been  one  death  from  ulceration  in  the  colon,  which  possibly  was  attribu- 
table to  its  use.  It  is  to  be  hoped  the  claim  that  corrosive  sublimate  is 
an  efficient  antiseptic  in  the  proportion  of  1  :  10,000  may  -prove  well 
founded. 

In  pressing  the  necessity  of  caution  and  discrimination,  1  have  ot, 
however,  intended  to  discourage  the  employment  of  intra-uterine  anti- 
sepsis in  cases  where  it  is  strictly  indicated.  Thus,  it  would  be  folly, 
in  a  fever  due  to  the  decomposition  of  placental  d6bris,  of  shreds  of 
decidua,  of  strips  of  membrane,  or  of  retained  coagula,  -or  in  diphthentis 
of  the  mucous  membrane,  to  treat  the  general  symptoms  and  neglect 
1  "Zur  Therapie  der  Puerperalen  Sepsis,"  Arch.f.  Gynaek.,  vol.  xi.  p.  41. 


1030  PUERPERAL  FEVER. 

the  local  cause  of  difficulty.  In  a  specific  case  it  may  prove  difficult 
to  decide  as  to  the  correct  course  to  pursue.  lu  general  it  may 
be  stated  that  it  is  proper  to  wash  out  the  entire  length  of  the  genital 
canal  when  fever  follows  prolonged  operations  conducted  within  the 
uterine  cavity  or  the  birth  of  a  dead  foetus,  and  in  cases  of  fever  asso- 
ciated with  a  fetid  discharge  which  persists  in  spite  of  the  vaginal  douche, 
with  the  presence  of  recognizable  portions  of  the  ovum  or  its  dependencies 
in  the  lochia,  with  the  repeated  discharge  of  decomposed  coagula,  or  with 
a  large,  flabby  uterus.  It  will,  however,  be  seen  that  with  proper  dis- 
infection during  and  immediately  after  labor,  the  occasions  for  late  iiitra- 
uteriue  injections  are  extremely  rare. 

The  operation  of  cleansing  the  uterus  should  be  conducted  writh  the 
most  scrupulous  care.  The  syringe  employed  should  produce  a  continu- 
ous and  not  an  interrupted  stream,  and  all  air  should  be  expelled  from 
the  pipe.  The  tube  to  be  passed  through  the  cervix  should  be  of  glass, 
of  the  size  of  the  little  finger,  and  bent  somewhat  to  conform  to  the 
pelvic  curve.  The  vagina  should  first  be  subjected  to  a  thorough  dis- 
infection, by  way  of  precaution  against  conveying  septic  materials  into 
the  uterus.  The  introduction  of  the  tube  should  be  made  with  the 
guidance  of  two  fingers  passed  through  the  external  os.  But  slight 
force  is  requisite  to  reach  the  internal  os.  It  is  neither  necessary 
nor  desirable  to  push  the  tube  to  the  fuudus.  The  fluid  injected 
should  be  tepid,  and,  if  carbolic  acid  is  used,  of  the  strength  of  two  or 
three  drachms  to  the  pint ;  if  corrosive  sublimate  is  employed,  the  strength 
should  not  exceed  1  :  3000.  It  should  be  introduced  very  slowly,  and 
pains  should  be  taken  to  ensure  its  unimpeded  escape,  which  can  usually 
be  accomplished  by  pressing  the  anterior  wall  of  the  cervix  forward  by 
means  of  the  glass  tube.  Langenbuch  recommends  securing  permanent 
drainage  by  leaving  a  bit  of  rubber  tubing  in  the  cervical  canal — a  plan 
concerning  the  merits  of  which  I  am  not  able  to  speak  from  experience. 
The  tube  is  said  to  be  Avell  tolerated,  and  to  possess  the  advantage  of  en- 
abling subsequent  injections  to  be  performed  without  disturbing  the  patient. 

In  many  cases  the  results  of  intra-uteriue  treatment  are  very  striking. 
Often  the  temperature  falls  notably  within  an  hour  or  two  of  the  opera- 
tion. This  result  is,  however,  rarely  permanent.  Usually  the  fever 
recurs,  and  the  operation  has  to  be  repeated.  The  patient  should  be 
carefully  watched,  and  with  the  first  sign  of  returning  danger  the  injec- 
tion should  be  repeated.  Two  or  three  injections  may  thus  be  called 
for  in  twenty-four  hours,  and  they  may  require  to  be  continued  for  a 
week.  Still,  by  the  means  indicated  a  certain  pretty  large  pi-oportion  of 
women  seemingly  destined  to  destruction  in  the  end  make  favorable 
recoveries.1 

Ehrendorfer2  relates  a  case  of  septic  endometritis  and  erysipelas  start- 

1  The  admirable  monograph  of  Dr.  T.  G.  Thomas,  entitled  The  Prevention  and  Treatment 
of  Puerperal  Fever,  has  already  done  much  good  in  calling  the  attention  of  the  profession 
at  large  to  the  practice  of  local  disinfection.  His  experience,  however,  based  upon  a  very 
large  consulting  practice,  has  perhaps  been  of  a  kind  to  furnish  him  with  an  undue  pro- 
portion of  puerperal  cases  calling  for  intra-uterine  treatment.  With  increasing  care  in 
the  management  of  labor  anil  of  the  birth  of  the  child  there  seems  reason  to  hope  that 
the  necessity  for  the  treatment  he  so  eloquently  advocates  may,  in  the  near  future,  dis- 
appear entirely. 

*  ''  Ueber  die  Verwendung  der  Jodoform  staebchen  bei  der  intrauterinen  nach  behaiid- 
lung  im  Wochenbette,"  Arch.J.  Gynaek.,  vol.  xxii.  S.  88. 


TREATMENT.  1031 

ing  from  the  genital  organs,  in  Spaeth's  Clinic,  where,  after  seven  days 
of  ineffective  uterine  irrigations,  two  bacilli,  containing  together  ten 
grains  of  iodoform,  were  introduced  into  the  uterus.  The  washings 
with  carbolic  acid  were  then  stopped.  On  the  next  day  the  discharge 
was  diminished  and  the  odor  was  less  marked.  On  the  fourth  day  two 
new  iodoform  bacilli  were  introduced.  The  patient,  in  spite  of  the  fact 
that  the  erysipelas  spread  over  nearly  the  entire  body,  eventually 
recovered. 

Of  the  symptoms,  the  first  in  order  which  calls  for  treatment  is 
usually  the  peritoneal  pain.  It  is,  as  we  have  seen,  commonly  of  a 
lancinating  character,  and  is  associated  with  hurried  breathing .  and 
extreme  frequency  of  the  pulse.  So  soon  as  the  pain  is  once  fairly 
under  control  the  violence  of  the  onset  begins  to  abate.  It  should  be 
met,  therefore,  by  the  hypodermic  injection  of  from  one-sixth  to  one- 
third  grain  of  morphia  in  solution.  The  anodyne  action  should  be 
maintained  by  doses  administered  by  the  mouth  in  quantities  and  at 
intervals  suited  to  the  severity  of  the  case.  The  most  important  object 
to  be  secured  is  freedom  from  spontaneous  pain.  It  is,  moreover,  good 
practice  to  push  the  opiate  until  pain  elicited  by  pressure  is  likewise 
controlled,  provided  it  can  be  accomplished  without  producing  narcosis. 
In  susceptible  patients  and  in  localized  inflammations  the  quantity 
required  may  not  be  very  great,  while  in  acute  general  peritonitis  the 
tolerance  of  the  drug  exhibited  by  puerperal  women  is  sometimes  ex- 
traordinary. Thus,  a  patient  of  Alonzo  Clark  took  the  equivalent 
of  934  grains  of  opium  in  four  days ;  a  patient '  of  Fordyce  Barker 
13,969  drops  of  Magendie's  solution  in  eleven  days;  and  one  of  my 
own,  at  the  Maternity,  the  equivalent  of  over  1700  grains  of  opium  in 
seven  days.1  In  this  latter  instance  the  patient  was  to  all  appearance 
moribund  when  the  treatment  was  begun.  Thus,  the  features  were 
pinched,  the  face  was  drawn,  the  pupils  were  dilated,  the  finger-tips 
were  blue  and  cold,  the  respirations  were  rapid,  and  the  pulse  was 
scarcely  perceptible.  In  this  condition  the  large  doses  of  opium  did  not 
produce  narcosis,  but  were  followed  by  restoration  of  the  circulation,  by 
normal  breathing,  and  by  the  disappearance  of  the  symptoms  of  shock. 
Any  attempt  to  relax  the  treatment  was  at  once  succeeded  by  a  recurrence 
of  the  alarming  symptoms.  At  the  expiration  of  the  disease  the  opium 
was  discontinued  abruptly  without  detriment  to  the  patient.  ^ 

In  contrast  to  cases  of  acute  peritonitis  an  extreme  susceptibility  to  opium 
is  often  observed  in  the  pytemic  variety.  Here  opiates  seem  to  me  rarely 
to  do  good.  They  do  not  hinder  the  migrations  of  the  round  bacteria, 
there  is  rarely  pain  to  relieve,' and  I  have  sometimes  thought  that  their 
adminstration  was  simply  the  addition  of  a  second  poison  to  the  one 
which  already  was  overwhelming  the  nervous  system. 

In  pelvic  peritonitis,  in  the  course  of  forty-eight  hours  plastic  exuda- 
tion is  thrown  out  and  the  pain  to  a  great  extent  subsides.     From  this . 
time  very  moderate  doses  of  opium,  as  a  rule,  are  needed  to  make  the 
patient  comfortable. 

In  France  leeches  applied  to  the  abdomen  are  much  used  as  a  means  ot 
relieving  peritoneal  sensitiveness.  That  they  do  this  is  beyond  question. 

i  The  details  of  this  case  have  been  reported  in  the  Am.  Jour,  of  Obit.,  Oct.,  1880, 
p.  864,  by  Dr.  F.  M.  Welles,  who  conducted  the  administration  of  the  opium. 


1032  PUERPERAL  FEVER. 

Their  disuse  in  this  country  is  due  probably  more  to  popular  prejudice 
than  to  their  inefficacy. 

In  the  beginning  of  an  attack  a  turpentine  stupe  to  the  abdomen  is  a 
source  of  comfort  to  many  women,  while  the  sharp  counter-irritation  exer- 
cises possibly  a  favorable  influence  upon  the  course  of  the  disease.  At  a 
later  period  I  commonly  employ  flannels  wrung  out  in  water  and  covered 
with  oil-silk  to  prevent  speedy  evaporation.  It  is  an  old  experience  that 
in  the  beginning  of  a  puerperal  fever  the  provocation  of  loose  stools  by 
purgatives  is  frequently  followed  by  a  fall  in  the  temperature  and  a  great 
improvement  in  the  patient's  condition.  The  result,  however,  is  far  from 
uniform,  as  in  other  cases  these  artificial  diarrhreas  have  a  tendency  to 
aggravate  the  peritoneal  symptoms.  Owing  to  this  uncertainty  in  their 
action,  purgative  remedies  should  be  administered  with  caution,  not  from 
any  theory  as  to  their  eliminative  powers,  but  because  of  the  ascertained 
existence  of  fecal  accumulation.  In  pelvic  inflammations  castor  oil  in 
two-  or  three-tablespoonful  doses,  or  five  to  ten  grains  of  calomel  rubbed 
up  with  twenty  grains  of  bicarbonate  of  sodium,  as  recommended  by 
Barker,  may  be  given  when  thus  indicated.  After  the  bowels  have  once 
been  freed,  however,  the  purgative  should  not  be  repeated.  In  cases  of 
intense  local  inflammation  and  in  general  peritonitis  enemata  should  alone 
be  employed  for  the  removal  of  constipation. 

Every  increase  of  body-heat  is  associated  with  rapid  tissue-waste,  with 
enfeebled  heart-action  and  with  exhaustion  of  the  nerve-centres.  Since 
the  modern  recognition  of  the  deleterious  effects  of  high  temperatures  per 
se,  antipyretic  remedies  in  place  of  the  old-time  cardiac  sedatives  have 
come  to  play  the  leading  role  in  the  treatment  of  fevers. 

Of  internal  antipyretic  agents  quinia  enjoys  a  deservedly  high  repute. 
In  the  remitting  forms  of  fever  it  may  be  administered  in  five-grain  doses 
at  intervals  of  four  to  six  hours.  Given  thus  in  medium  doses,  it  moder- 
ates the  fever,  diminishes  the  sweating,  and  in  most  patients  lessens  gas- 
tric and  intestinal  disturbances.  In  continued  fevers  it  should,  on  the 
contrary,  be  given  in  a  single  dose  large  enough  to  procure  a  distinct 
remission.  By  making  a  break  in  the  febrile  symptoms,  if  only  of  a  few 
hours'  duration,  a  retardation  of  the  destructive  processes  is  accomplished. 
At  the  first  administration  twenty  to  thirty  grains  may  be  given.  In 
favorable  cases  the  temperature  falls  in  the  course  of  a  few  hours  below 
101°.  When  the  high  temperature  is  only  temporarily  held  in  check,  at 
the  end  of  twenty-four  hours,  if  all  symptoms  of  cinchonism  have  dis- 
appeared, the  same  dose  should  be  repeated.  If  the  doses  mentioned, 
given  in  the  manner  prescribed,  produce  no  perceptible  effect  upon  the 
fever,  their  continuance  may  be  regarded  as  unnecessary. 

C.  Braun  and  Richter  speak  favorably  of  the  action  of  salicylate  of 
sodium.1  It  possesses  antipyretic  properties,  though  in  a  less  degree  than 
quinia.  It  is,  however,  rapidly  absorbed,  circulates  through  all  the 
parenchymatous  organs,  and  finally  is  discharged  unchanged  in  the  urine. 
It  is  said  by  Binz,  in  small  doses,  to  hinder  the  action  of  the  disease- 
producing  ferments,  while  it  leaves  untouched  the  normal  ferments  of  the 
organism.  It  is  of  special  service  where  quiuia  is  not  well  tolerated,  or 
when  given  fifteen  to  twenty  grains  at  a  time  every  four  to  six  hours  as 

1Kichter,  "Ueber  intrauterine  Injectionen,"  etc.,  Zeitschr.  fur  Geburtsk.  und  Gynaek.. 
Bd.  ii.  Heft  1,  p.  146. 


TEE  A  TMEST.  1033 

an  adjuvant  to  large  single  doses  of  quinia.     The  remedy  should  be 
continued  until  all  traces  of  febrile  disturbance  have  disappeared. 

A  more  powerful  remedy  than  salicylic  acid,  where  quinia  has  failed 
is  the  Warburg's  tincture.     Some  patients  find,  however,  that  it  is  some- 
what difficult  to  retain  upon  the  stomach. 

Not  many  years  ago,  owing  to  the  encomiums  of  Fordyce  Barker,1 
the  tincture  of  veratrum  viride  was  in  great  favor  in  puerperal  fever  as 
a  means  of  reducing  the  excited  pulse  of  inflammation.  The  plan  recom- 
mended was  to  administer  five  drops  hourly,  in  conjunction  usually  with 
morphia,  until  the  pulse  was  brought  down  to  70  or  80  beats  to  the  min- 
ute. If  the  pulse  had  once  been  reduced,  then  three,  two,  or  one  drop 
hourly  would  be  found  sufficient  to  control  it.  Vomiting  and  collapse 
from  its  use  were  no  cause  for  alarm,  as  they  were  temporary  symptoms, 
and  were  followed  by  a  fall  of  the  pulse  to  30  or  40  a  minute,  which  was 
rather  of  favorable  prognostic  significance.  In  the  rapid  pulse  of  exhaus- 
tion, however,  veratrum  should  not  be  given.  Since  the  introduction  of 
the  thermometer  into  practice  the  reduction  of  the  pulse  by  veratrum  has 
been  found  to  be  associated  with  a  fall  in  the  temperature  of  the  body. 
Of  late,  however,  veratrum  has  gone  rather  out  of  vogue,  not  because  it 
is  not  a  very  effective  agent,  but  because  its  adminstration  is  an  art  to  be 
acquired,  and  cannot  safely  be  entrusted  to  an  unskilled  assistant.  Then, 
too,  in  the  last  ten  years  there  has  grown  up  a  better  acquaintance  with 
less  dangerous  remedies. 

Braun  recommends  in  severe  cases,  where  quinia  alone  is  without, 
effect,  to  give  in  addition  from  twelve  to  twenty-four  grains  of  digitalis  in 
infusion  per  diem  until  its  specific  action  is  produced.  Unlike  veratrum, 
digitalis  effects  a  permanent  slowing  of  the  heart.  By  prolonging  the 
cardiac  diastole  and  contracting  the  arterioles  it  allows  the  left  ventricle 
to  fill,  restores  the  arterial  tension,  diminishes  correspondingly  the  intra- 
venous pressure,  and  promotes  absorption.  Its  tendency  to  produce  gas- 
tric disturbances  and  the  distrust  felt  as  to  its  safety  have  prevented  its 
becoming  popular  in  practice. 

Alcohol  as  an  adjuvant  to  treatment  is  indicated  in  all  cases,  whether 
quinia  or  salicylic  acid  or  veratrum  be  simultaneously  employed.  It 
stimulates  and  sustains  the  heart,  it  retards  tissue-waste,  and  is  in  itself  an 
antipyretic  of  no  mean  value.-  Usually  I  give  it  in  conjunction  with 
quinia,  one  or  two  teaspoonfuls  hourly  of  either  whiskey,  rum,  or  brandy, 
in  accordance  with  the  recommendation  of  Breisky.2  But  many  years 
before  I  had  learned  from  my  friend  Prof.  Barker  that  the  specific  influ- 
ence of  veratrum  was  in  many  cases  not  obtained  until  the  use  of  alcohol 
was  combined  with  it. 

The  antipyretic  action  of  drugs  is  probably  due  for  the  most  part  to 
some  direct  influence  they  exert  upon  the  oxygenation  of  the  tissues.  Of 
course  the  less  the  fire  the  less  the  heat.  It  is  well,  however,  to  support 
their  internal  administration  by  the  external  employment  of  cold.  Cold 
owes  its  effect  in  fevers  partly  to  the  abstraction  of  heat  from  the  body- 
surface,  and  in  a  still  more  important  degree  to  the  impression  which  it 
produces  upon  the  nervous  system.  In  healthy  persons  the  action  of  cold 
is  to  increase  the  consumption  of  oxygen  and  the  production  of  carbonic 

1  The  Puerperal  Diseases,  p.  347. 

2  Ueber  Alcohol  und  Chinin-behandlung,  Bern,  1875. 


1034  PUERPERAL  FEVER. 

acid.  The  additional  heat  thus  generated  renders  it  possible  to  sustain 
the  vicissitudes  of  climate.  In  fevers  the  primary  effect  of  cold  is  simi- 
lar in  character.  Its  main  therapeutical  action  is  derived  from  its  sec- 
ondary influence  upon  the  nerve-centre  which  regulates  the  body-heat. 
If  the  cold  employed  be  sufficiently  intense  or  sufficently  prolonged,  there 
follows,  not  always  immediately,  but  in  the  course  of  an  hour  or  two,  a 
marked  lowering  of  the  temperature,  which  can  only  be  accounted  for  by 
assuming  an  indirect  influence  exerted  through  the  sympathetic  nerve  and 
the  medulla  oblongata.  This  peculiarity  renders  the  external  application 
of  cold  a  most  valuable  addition  to  the  therapeutical  resources  available 
in  fevers. 

In  cases  of  moderate  severity  frequently  sponging  the  patient  with  cold 
water  will  be  found  to  be  a  grateful  practice.  An  ice-cap  to  the  head, 
where  the  blood  lies  near  the  surface,  will  often  affect  the  entire  temper- 
ature of  the  body.  From  immemorial  times  it  has  been  employed  to 
control  delirium  and  promote  sleep.  An  ice-bag  placed  over  the  inguinal 
region  is  locally  beneficial  to  deep-seated  pelvic  inflammations,  and,  ac- 
cording to  Braun,  is  capable  of  effecting  a  rapid  fall  of  temperature. 
Ice-cold  drinks  should  be  freely  allowed. 

Schroeder  recommends  a  permanent  stream  of  cold  water  in  the  uterine 
cavity  by  means  of  a  large  irrigator  and  a  drainage-tube ;  others  advise 
cold  rectal  injections  maintained  for  long  periods  by  the  aid  of  a  tube 
with  a  double  current. 

In  fevers  of  great  violence  the  systematic  application  of  cold  by  means 
of  baths  or  the  wet  pack  is  capable  in  some  cases  of  rendering  important 
service.  The  temperature  of  the  bath  should  range  from  70°  to  80°.  Its 
duration  should  not  exceed  ten  minutes.  The  patient  should,  when  re- 
moved to  the  bed,  be  wrapped  in  a  sheet  without  drying,  and  should  be 
comfortably  covered.  In  employing  the  wet  pack  two  beds  should  be 
placed  side  by  side.  The  body  and  thighs  of  the  patient  should  be 
wrapped  in  a  sheet  wrung  out  in  cold  water,  and  be  allowed  to  remain  in 
the  pack  from  ten  to  twenty  minutes.  As  the  sheet  becomes  heated  the 
patient  should  be  placed  in  a  fresh  one  upon  the  second  bed,  and  the  trans- 
fers should  be  continued  until  the  desired  fall  of  temperature  is  effected. 
Braun  claims  that  four  packs  are  equivalent  in  action  to  one  full  bath. 

Both  these  methods  are,  however,  open  to  the  objection  that  they  can- 
not be  carried  out  without  considerable  disturbance  of  the  patient — 
a  point  of  no  small  importance  in  cases  of  peritonitis.  G.  B.  Kibbie 
has  invented  a  fever-cot  which  obviates  the  ordinary  difficulties  of  this 
mode  of  treatment.  The  cot  is  covered  with  "  a  strong,  elastic  cotton 
netting,  manufactured  for  the  purpose,  through  which  water  readily 
passes  to  the  bottom  below,  which  is  of  rubber  cloth  so  adjusted  as  to 
convey  it  to  a  vessel  at  the  foot."  T.  G.  Thomas,1  who  has  em- 
ployed this  apparatus  extensively  to  reduce  high  temperatures  after 
ovariotomies,  explains  as  follows  the  modus  operand!:  "Upon  this  cot 
a  folded  blanket  is  laid,  so  as  to  protect  the  patient's  body  from  cutting  by 
the  cords  of  the  netting,  and  at  one  end  is  placed  a  pillow  covered  with 
india-rubber  cloth,  and  a  folded  sheet  is  laid  across  the  middle  of  the  cot 
about  two-thirds  of  its  extent.  Upon  this  the  patient  is  now  laid ;  her 

1  "  The  Most  Effectual  Method  of  Controlling  the  High  Temperature  occurring  after 
Orariotomy,"  JV.  Y.  Med.  Jour.,  August,  1878. 


TREATMENT.  1035 

clothing  is  lifted  up  to  the  armpits,  and  the  body  enveloped  by  the  folded 
sheet,  which  extends  from  the  axillae  to  a  little  below  the  trochanters. 
The  legs  are  covered  by  flannel  drawers  and  the  feet  by  warm  woollen 
stockings,  and  against  the  soles  of  the  latter  bottles  of  warm  water  are 
placed.  Two  blankets  are  then  placed  over  her,  and  the  application  of 
water  is  made.  Turning  the  blankets  down  below  the  pelvis,  the  physi- 
cian now  takes  a  large  pitcher  of  water,  at  from  75°  to  80°,  and  pours  it 
gently  over  the  sheet.  This  it  saturates,  and  then,  percolating  the  net- 
work, it  is  caught  by  the  india-rubber  apron  beneath,  and,  running  down 
the  gutter  formed  by  this,  is  received  in  a  tub  placed  at  its  extremity  for 
that  purpose.  Water  at  higher  or  lower  degrees  of  heat  than  this  may 
be  used.  As  a  rule,  it  is  better  to  begin  with  a  high  temperature,  85°,  or 
even  90°,  and  gradually  diminish  it.  The  patient  now  lies  in  a  thor- 
oughly soaked  sheet,  with  warm  bottles  to  her  feet,  and  is  covered  up 
carefully  with  dry  blankets.  Neither  the  portion  of  the  thorax  above 
the  shoulders  nor  the  inferior  extremities  are  wet  at  all.  The  water  is 
applied  only  to  the  trunk.  The  first  effect  of  the  affusion  is  often  to 
elevate  the  temperature — a  fact  noticed  by  Currie  himself — but  the  next 
affusion,  practised  at  the  end  of  an  hour,  pretty  surely  brings  it  down. 
It  is  better  to  pour  water  at  a  moderate  degree  of  coldness  over  the  sur- 
face for  ten  or  fifteen  minutes  than  to  pour  a  colder  fluid  for  a  shorter 
time.  The  watej*  slowly  poured  robs  the  body  of  heat  more  surely  than 
when  used  in  the  other  way.  The  water  collected  in  the  tub  at  the  foot 
of  the  bed,  having  passed  over  the  body,  is  usually  8°  or  10°  warmer 
than  it  was  when  poured  from  the  pitcher.  On  one  occasion  Dr.  Van 
Vorst,  my  assistant,  tells  me  that  it  had  gained  12°.  At  the  end  of 
every  hour  the  result  of  the  affusion  is  tested  by  the  thermometer,  and 
if  the  temperature  has  not  fallen  another  affusion  is  practised,  and  this 
is  kept  up  until  the  temperature  comes  down  to  100°,  or  even  less.  It 
must  be  appreciated  that  the  patient  lies  constantly  in  a  cold  wet  sheet, 
but  this  never  becomes  a  fomentation,  for  the  reason  that  as  soon  as  it 
abstracts  from  the  body  sufficient  heat  to  do  so  it  is  again  wet  with  cold 
water  and  goes  on  still  with  its  work  of  heat-abstraction.  I  have  kept 
patients  upon  this  cot  enveloped  in  the  wet  sheet  for  two  and  three  weeks, 
without  discomfort  to  them  and  with  the  most  marked  control  over  the 
degree  of  animal  heat.  Ordinarily,  after  the  temperature  has  come 
down  to  99°  or  100°,  four  or  five  hours  will  pass  before  affusion  again 
becomes  necessary." 

Since  reading  this  account,  I  have  made  a  good  many  trials  of  the 
method  upon  puerperal  women,  and  have  not  found  that  it  agrees  with 
all  in  an  equal  degree.  In  some  instances  the  affusions  have  been  fol- 
lowed, in  spite  of  hot  bottles  to  the  feet  and  the  administration  of  stimu- 
lants, by  such'  a  degree  of  depression  and  impairment  of  cardiac  force, 
as  shown  by  the  persistent  coldness  of  the  extremities,  that  it  has  been 
necessary  to  discontinue  them.  On  the  other  hand,  I  can  look  back 
upon  cases,  apparently  so  desperate  that  the  condition  of  the  patients  was 
looked  upon  as  hopeless,  where  they  proved  the  means  of  saving  life  as 
by  a  miracle.  Of  course,  the  difference  depends  upon  whether  the  high 
temperature  is  the  sole  cause  of  the  alarming  symptoms,  or  whether  the 
latter  are  in  part  due  to  blood-dissolution  and  secondary  changes  in  the 
parenchymatous  organs. 


1036  PUERPERAL  FEVER. 

The  use  of  the  coil  in  fever,  whether  of  rubber  or  of  metal  tubing,  I  can 
highly  recommend.  Either  the  night-dress  or  a  towel  should  be  placed 
between  the  coil  and  the  skin.  A  current  of  cold  water  passing  through 
the  tube  rapidly  abstracts  the  surface  heat,  and  is  usually  grateful  to  the 
patient.  The  lowering  of  the  temperature  by  this  means  is  much  slower 
than  by  cold  affusions.  Disturbance  of  the  patient  is,  however,  avoided, 
and  the  method,  so  far  as  I  have  tried  it,  has  been  free  from  the  objec- 
tions incident  to  the  direct  application  of  Avater  to  the  skin. 

It  is  hardly  necessary  to  state  that  in  puerperal,  as  in  other  fevers,  the 
patient's  strength  requires  to  be  sustained  and  the  waste  of  tissue  to  be 
repaired,  as  far  as  possible,  by  the  regulated  administration  of  liquid  food, 
as  milk  and  beef-tea,  in  such  quantities  as  can  be  borne  by  the  stomach, 
and  at  one  to  two  hours'  intervals. 

In  the  treatment  of  encysted  peritoneal  effusions,  and  in  inflammatory 
exudations  into  the  pelvic  and  adjacent  cellular  tissue,  after  the  acute 
symptoms  have  subsided  the  attention  should  be  directed  to  the  afternoon 
fever  and  to  promoting  the  assimilation  of  food.  So  soon  as  the  sweating 
and  fever  are  checked  the  absorption  of  the  plastic  materials  begins.  The 
most  important  agents  for  accomplishing  this  object  are  quiuia,  in  mode- 
rate doses,  combined  with  some  form  of  alcohol  and  with  tepid  sponging. 
Deep-seated  pain  in  the  iliac  region  is  best  relieved  by  a  large  blister  upon 
the  side  over  the  point  where  the  tenderness  is  felt.  Prolonged  rest  in 
bed  should  be  enjoined.  Even  after  convalescence  is  well  advanced,  so 
long  as  the  exudation  remains  unabsorbed  the  resumption  of  household 
duties  is  pretty  certain  to  be  followed  by  a  relapse  or  by  the  development 
of  a  chronic  condition  of  a  most  intractable  description.  The  sooner  the 
patient's  stomach  can  be  got  to  digest  and  absorb  beefsteak  and  iron  the 
more  speedy  will  be  her  recovery. 

In  pelvic  exudations  the  hot  vaginal  douche,  warm  baths,  and  the 
application  of  flannels  wrung  out  in  water  to  the  abdomen  aid  in  dimin- 
ishing the  local  pain,  and,  perhaps,  in  causing  a  disappearance  of  the 
tumor.  The  action  of  mercurials  or  of  iodide"  of  potassium  in  melting 
away  plastic  inflammatory  materials  is  sometimes  very  striking,  but  more 
frequently  they  either  do  no  good  or  else  do  harm  by  disturbing  the 
digestion. 

If  fever,  chills,  and  sweating  announce  the  presence  of  pus,  the  most 
careful  exploration  should  be  made  to  determine,  if  possible,  the  seat 
of  suppuration.  It  is  of  great  advantage  to  treat  pelvic  abscesses  as 
abscesses  are  treated  elsewhere  in  the  body.  If  the  redness  of  the  skin 
above  Poupart's  ligament  indicates  a  tendency  to  point  in  that  direction, 
an  aspirator-needle  should  be  introduced  to  make  sure  of  the  diagnosis. 
If  the  sac  is  near  the  surface,  a  free  incision  should  be  made  and  the  pus 
should  be  allowed  to  escape.  In  many  cases  I  make  these  incisions  three 
to  four  inches  in  length.  The  redness  of  the  external  skin  makes  it  cer- 
tain that  the  abscess  has  become  adherent  to  the  abdominal  wall,  and  that 
the  incision  consequently  will  not  communicate  with  the  peritoneum. 
After  the  abscess  has  been  opened  it  should  be  cleansed  twice  daily,  and 
the  cavity  should  be  filled  with  oakum.  If,  after  a  time,  the  granulations 
become  flabby,  Peruvian  balsam  or  iodoform  should  be  introduced  into  the 
sac  at  each  change  of  the  dressing.  I  can  recommend  this  plan  as  essen- 
tially a  mild  procedure.  With  a  large  opening  for  the  discharge  of 


TREATMENT.  1037 

pus  the  fever  and  sweating  disappear,  the  appetite  returns,  and  the 
abscess  fills  rapidly  by  granulation.  With  a  small  incision  hectic  is 
apt  to  persist,  and  the  abscess  to  end  in  the  formation  of  interminable 
fistulse. 

If  softening  and  bagginess  or  distinct  fluctuation  indicate  that  the 
pus  can  be  reached  through  the  vaginal  cul-de-sac,  the  aspirator-needle 
should  be  inserted  deeply  at  the  suspected  point,  and  if  a  large  amount 
of  pus  is  detected,  an  incision  should  be  made  with  a  long-handled 
bistoury,  using  the  needle  as  a  director,  and  making  the  opening  large 
enough  to  permit  the  introduction  of  a  drainage-tube.  I  prefer  for 
this  purpose  a  self-retaining  Nelaton  catheter,  which  is  easily  passed 
by  means  of  a  uterine  sound  inserted  into  the  eye  at  the  extremity. 
Through  the  tube — without  disturbing  the  patient — the  pus-cavity  can 
be  washed  as  frequently  as  required,  and  with  drainage  and  cleanliness 
cases  of  the  longest  standing  may  be  expected  to  recover. 

P.  F.  Munde1  has  reported  a  number  of  cases  of  chronic  character 
where  the  aspiration  of  pus  has  been  followed  by  rapid  absorption  of  the 
intra-pelvic  exudation.  The  presence  of  pus  was  suspected  because  of  a 
boggy,  doughy  feeling  in  the  exudation  tumor. 

1  "  Diagnosis  and  Treatment  of  Obscure  Pelvic  Abscess,"  etc.,  Arch,  of  Med.,  December, 
1880. 


BERIBERI. 

BY  DUANE  B.  SIMMOXS,  M.  D. 


DEFINITION. — Beriberi  is  a  disease  of  inanition,  most  common  in 
tropical  countries,  though  found  in  high  latitudes  (41°  N.),  especially  in 
low-lying  seaboard  towns,  during  the  summer  months,  and  is  both 
endemic  and  epidemic.  It  is  usually  chronic  in  form,  but  is  subject  to 
exacerbations  of  varying  degrees,  and  has  for  its  characteristic  symptoms 
anaesthesia  of  the  skin,  hyperresthesia  and  paralysis  of  the  muscles, 
anasarca,  palpitation,  cardiac  and  arterial  murmurs  (in  the  wet  form), 
praecordial  oppression,  and  abdominal  pulsation. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — It  was  for  a  long 
time  confounded  with  a  great  variety  of  other  diseases.  The  Anglo- 
Indian  physicians  of  Ceylon  and  the  Malabar  coast  were  no  doubt  the 
first  to  recognize  the  specific  nature  of  the  disease,  though  it  is  claimed 
that  Chinese  medical  works  of  the  thirteenth  century  contain  a  fairly 
accurate  description  of  it. 

The  literature  of  beriberi,  at  the  first  glance,  appears  to  be  very 
meagre,  as  some  of  the  most  popular  medical  works  make  no  mention  of 
the  disease  at  all,  while  others  only  give  it  a  passing  notice.  Its  bibli- 
ography, however,  is  very  considerable,  as  may  be  seen  in  the  exhaustive 
list  in  Billings'  .Index  Catalogue,  but  for  want  of  space  we  refer  only 
to  the  most  recent  contributions  to  the  subject.  These  are — an  article 
by  A.  LeRoy  dc  Mericourt;1  an  essay  by  Tarissau,  entitled  Beriberi  in 
Brazil ;  an  article  by  Anderson,2  and  an  essay  by  myself.3 

For  a  long  time  beriberi  was  supposed  to  have  a  peculiar  territorial 
limitation.  It  is  now  known  to  be  more  or  less  prevalent  on  all  the 
islands  and  shores  of  Eastern  Asia  and  Africa  from  Japan  to  the  Cape  of 
Good  Hope,  and  in  Brazil. 

ETIOLOGY. — I  know  of  no  disease  in  regard  to  which  a  greater  diver- 
sity of  opinion  exists  as  to  its  cause.  Indeed,  as  one  has  observed, 
"  autant  d'auteurs,  autant  d'opinions  diverses."  Ten  years'  study  and 
observation  of  the  malady  under  a  great  variety  of  circumstances  and 
conditions  have  led  me  to  the  definite  conclusion  that  its  exciting  cause  is 
a  specific  poison  or  germ,  having  many  striking  resemblances  in  its  mode 
of  production  to  paludal  or  marsh  miasm,  though  entirely  distinct  and 
separate  from  it.  A  great  variety  of  predisposing  causes,  however,  exert 
a  powerful  influence  in  rendering  individuals  or  classes  susceptible  to  the 

1  Dictionnaire  Encyclopedique  des  Sciences  Medicales,  Paris,  1876. 

*  Guy's  Hospital  Reports.  3  Chinese  Maritime  Customs  Medical  Report  (1880). 

1038 


CLINICAL  HISTORY  AND  SYMPTOMS.  1039 

disease,  such  as  age,  sex,1  occupation,  race,  mode  of  life,  diet,  and  cli- 
mate. 

_  CLINICAL  HISTORY  AND  SYMPTOMS. — There  are  three  forms  of  the 
disease  :  1st.  Beriberi  hydrops  (wet  beriberi),  in  which  there  is  a  hydne- 
mic  condition  of  the  blood,  distension  of  the  general  areolar  tissue,  with 
serum,  and  effusion  into  the  serous  cavities.  2d.  Beriberi  atrophia  (dry 
or  atrophic  beriberi),  in  which  there  is  a  notable  deficiency  of  fluids  in 
the  vessels  and  areolar  tissue,  and  atrophy  of  the  muscles.  3d.  Mixed 
beriberi,  in  which  the  above  forms  lose  the  sharp  lines  of  distinction  and 
merge  into  each  other.  Cases  complicated  with  dysentery,  diarrhoea,  and 
especially  with  continued  fevers  of  the  typhoid  type,  are  not  uncommon.2 
These  last,  besides  being  of  grave  prognosis,  are  frequently  very  embar- 
rassing and  difficult  of  diagnosis. 

In  general  terms,  wet  beriberi  may  be  divided  into  two  stages — 
the  prodromic  stage  and  the  stage  of  attack ;  and  into  several  types — the 
acute  or  pernicious,  and  the  chronic.  From  the  very  insidious  nature  of 
the  approach  of  the  disease,  sometimes  extending  over  a  period  of  several 
weeks,  it  is  often  very  difficult,  or  even  impossible,  to  determine  the 
exact  time  of  its  invasion.  It  is  generally  admitted  that  a  residence  of 
some  weeks  in  an  infected  locality  is  necessary  before  any  decided  symp- 
toms make  their  appearance.  As  in  many  other  diseases  of  slow  develop- 
ment, the  symptoms  of  the  prodromic  stage  are  certain  not  easily  defined 
feelings  of  indisposition,  such  as  an  occasional  sense  of  chilliness,  inapt- 
itude for  mental  exertion,  and  especially  a  tired  feeling  in  the  lower 
extremities.  A  period  of  uncertain  length  now  intervenes,  during  which 
the  characteristic  symptoms  appear  and  constitute  the  stage  of  attack. 
The  first  of  these  symptoms  is,  generally,  anaesthesia  of  the  skin  over  the 
anterior  tibial  muscles,  in  the  tips  of  the  fingers,  and  around  the  mouth, 
in  the  order  given.  Paralysis  in  varying  degrees  next  declares  itself  in 
certain  groups  of  muscles,  usually  those  immediately  underlying  the 
regions  of  anaesthesia.  One  of  the  consequences  of  this  is  a  drooping 
of  the  toes,  causing  the  patient  while  walking  to  lift  the  feet  high  so  as 
to  clear  the  ground,  thus  occasioning  the  peculiar  gait  noticed  by  many 
observers  as  characteristic  of  the  disease.  A  sense  of  constriction  in  the 
muscles  of  the  calves  is  experienced  at  the  same  time,  arising  from  a  veri- 
table contraction,  which  causes  their  apparent  enlargement  and  hardening, 
with  tension  of  the  tendo  achillis.  A  feeling  of  tightness  in  the  chest 
usually  accompanies  this  condition,  due,  no  doubt,  to  partial  paralysis  of 
the  muscles  of  respiration.  If  firm  pressure  be  now  made  upon  the 
muscles  in  various  parts  of  the  body,  a  greater  or  less  degree  of  tender- 
ness will  be  found  to  exist  in  many  of  them,  and  especially  those  occupy- 
ing the  posterior  part  of  the  leg,  back  of  the  forearm,  inside  of  the  arm, 
and  upper  part  of  the  chest.  Tenderness  of  the  periosteum  of  the  long 
bones  and  a  peculiar  roughness  of  their  surfaces  often  exist  also.  _  Pal- 
pitation of  the  heart,  especially  on  making  any  considerable  exertion,  is 
a  frequent  and  often  troublesome  symptom,  even  at  this  stage  of  the 
disease. 

Up  to  this  point  the  above  symptoms  are  common  to  both  the  wet  and 

1  Women  suffer  from  the  disease  much  less  frequently  than  men. 

2  Some   authors  have  designated   fatty  or  convulsive  forms  of  the  disease,  which   J 
think  unnecessary. 


1040  BERIBERI. 

dry  forms  of  the  malady,  and  to  them  the  characteristic  features  either  of 
beriberi  hydrops  or  atrophia  are  now  added.  The  first  manifestation  of 
anasarca,  the  pathognomonic  symptom  of  wet  beriberi,  is  in  an  cedematous 
condition  of  the  areolar  tissue  of  the  anterior  part  of  the  legs.  This,  in 
reality,  is  more  or  less  general  even  at  an  early  stage  of  the  disease,  as  is 
evident  from  the  plump  appearance  of  the  patient  and  a  certain  sallow- 
white  color  of  the  skin,  especially  of  that  of  the  face.  In  uncomplicated 
cases  the  temperature  is  normal,  or  it  may  be  at  times  a  little  below  the 
normal  point.  There  is  also  little  or  no  increase  in  the  frequency  of  the 
pulse.  Its  quality,  however,  is  changed,  and  somewhat  characteristic  for 
both  forms  of  the  disease.  Thus  in  the  wet  form  it  is  full,  large,  and 
easily  compressible,  indicating  a  great  diminution  of  arterial  tone,  while 
in  the  dry  form  there  is  nearly  an  opposite  condition.  If  the  heart  be 
now  examined,  a  decided  systolic  murmur  will  be  heard,  most  distinctly 
over  the  pulmonary  valves ;  and  in  most  cases  of  wet  beriberi  it  exists 
in  all  the  large  arterial  trunks.  The  heart  furnishes  the  usual  signs  of 
dilatation  and  want  of  tone.  In  the  dry  form  the  cardiac  murmurs  are 
either  slight  or  wanting  altogether,  and  the  area  of  cardiac  duluess  is 
variable,  and  frequently  diminishes  as  the  disease  advances. 

In  both  wet  and  dry  beriberi  the  appetite  is  little  impaired  in  the 
earlier  stages,  but  if  in  the  former  the  stomach  is  over-distended,  there 
is  increased  prsecordial  oppression,  and  sometimes  sudden  death.  The 
bowels  in  the  wet  form  are  sluggish,  and  urine  scanty ;  in  the  other  there 
is  but  little  deviation  from  the  normal  in  these  respects. 

The  cases  of  the  subacute  type  nre  by  far  the  most  numerous.  From 
this  it  is  evident  that  the  acute  or  pernicious  type  of  the  malady  is,  in 
most  cases,  only  an  exaggeration  of  the  subacute,  as  observed  in  some 
other  diseases,  notably  rheumatism  and  those  of  marsh  malarial  origin. 
The  term  pernicious  is,  strictly  epeaking,  applicable  to  the  wet  form  of 
the  disease  only,  as  the  dry  form  is  rarely,  if  ever,  rapidly  fatal.  A 
marked  case  of  wet  beriberi  is  always  to  be  regarded  as  dangerous,  from 
the  suddenness  with  which  pernicious  symptoms  often  declare  themselves. 
In  these  the  anasarca  (which,  as  has  been  stated,  constitutes  the  leading 
clinical  difference  between  the  two  forms  of  the  malady)  plays  an  import- 
ant role.  It  often  happens  that  in  the  course  of  a  few  hours  the  local 
osdema  in  the  extremities  and  the  slight  puffiness  of  the  face  become  general 
and  extreme,  and  the  neck  is  enormously  swollen  by  the  distension  of  the 
veins,  both  deep  and  superficial.  The  pleural  and  pericardial  sacs  are 
more  or  less  distended  vrith  serum,  thus  mechanically  embarrassing  the 
action  of  the  organs  they  contain.  The  action  of  the  heart  now  becomes 
laborious,  the  lungs  cedematous  and  filled  with  coarse  rales,  and  a  terrible 
sense  of  suffocation  comes  over  the  patient,  causing  him  to  seek  relief  by 
constant  change  of  position.  The  stomach  is  irritable,  a  greenish-yellow 
fluid  is  vomited,  and  death  closes  the  scene.  The  acute  stage  of  dry  beri- 
beri, on  the  contrary,  is  characterized  by  a  rapid  diminution  of  the  fluids 
of  the  body  and  muscular  atrophy. 

The  annual  appearance  in  the  same  individual  of  either  wet  or  dry 
beriberi,  and  its  long  continuance,  constitute  the  chronic  type  of  the 
disease. 

MORBID  ANATOMY. — The  morbid  anatomical  changes  in  beriberi  vary 
considerably  with  its  form.  Few,  if  any,  observers  claim  seriously  to 


MORBID  ANATOMY.  1041 

have  found  in  either  the  wet  or  dry  form  of  the  disease  evidences  of  acute 
inflammatory  action  in  any  of  the  tissues  or  organs.  The  blood  un- 
doubtedly undergoes  important  morbid  changes,  whereby  its  nutritive  and 
oxygenating  power  is  impaired,  indicating  that  this  is  a  disease  of  inan- 
Ilns  shows  itself  most  markedly  in  necrobiotic  and  degenerative 
changes,  especially  in  the  muscular  tissues,  which  are  the  seat  of  the 
leading  morbid  phenomena  in  all  stages  of  both  forms  of  this  disease 
I  he  respiratory,  digestive,  and  glandular  systems  rarely  undergo  morbid 
changes  other  than  those  of  a  secondary  or  passive  kind,  such  as  eno-oree- 
meut  with  serum  and  venous  blood. 

^  The  condition  of  the  organs  contained  in  the  cranial  and  spinal  cavities 
is  variable  and  inconstant.  According  to  some  observers,  the  substance 
of  the  brain  and  spinal  cord  is  hardened.  The  greater  number  by  far, 
however,  have  found  it  more  or  less  softened.1  The  heart  in  wet  beriberi 
is  habitually  large  and  flabby,  its  muscular  tissue  softened  and  of  a  pale- 
yellow  and  macerated  appearance.  Its  cavities  are  engorged  with  dark 
blood,  sometimes  fluid,  but  more  often  clotted.  These  clots  are  often 
voluminous  in  the  right  heart,  semi-fibrinous,  and  extend  into  the  pul- 
monary artery  and  great  venous  trunks,  which  are  enormously  enlarged. 
The  cardiac  muscular  tissue  I  always  found  to  have  undergone  metamorphic 
changes,  varying  from  granular  clouding  to  advanced  fatty  degeneration.2 
The  tissue  of  the  paralyzed  voluntary  muscles  undergoes  degenerative 
changes  in  both  forms  of  the  disease.  In  the  extreme  atrophy  of  dry 
beriberi  I  have  not  unfrequently  found  many  of  the  sarcolemma  sheaths 
completely  emptied  of  their  contents.  The  power  of  regeneration  in 
these  cases  is  often  wonderfully  displayed  by  an  almost  complete  restor- 
ation of  the  lost  elements,  and,  in  a  corresponding  degree,  of  the  function 
of  the  part. 

It  ^  would  appear  that  in  wet  beriberi  the  heart  is  first  weakened  by 
paresis  of  the  cardiac  ganglia,  with  consequent  incomplete  emptying  of  its 
cavities.  This,  in  connection  with  rapid  degenerative  changes  in  its  muscu- 
lar tissue,  causes  the  walls  to  yield  to  the  blood-pressure,  producing  dilata- 
tion and  tricuspid  insufficiency,  with  regurgitation  and  consequent  capil- 
lary stasis  and  dropsy.  Vaso-motor  nerve-paralysis,  acting  at  the  same 
time  on  the  pulmonary  artery  and  arterioles,  and  on  other  large  arterial 
trunks,  probably  gives  rise  to  the  murmurs  heard  in  them.  In  the  dry 
form  of  the  disease  the  vaso-motor  nerve-paralysis  is  less  pronounced, 
and  the  degenerative  changes  in  the  muscular  tissue  of  the  heart  slower, 
while  the  marked  decrease  in  the  fluids  of  the  system  and  the  great  fail- 
ure of  nutrition  tend  toward  atrophic  changes.  From  this  it  follows 
that  we  usually  have,  instead  of  a  large  dilated  heart,  a  small  weak  one, 
with  a  narrow  tricuspid  orifice  instead  of  a  dilated  one  ;  little  or  no  inter- 

1  The  former  condition  was  undoubtedly  observed  in  autopsies  made  of  the  dry  or  atro- 
phic form  of  the  disease,  though  this  fact  is  not  mentioned.  The  latter,  or  softened, 
condition  of  the  cerebro-spinal  contents  belongs  to  the  wet  form  of  the  disease  (my  own 
cases  being  of  this  kind).  I  regard  this  softening  as  not  ante-mortem,  but  as  consecutive 
to  serous  imbibition  (as  observed  by  Eismann  and  Sanders  in  chlorosis),  and  as  taking 
place  during  the  last  moments  of  life  or  after  death,  when  the  vital  forces  no  longer  oppose 
themselves  to  the  mechanical  disintegrating  power  of  the  fluid  with  which  the  nervous  as 
well  as  all  the  other  tissues  of  the  body  are  engorged. 

2 1  believe  this  to  be  the  condition  of  the  heart-muscle  in  all  cases  of  death  from  the 
wet  form  of  beriberi.  In  this  opinion  I  am  supported  by  Oudenhoven  and  many  of  the 
Dutch  observers. 


VOL.  I.— 6 


1042  EEEIBEEL 

costal  pulsation,  arid  hence  less  cardiac  dulness ;  no  venous  distension  or 
capillary  stasis,  and  hence  no  dropsy. 

PROGNOSIS. — In  temperate  climates  the  prognosis  of  uncomplicated 
beriberi  is  favorable  in  a  majority  of  cases.  In  seasons  of  its  epidemic 
prevalence,  however,  all  cases  of  the  wet  form  of  the  disease  must  be 
carefully  watched,  as  it  not  uiifrcquently  happens  that  grave  symptoms 
suddenly  appear  at  a  time  when  no  danger  has  been  anticipated.  An  un- 
favorable prognosis  may  be  ventured  -when,  in  a  case  of  wet  beriberi,  relief 
is  not  obtained  by  free  purging  or  when  vomiting  sets  in.  In  dry  beri- 
beri the  termination  in  death  is  exceedingly  rare  as  a  direct  result  of 
the  action  of  the  poison  producing  the  disease,  so  that  when  death  does 
occur  it  is  chiefly  from  exhaustion.  The  time  of  recovery  depends  on 
the  amount  of  muscular  degeneration,  and  also  upon  the  season  of  the 
year  when  the  attack  occurred,  as  all  cases  of  both  forms  of  beriberi 
usually  get  well  without  treatment  during  the  winter  mouths. 

TREATMENT. — The  well-established  fact  of  the  influence  of  certain 
localities  in  the  production  of  beriberi  makes  the  removal  of  the 
patient  from  them  a  hygienic  measure  of  great  importance,  and  this  is 
frequently  the  only  treatment  necessary  if  it  can  be  done  early.  The 
effect  of  the  change  is  often  almost  magical,  especially  if  it  be  made  to 
an  elevated  locality  and  among  the  mountains. 

Diet  is  an  important  element  in  the  treatment  of  beriberi.  At  the  head 
of  the  list  of  foods  to  be  avoided  is  rice.  Coarsely  prepared  grains,  such 
as  wheat,  barley,  certain  kinds  of  beans,1  apparently  because  of  more  or 
less  laxative  properties,  are  preferable  as  articles  of  food. 

No  drug  has  been  discovered  possessing  specific  properties  in  this  dis- 
ease. In  the  wet  form,  medication  consists  in  the  administration  of  drugs 
calculated  to  draw  off  the  excess  of  serum  in  the  areolar  tissues  and  in 
the  serous  sacs.  First  in  point  of  efficacy  for  this  purpose  are  the 
hydragogue  cathartics.  In  my  own  practice  the  sulphate  of  magnesia, 
in  large  and  repeated  doses,  has  given  the  best  results;  elaterium,  a 
powder  of  jalap,  squill,  and  digitalis,  and,  in  fact,  any  medicine  which 
will  give  frequent  and  copious  stools,  are  sure  to  afford  marked  relief  to 
the  more  urgent  symptoms,  and  in  many  cases  will  alone  effect  a  cure. 
Care  must  be  taken,  however,  not  to  exhaust  the  patient,  though  I  have 
never  seen  the  judicious  use  of  this  method  of  treatment  do  harm. 

Copious  bleeding  is  recommended  by  Anderson,  especially  in  the  stage 
of  greatest  danger,  but  I  have  never  been  able  to  convince  myself  of  its 
safety. 

The  almost  specific  virtue  claimed  by  the  old  Indian  physicians  for 
treeak  farook  is  no  doubt  due  to  its  cathartic  properties. 

Diuretics  are  indicated  for  the  same  reason  as  cathartics,  and  any  of 
the  more  active  are  productive  of  good  results.  They  are  too  slow  in 
their  action,  however,  to  be  relied  on  otherwise  than  as  adjuvants  to 
cathartics.  I  have  found  juniper  gin  to  answer  an  excellent  purpose, 
both  as  a  stimulant  and  diuretic,  where  there  was  danger  of  exhaustion 
from  the  free  use  of  cathartics. 

The  medical  treatment  of  dry  beriberi  differs  materially  from  that  of 

1  A  small  red  bean  called  adzuke,  possessing  both  laxative  and  diuretic  properties,  is  a 
favorite  remedy  with  the  Japanese  for  beriberi.  It  is  used  alone  or  mixed  with  rice,  and 
is  not  unfrequently  the  only  means  resorted  to  for  the  successful  cure  of  mild  cases. 


TREATMENT.  1043 

the  wet  disease.  Cathartics  and  diuretics  are  alike  useless,  and  the  for- 
mer injurious.  The  ordinary  means,  such  as  electricity,  strychnia,  fric- 
tions, etc.,  employed  in  cases  of  muscular  atrophy  and  paralysis  from  other 
causes,  are  indicated  when  the  active  stage  has  passed,  but  they  are  use- 
less, and  even  injurious,  before  this  time.  The  muscular  hyperaesthesia 
common  to  both  forms  of  the  disease  may  be  generally  greatly  relieved 
by  anodyne  liniments  containing  aconite.  The  internal  use  of  the  latter 
is  highly  recommended  by  some.  Hypodermic  injections  of  morphia 
afford  relief  to  the  painful  sense  of  constriction  in  the  calves  of  the  legs 
so  often  complained  of. 


INDEX  TO  VOLUME  I. 


A. 

Abdomen,  state  of,  in  cholera,  741 

in    general    peritonitis   of  puerperal 

fever,  1010 

in  relapsing  fever,  390 
in  septicaemia,  977 
in  septicaemia  lymphatica,  1011 
in  septicaemia  venosa,  1012 
Abdominal  cavity,  lesions  of,  in  general  peri- 
tonitis of  puerperal  fever,  989 
glands,  lesions  of,  in  typhoid  fever,  264 
organs,  alterations  of,  in  scarlet  fever,  531 
Abortion  from  septicaemia,  972 
Abortive  form  of  the  plague,  777 
of  relapsing  fever,  395 
of  typhoid  fever,  298 
of  typhus  fever,  354 

Abortive  treatment  of  erysipelas,  value,  638 
Abscess  in  symptomatic   parotitis,  date  of 

pointing,  627 

metastatic,  of  lungs,  complicating  relaps- 
ing fever,  404 
Abscesses  complicating  cholera,  735 

variola,  445 

following  the  plague,  781 
frequency  of,  in  pyaemia,  976 
in  erysipelas,  treatment,  638 
in  para-  and  perimetritis,  1008 
in  puerperal  fever,  989 
metastatic,  of  pyaemia,  modes  of  produc- 
tion, 963 

of  pyaemia,  treatment,  981 
pelvic,  of  puerperal  fever,  treatment,  1036 
pulmonary,  in  puerperal  fever,  989 
Acids,  mineral,  use  of,  in  cholera,  768 
Aconite,  use  of,  in  rubeola,  580 
in  scarlet  fever,  543 
in  yellow  fever,  651 

Acute  diseases,  relation  of,  to  rubeola,  561 
form  of  glanders  in  man,  920 

in  horse,  914 
Adenitis  complicating  scarlet  fever,  511 

vaccination,  468 

Adenopathy  complicating  erysipelas,  634 
Adhesions  from  infiltration,  55 
Adulteration  of  food,  197 
Adynamic  form  of  typhus  fever,  354 
Age,  influence  of,  on  causation  of  anthrax 

in  man,  940 

of  cerebro-spinal  meningitis,  802 
of  diphtheria,  680 


Age,  influence  of,  on  causation  of  erysipelas 

630 

of  influenza,  860 
of  idiopathic  parotitis,  620 
of  the  plague,  775 
of  pertussis,  830 
of  relapsing  fever,  371 
of  rotheln,  583 
of  rubeola,  561 
of  typhoid  fever,  242 
of  typhus  fever,  342 
proper  for  vaccination,  477 
Aged,  typhoid  fever  in  the,  301 
Agminated  glands,  lesions  of,  in  cholera,  745 
Air,  amount  supplied  in  ventilation,  179 
carbonic  acid  as  a  cause  of  impurity,  177 
-currents,  direction  of,  test,  178 
distribution  of,  in  ventilation,  180 
estimation  of  carbonic  acid,  178 
fresh,  value  of,  in  convalescence,  20fi 
humidity  of,  as  a  cause  of  disease,  133 
impure,  as  a  cause  of  disease,  177 

influence  of,  on  causation  of  glanders, 

912 
impurities  of,  due  to  offensive  effluvia, 

181 

sources  of  impurity,  177 
standards  of  impurity,  178 
transmission  of  the  plague  by,  776 
velocity  of,  in  ventilation,  180 
vitiated,  as  a  cause  of  pyaemia,  9o9 
supply,  method  of  calculating  amount  of, 

in  ventilation,  179 
Albuminoid  infiltration,  72 
Albuminuria  complicating  diphtheria,  674 
relapsing  fever,  407 
scarlet  fever,  525 
typhus  fever,  355 
following  rubeola,  574 
in  typhoid  fever,  treatment,  334 
Alcohol,  use  of,  in  algid  form  of  pernicious 

malarial  fever,  608 
in  anthrax,  938,  944 
in  cerebro-spinal  meningitis,  831 
in  cholera,  767 
in  influenza,  876 
in  puerperal  fever,  1033 
in  pyaemia,  982 
in  scarlet  fever,  544 
in  typhoid  fever,  324 
in  typhus  fever,  366 

Algid  form  of  pernicious  malarial  fever,  606 
1045 


1046 


INDEX. 


Algid  causes  of  death,  G07 
frequency,  607 

mortality-rate,  607 
symptoms,  606 
treatment,  607 

Alum,  use  of,  in  pertussis,  845 
Ammonium  bromide,  use  of,  in  pertussis,  846 
carbonate,  use  of,  in  scarlet  fever,  544 
chloride,  use  of,  in  diphtheria,  704,  705 
Amyloid  bodies,  86 
degeneration,  84 
Anaesthesia  of  skin  in  beriberi,  1039 

significance  of,  in  general  diagnosis,  165 
Anesthetic  form  of  leprosy,  791  > 
Analysis  of  urine,  importance  of,  in  general 

diagnosis,  165 
Anasarca,  69 

complicating  scarlet  fever,  529 
date  of  appearance  in  scarlet  fever,  529 
in  beriberi,  1040 
Anginose  form  of  anthrax,  941 

,of  scarlet  fever,  510 

Animals,  cerebro-sninal  meningitis  in,  804 
diphtheria  in,  68'3 

transmission  of  diphtheria  from,  683 
Animal  vaccine,  advantages,  475 
Anodyne  liniments,  use  of,  in  beriberi,  1043 
Anorexia  in  relapsing  fever,  389 
in  typhoid  fever,  285 
in  typhus  fever,  350 

significance  of,  in  general  diagnosis,  162 
ANTHRAX,  OR  MALIGNANT  PUSTULE,  926 
Synonyms,  926 
Definition,  926 
History,  926 

Geographical  distribution,  926 
Etiology — specific  origin,  928 
Modes  of  transmission,  928 
Transmission  from  eating  flesh  of  an- 
thrax animals,  928 
by  milk,  929 
by  insects,  929 
by  alkaline  soils,  929 
Season,  relation  of,  to  causation,  931 
Plethora,  relation  of,  to  causation,  981 
Sex,  relation  of,  to  causation,  931 
Age,  relation  of,  to  causation,  931 
Bacillus,  931 

relation  to  causation,  931 

physical  characters,  932 

eflect  of  heat  and  cold  on  activity, 

933 

effect  of  oxygen  on  activity,  933 
mode  of  entering  body,  933 
effect  on  blood-vessels,  934 
Forms,  934 
Symptoms — Incubation  period,  934 

duration  of,  934 
Apoplectiform  form,  934 
Anthrax  fever,  934 
Localized  external  anthrax,  935 
Character  and  seat  of  lesions,  935 
Morbid  anatomy — changes  in  blood,  935 
Spleen,  935 
Lymphatic  glands,  935 
Connective  tissue  and  muscles,  935 
Gastro-inteetinal  tract,  936 


ANTHRAX — Morbid  anatomy  of  vagina  and 

uterus,  936 

Liver  and  kidneys,  936 
Diagnosis — from    other    bacteridian    dis- 
eases, 936 
Swine  plague,  936 
Prognosis,  936 
Mortality,  936 
Treatment,  937 
Preventive,  936 
Drainage  of  anthrax  soil,  937 
Disinfection  of  stables,  etc.,  937 
Disposal  of  carcases  of  sick  animals, 

937 

Isolation,  937 
Bv  inoculation,  937 
Methods  of,  937 
Pasteur's  method,  937 
Dangers  in,  938 
General,  alcohol,  938 
Use  of  carbolic  acid,  938 
nitro-muriatic  acid,  938 
potassium  iodide,  hypodermical- 

ly,  938 
quinia  sulphate,  hypodermical 

ly,  938 
Local,  938 
Cauterization,  938 
Incision  of  nodule,  938 
Anthrax  or  Malignant  Pustule  in  Man,  939 
Svnonyms,  939 
Ilistory,  939 
Etiology,  939 

Origin  from  lower  animals,  939 
Modes  of  infection,  939 
direct,  939 

by  handling  sick  animals,  939 
by  insect-bites,  etc.,  939 
by  food,  939 
by  blood,  939 
by  air,  939 
Occupation,   relation   of,   to  causation, 

939 
Age  and  sex,  relation  of,  to  causation, 

940 
Relative    susceptibility    of    man    and 

animals,  940 
Forms,  940 

Symptoms — of  incubation  period,  940 
Local  lesions,  940 
Temperature,  940 
Relation  of,  to  local  lesions,  940 
Malignant  anthrax,  940 
Symptoms,  940 
local,  940,  941 
general,  941 

Anthrax  intestinalis,  941 
Symptoms,  941 
general,  941 
eruptions,  941 
gastro-intestinal  tract,  941 
nervous  system,  941 
Duration,  941 
Anthrax  angina,  941 
Symptoms,  941 
general,  941 
local,  941 


INDEX. 


1047 


Anthrax — Duration  of  anthrax  angina,  940 
Morbid  anatomy,  941 
Changes  in  blood,  942 
Spleen,  942 

Lymphatic  glands,  942 
Liver  and  kidneys,  942 
Skin  and  mucous  membranes,  942 
Appearance  of  pustule,  942 
Position  of  bacillus,  942 
Diagnosis — signs,  pathognomonic  of,  942 
From  bites  of  insects,  942 
Boils  and  carbuncles,  942 
Plague-boil,  942 
Glanderous  nodule,  942 
Importance  of  detection  of  bacillus,  942 

Of  malignant  anthrax  oedema,  942 
Internal  anthrax,  943 
Prognosis,  943 
Mortality,  943 
Treatment — Preventive,  943 
Disinfection,  943 
Local,  943 
Cauterization  of  preliminary  papule  in 

external  form,  943 
Method  of  cauterization,  943 
Excision  of  parent  nucleus,  943 
Caustics  used  in,  943 
Hypodermic  injections    into  swelling, 

943 

Constitutional,  944 
Carbolic  acid,  use  of,  944 
Alcohol,  use  of,  944  . 
Diet,  944 

Of  anthrax  oedema,  944 
Antipyretics,  use  of,  in  relapsing  fever,  428 
Antipyretics,  use  of,  in  cerebro-spinal  men- 
ingitis, 833 
Antisepsis  in  septicaemia,  983 

value  of,  iu  prevention  of  puerperal  fever, 

1024 

Antiseptic  treatment  of  scarlet  fever,  545 
Antiseptics,  use  of,  in  cholera,  770 
in  glanders  in  man,  924 
in  pyaemia,  980 

Aphasia  in  cerebro-spinal  meningitis,  810 
Apoplectic  form  of  anthrax  in  animals,  934 
Appetite  in  cerebro-spinal  meningitis,  814 
as  a  guide  to  necessary  amount  of  food, 

195 
loss  of,  significance,  in  general  diagnosis, 

162 

Arcus  senilis,  significance,  in  general  diag- 
nosis, 151 
Argyria,  93 

Arsenic,  use  of,  in  relapsing  fever,  427 
Arsenical   poison   as  cause  of  obscure  dis- 
eases, 193 
Arterial  emboli,  63 

murmur  in  beriberi,  1040 
thrombosis  following  typhoid  fever,  293 
Arteritis  from  thrombosis,  61 

in  pyaemia,  967 
Articular  enlargement,  significance  of,   in 

general  diagnosis,  160 
Artificial  alimentation  in  diphtheria,  713 
Asthenic  form  of  simple  continued   fever, 
233 


Asthenic  form  of  inflammation,  46 
Ataxic  form  of  typhus  fever,  354 
Ataxo-adynamic  form  of  typhus  fever,  354 
Atmosphere,  impure,  influence  of,  on  causa- 
tion of  puerperal  fever,  1013,  1014 
necessity  of,  for  prevention  of  pyaemia 

and  septicaemia,  980 

Atmospheric  variations  as  a  cause  of  diph- 
theria, 682 
Atrophy   following   diphtheritic    paralysis, 

676 

Atropia,  use  of,  in  relapsing  fever,  429 
Auditory  nerve,  lesion  of,  in  cerebro-spinal 
meningitis,  824 

B. 

Bacillus  of  anthrax,  characters  of,  931,  932 

mode  of  entering  body,  933 
of  glanders,  914 
of   pearly    distemper,    innocuousness  of, 

from  cooking,  105 
species  of,  142 
tuberculosis,  99  et  seq. 
description,  100 
duration  of  effects,  104 
cultivation,  100 
local   and  general  effects  of  invasion, 

103 

methods  of  detection,  102 
milk  as  a  means  of  dissemination,  105 
mode  of  entrance  into  intestinal  canal, 

104 

into  respiratory  organs,  104 
typhosus,  258 
Bacteria  in  healthy  bodies,  144 

influence  of,  on  causation  of  pyaemia,  958 
liability  to  error,  from  minuteness,  143 
of  cholera,  748 
of  leprosy,  791 
of  puerperal  fever,  995 
Bacterium  termo  as  a  cause  of  putrefaction, 

142 
Barometric  variations,  influence  of,  on  course 

and  causation  of  disease,  134 
Bartholini's  glands,  suppuration  of,  compli- 
cating typhoid  fever,  296 
Baths,  cold,  use  of,  in  puerperal  fever,  1034 

in  relapsing  fever,  428 
warm,  use  of,  in  hydrophobia,  907 

in  variola,  453 

Bed-linen,  as  a  means  of  disseminating  ty- 
phoid fever,  253 

Bed-sores,  complicating  relapsing  fever,  400 
typhoid  fever,  297 
typhus  fever,  355 
in  typhoid  fever,  treatment  of,  335 
Belladonna    as  a    prophylactic   in  scarlet 

fever,  536 
use  of,  in  cerebro-spinal  meningitis,  833 

in  pertussis,  846 
Benignant  tumors,  114 
Benzoic  acid  as  a  prophylactic  in  scarlet 

fever,  537 
BERIBERI,  1038 
Definition,  1038 
Geographical  distribution,  1038 


1048 


IXDEX. 


BERIBERI — History,  10"8 
Etiology — Specific  poison,  1038 

resemblance  of,   to   marsh-ruiasm, 

1038 

Predisposing  causes,  1039 
Varieties,  1039 

Symptoms — Anaesthesia  of  skin,  1039 
Muscular  paralvsis,  1039 
Peculiarity  of  gait,  1039 
Cramps,  1039 
Muscular  tenderness,  1039 
Periosteal  tenderness,  1039 
Palpitation  of  heart,  1039 
Symptoms,  special — Of  wet  form,  1040 
Anasarca,  1040 
Quality  of  pulse,  1040 
Cardiac  murmur,  1040 
Arterial  murmur,  1040 
Of  dry  form,  1040 
Quality  of  pulse,  1040 
Condition  of  heart,  1040 
Morbid  anatomy,  1040 
Alterations  in  blood,  1041 
Heart,  1041 
Muscles,  1041 
Prognosis,  1042 

Treatment — By  change  of  residence,  1042 
By  diet,  1042 
Of  wet  form  by  hydragogue  cathartics, 

1042 

Sulphate  of  magnesium,  1042 
Elaterium,  1042 
Treeak  farook,  1042 
Diuretics,  1042 
Juniper  gin,  1042 

Of  the  dry  form  by  electricity,  1043 
Strychnia,  1043" 
Frictions,  1043 

Use  of  anodyne  liniments,  1043 
Use  of  hypodermics  of  morphia,  1043 
Bites  of  rabid  dogs,  treatment,  905 
Bladder,  diphtheria  of,  general  sepsis  from, 

G74 

lesions  of,  in  rabies,  903 
in  relapsing  fever,  414 
symptoms  of  diphtheria  of,  674 
Blindness  in  cerebro-spinal  meningitis,  811 
Blisters,  use  of,  in  cerebro-spinal  meningitis, 

830 

Blood,  alterations  of,  in  anthrax,  935-942 
in  beriberi,  1041 

in  cerebro-spinal  meningitis,  824 
in  cholera,  747 
in  pyaemia,  9b'8 
in  relapsing  fever,  411 
in  scarlet  fever,  530 
in  septicaemia,  971 
in  typhoid  fever,  268 
in  typhus  fever,  356 

altered,  as  a  cause  of  symptomatic  par- 
otitis, 626 

condition  of,  in  pynemia,  9G3 
contamination  of,  sources,  in  pyaemia,  958 
degeneration  of,  complicating  diphtheria, 

675 

Blood-vessels,  calcification  of,  88,  90 
changes  in  inflammation,  43 


Blood-vessels,  lesions  of,  in  typhoid  fever. 

267  _ 

new  formation  of,  55 

Body,  portion  of,  most  suitable  for  vaccin- 
ating, 477 
Bones,  chronic  diseases  of,  following  rubeola, 

574 
cranial,  lesions  of,  in  symptomatic  parotitis, 

626 

in  glanders,  922 
in  pyaemia,  967 
Bone-marrow,  lesions  of,  in  relapsing  fever, 

417 

Boric  acid,  use  of,  in  diphtheria,  709 
Bovine  vaccine,  473 
Bowels,  state  of,  in  relapsing  fever,  390 
in  remittent  fever,  602 
condition  of,  in  typhus  fever,  350 
Brain,  lesions  of,  in  cerebro-spinal  menin- 
gitis, 823 
in  cholera,  746 
in  glanders,  923 
in  relapsing  fever,  413 
in  typhoid  fever,  266 
in  typhus  fever,  358 

and   membranes,    lesions   of,  in   cerebro- 
spinal  meningitis,  822 
and  membranes,  lesions  of,  in  pyaemia,  966 
and  spinal  cord,  lesions  of,  in  rabies  and 

hydrophobia,  903 

softening  of,  following  cerebro-spinal  men- 
ingitis, 820 

Breath,  odor  of,  in  typhus  fever,  353 
Bright's  disease,  aggravation  of,  by  influenza, 

870 

Bromine,  use  of,  in  diphtheria,  708 
Bromide  of  potassium,  use  of,  in  relapsing 

f  fever,  430 

Bronchi,  lesions  of,  in   rabies   and   hydro- 
phobia, 902 
symptoms   of   formation   of    diphtheritic 

membrane,  671 

Bronchial  glands,  lesions  of,  in  influenza,  872 
Bronchitis,  complicating  influenza,  868 
rubeola,  571 
typhoid  fever,  294 
typhus  fever,  355 

frequency  of,  in  typhoid  fever,  277 
in  rubeola,  treatment,  581 
in  septicaemia,  977 
in  typhus  fever,  353,  354 
Broncho-pneumonia,  complicating  diphthe- 
ria, 672 

Bryce's  test  of  vaccinal  infection,  461 
Buboes,  characters  of,  in  grave  form  of  the 

plague,  778 
date  of  appearance  of,  in  grave  form  of 

the  plague,  778 
of  the  plague,  treatment,  784 
pathology  of,  in  the  plague,  781 
seat  of,  in  grave  form  of  the  plague,  778 

c. 

Cadaveric  rigidity  after  cholera,  741 
Caecum   and   colon,  lesions   of,    in    tvphoid 
fever,  263 


INDEX. 


1049 


Calcification,  87 
causes,  87 

of  blood-vessels,  88,  90 
of  thrombi,  60,  89 

Calabar  bean,  use  of,  in  cerebro-spinal  men- 
ingitis, 834 

Calm  stage  of  yellow  fever,  645 
Calomel  as  a  specific  in  typhoid  fever,  336 
use  of,  in  cholera,  766  * 

in  hemorrhagic  form  of  pernicious  ma- 
larial fever,  613 

Camphor,  use  of,  in  cholera,  768 
Cancer,  117,  123 

hereditary  nature,  129 
relation  of,  to  epithelial  tumors,  118 
Capillary  bronchitis,  complicating  influenza, 

_868 
Capillaries,  intestinal,  lesions  of,  in  cholera, 

745 

Carbolic  acid,  nse  of,  in  anthrax,  938 
in  diphtheria,  707 
in  glanders,  924 
in  scarlet  fever,  545 
Carbonic  acid,  as  a  cause  of  impure  air,  177 

amount  of,  in  pure  and  impure  air,  178 
Carbuncles,  character  of,  in  grave  form  of 

the  plague,  778 

seat  of,  in  grave  form  of  plague,  778 
Cardiac  degeneration,  complicating  diphthe- 
ria, 675 

following  typhoid  fever,  293 
complicating  typhus  fever,  355 
dilatation,  complicating  scarlet  fever,  523 
inflammation,  complicating  scarlet  fever, 

522 

murmur  in  beriberi,  1040 
sounds  in  typhoid  fever,  276 
thrombi  in  diphtheria,  687 
Caseation,  79 

Cataract,  hereditary,  nature,  129 
Catarrh,  absence  of,  in  rubeola,  568 

of  influenza,  treatment,  874 
Catarrhal  affections  as  predisposing  causes 

of  pertussis,  839 
inflammation,  52 

pneumonia,  complicating  influenza,  869 
pock  in  vaccinia,  463 
symptoms  in  inflnerrza,  866 

in  prodromal  stage  of  rubeola,  564 
Causes  of  olitis  in  scarlet  fever,  520 
Caustics*  nse  of,  in  hydrophobia,  905 
Cauterization,  use  of,  in  external  anthrax, 

938,  943 
Cathartics,  use  of,  in  wet  beriberi,  1042 

in  scarlet  fever,  554 

Cellular  tissue,  lesions  of,  in  pyaemia,  966 
Cellulitis,  pelvic,  in  puerperal  fever,  988 
Cerebral  softening  from  embolism,  65 

symptoms  in  yellow  fever,  644 
Cerebro-spinal  meningitis,  795 
Certificates  of  death,  duty  of  a  physician  in 

regard  to,  210 

Cesspools  beneath  dwellings,  dangers  of,  192 
contamination  of  water  by,  192 
evils  of,  126 

Change  of  residence  as  cause  of  typhoid  fever, 
244 


Cheesy  degeneration,  79 

metamorphosis,  79 
Chicken-pox,  481 

Child-bed  fever,  relation  to  erysipelas,  630 
Childhood,  influence  of,  on  occunenceof  per- 
tussis, 839 
Children,  causes  of  frequency  of  diphtheria 

in,  682 

typhoid  fever  in,  301 
Chills  in  pyaemia,  973 
Chinolin,  use  of,  in  diphtheria,  703 
Chloral  hydrate,  use  of,  in   cerebro-spinal 

meningitis,  834 
in  hydrophobia,  907 
in  pertussis,  846 
in  relapsing  fever,  430 
Chloride  test  for  detecting  pollution  of  wa- 
ter-supply, 192 

Chloroform,  use  of,  in  cholera,  768 
in  hydrophobia,  907 
in  relapsing  fever,  431 
CHOLERA,  715 
Definition,  715 
Synonyms,  715 
History,  715  et  seq. 
Etiology — predisposing  causes,  720 
Influence  of  high  temperature  in  origin 

and  spread,  720 

Season,  influence  of,  on  causation,  720 
Over-crowding  and  filth  as  causes,  720 
Intemperance  as  a  cause,  721 
Contagiousness,  721 
Modes  of  transmission,  721 
Channels  of  entrance  into  system,  721 
Propagation  of,  by  fomites,  721 

by  drinking-water,  723 
Cases  illustrating  spread  of,  by  drinking- 
water,  724 
Influence  of  height  of  subsoil-water  on 

prevalence,  722 

Humidity  of  soil  as  a  cause,  722 
Special  fomites  of,  723 
Cases  illustrating  spread  of,  by  fomites, 

727 

Cases  illustrating  contagiousness,  728 
Objections  to  contagious  nature,  729 
Individual  immunity,  730 
Different  grades  of,  from  intensity  of 

poison,  731 
Specific  origin,  747 
Nature  of  poison,  743 
Influence  of  bacteria  in  production,  748 
Koch's  investigations  in  regard  to  ba- 
cilli, 745,  749 
Symptoms,  731 
Mild  forms,  732 
"  Cholerine  "  stage,  732 
Number  of  stools  in  mild  forms,  732 
Character  of  stools  in  mild  forms,  732 
Grave  forms,  733 
Physiognomy  in  grave  forms,  733 
Stools  in  grave  forms,  733 
Typhoid  state,  734 
Stage  of  collapse,  734 
Reaction,  734 
Convalescence,  735 
Temperature,  736 


1050 


IXDEX. 


CHOLERA — Symptoms  :  Difference  between 
axillary,  vaginal,  and  rw.tal  tem- 
perature, 736 
Special  symptoms — Low  temperature  of 

mouth,  736 

Condition  of  skin,  736 
Color  of  skin,  737 
Condition  of  heart  and  pulse,  737 
Veins,  737 
Vomiting,  738 
Character  of  vomit,  738 
Diarrhoea,  738 
Results  of  diarrhoea,  738 
Characters  of  stools,  739 
Condition  of  urine,  739 
Cramps,  740 
Causes  of  cramps,  740 
State  of  abdomen,  741 

of  nervous  system,  741 
Complications  and  sequelse,  735 

Complicated  bv  diphtheritic  exudations, 

735 

Inflammation    of    parotid    and    sub- 
maxillary  glands,  735 
Abscesses  and  ulcers,  735 
Cutaneous  eruptions,  735 
Morbid    anatomy  —  general     appearance 

after  death,  741 
Cadaveric  rigidity,  741 
Muscular  contractions  after  death,  741 
Appearance,  post-mortem,  of  abdominal 

cavity,  743 

Changes  in  stomach,  743 
Intestinal  canal,  743 
Intestinal  mucous  membrane,  743 
Nature  of  exfoliation  from  intestinal 

canal,  744 
Changes  in  isolated   and  agminated 

glands,  745 
Capillaries   and   veins  of   intestinal 

canal,  745 
Liver,  745 
Gall-bladder,  746 
Spleen,  746 
Heart,  746 
Pericardium,  747 
Lungs,  746 

Brain  and  spinal  marrow,  746 
Kidneys,  746 
Blood,"  747 

Diagnosis — from  cholera  morbus,  750 
from  irritant  poisoning,  752 
Order  of  symptoms  as  a  ground  for,  753 
Prognosis,  753 

Symptoms  indicating  favorable  and  un- 
favorable, 7-54 

Mortality — in  different  epidemics,  754 
Influence  of  age,  754 
Sex,  754 

Social  condition,  754 
Treatment,  759 
Preventive,  755 
Disinfection,  758 

Modes  of  applying  disinfectants,  758 
Importance  of  maintaining  high  de- 
gree  of  health  during  epidemics, 
758 


CHOLERA — Treatment :  Quarantine  and  san- 
itary  cordons  for   prevention,  755 


Mode  of  carrying  out  quarantine,  757 
Cases  illustrating  value  of  quarantine, 

757 

Use  of  drinking-water  during  epidem- 
ics, 759 

General  management,  760 
Importance  of  early  recognition,  732 
Necessity  of  rest,  760 

of  prompt,  760 
Diarrhoea,  760 
Vomiting,  761 
Hiccough,  762 
Injection  of  sodium  chloride  into  veins, 

762 

Stage  of  collapse,  763 
Diet  of  stage  of  reaction,  763 
For  restoration  of  circulation  in 

of  collapse,  763 
Stage  of  reaction,  763 
Undue  reaction,  764 
Urinary  suppression   in  stage  of  reac- 
tion, 764 

Convalescence,  764 
Use  of  venesection  in,  764 
Emetics,  765 
Calomel,  766 
Alcohol,  767 
Opiates,  767 
Mineral  acids,  768 
Camphor,  768 
Chloroform,  768 
Intravenous  injections,  768 
Hot  applications,  769 
Cold  affusions,  769 
Of  cramps,  769 
Necessity  of  cold  water  to  allav  thirst, 

770 

Use  of  antiseptic  remedies,  770 
Cholerine,  732 

Chorea,  following  typhoid  fever,  293 
Chronic  diseases,  relation  of,  to  rubeola,  561 
forms  of  erysipelas,  634 
of  glanders,  915,  923 

Cicatrix,  condition  during  incubation  of  hy- 
drophobia, 895 

in  hydrophobia,  excision,  906-908 
in  vaccinia,  description,  460 
Classification   of  puerperal    inflammations, 

986 
Cleanliness,  importance  of,  in  prevention  of 

pyremia,  980 
in  variola,  454 

Climate,  as  a  cause  of  disease,  185 
definition  of  term,  185 
influence  of,  on  causation  of  influenza,  860 
on  causation  of  rabies  and  hydrophobia, 

887 

of  rubeola,  560 

Clinical  history  of  influenza,  864 
Clothing  as  a  cause  of  disease,  198 
Cloudy  swelling,  72 
Coagulation  of  exudations,  43 
Cohnheim's  theory  of  production  of  morbid 
growths,"  106 


IXDEX. 


1051 


Colchicura,  use  of,  in  dengue,  885 
Cold  as  a  cause  of  disease,  133 

and  damp,  influence  of,  on  causation  of 

glanders,  912 

bath,  use  of,  in  diphtheria,  702 
in  puerperal  fever,  1034 
in  typhoid  fever,  327 
Centra-indications  to  use  of,  in  diphtheria, 

703 

Use  of,  in  algid  form  of  pernicious  mala- 
rial fever,  608 

in  cerebro-spinal  meningitis,  830 
in  cholera,  769 
in  diphtheria,  702 
in  puerperal  lever,  1033 
in  tlie  hyperpyrexia   of  scarlet    fever, 

541 

in  scarlet  fever,  542 
in  yellow  fever,  G51 

water,  intra-uterine  injections  of,  in  puer- 
•  peral  fever,  1034 

mode  of  applying,  in  scarlet  fever,  542 
Cold  stage  of  intermittent  fever,  592 
of  intermittent  fever,  theory  of  cause,  593 

treatment,  594 

of  yellow  fever,  treatment,  653 
Cold  water,  use  of,  in  typhus  fever,  364 
Collapse  in  cerebro-spinal  meningitis,  treat- 
ment, 831 
in  cholera,  734 

treatment,  763 

of  lungs,  complicating  influenza,  869 
Collections  of  water,  influence  on  health  of 

a  community,  187 
Colloid  degeneration,  83 

metamorphosis,  83 

Color  of  skin,  significance  of,  in  general  di- 
agnosis, 159 
Coma,  in  cerebro-spinal  meningitis,  812 

significance  of,  in  general  diagnosis,  166 
Comatose  form  of  pernicious  malarial  fever, 

608 

Diagnosis,  609 
Symptoms,  609 
Treatment,  609 

Coma-vigil  in  typhus  fever,  349 
Compresses,  hot  water,  use  of,  in  variola,  4-53 
Complications  of  cholera,  735 
of  erysipelas,  633 
of  idiopathic  parotitis,  623 
of  influenza,  868 
of  pertussis,  843 
of  plague,  780 
of  relapsing  fever,  396-410 
of  rb'theln,  587 
of  rubeola,  570 

causes,  570 
of  scarlet  fever,  510 
of  typhoid  fever,  292 

treatment,  335 
of  vaccination,  468 
of  vaccinia,  464 
of  varicella,  483 
of  variola,  445 
Confluent  small-pox,  440 
Conjunctiva,  condition  of,  in  human  glan- 
ders, 921 


Conjunctiva,  symptoms  of  diphtheria  of,  670 
Conjunctiva!  diphtheria,  local  treatment,  712 
Conjunctivitis,  diphtheritic,  symptoms,  670 
Consanguineous  marriages,  effects,  131 
Constipation   in   cerebro-spinal   meningitis, 

814 

in  grave  form  of  the  plague,  779 
in  rubeola,  treatment,  58 1 
in  typhoid  fever,  treatment,  333 
in  typhus  fever,  treatment,  307 
significance  of,  in  general  diagnosis,  163 
Constitutional  infection,  absence  of,  in  vac- 
cinia, 460 

of  syphilis,  hereditary  nature,  127 
taints,  conveyance  of,  by  vaccination,  471 
treatment  of  anthrax,  944 

of  pyaemia,  982 

Contagion  as  a  cause  of  disease,  135,  200 
definition  of,  200 
of  dengue,  884 

of  erysipelas,  manner  of  propagation,  630 
of  erysipelas,  nature,  630 
of  influenza,  862 

of  relapsing  fever,  transmission,  373 
of  rabies  and  hydrophobia,  891 
of  rabies  and  hydrophobia,  dissemination, 

891 

of  rotheln,  nature,  583 
of  rubeola,  modes  of  dissemination,  558 
mode  of  entering  the  body,  558 
nature,  557 

in  typhus  fever,  nature,  343* 
modes  of  transmission,  344 
Contagium  of  variola,  duration  of  activity, 

435 

mode  of  entering  body,  435 
nature,  435 

period  of  greatest  activity,  435 
Contagious  diseases,  characteristics,  137 
Contagious  nature  of  cholera,  objections  to, 

729 

Contagiousness  of  anthrax,  928 
of  cerebro-spinal  meningitis,  803 
of  cholera,  721 
of  dengue,  884 
of  diphtheria,  678 
of  erysipelas,  630 
of  glanders,  911 
of  influenza,  862,  863 
of  leprosy,  788 
of  the  plague,  776 
of  puerperal  fever,  1017 
of  pyremia,  960 

of  rabies  and  hydrophobia,  891 
of  scarlet  fever,  494 
of  typhoid  fever,  248 
of  typhus  fever,  343 

period  of  greatest,  345 
of  varicella,  481 
of  variola,  435 

Convalescence,  choice  of  diet,  20fi 
in  cerebro-spinal  meningitis,  819 

management,  835 
in  cholera,  735 

management,  764 
in  chronic  glanders  in  man,  922 
in  dengue,  8S2 


1052 


ETDEX. 


Convalescence  in  grave  form  of  the  plague, 

779 

in  erysipelas,  management,  639 
in  influenza,  treatment,  875 
in  relapsing  fever,  393 
in  scarlet  fever,  management,  544 
in  typhoid  fever,  management,  335 
in  typhus  fever,  management,  368 
Convulsions  during  hot  stage  of  intermittent 

fever,  treatment,  597 
in  cerebro-spinal  meningitis,  810 
in  relapsing  fever,  384 
complicating  rubeola,  572 
in  prodromal  stage  of  rubeola,  .565 
in  rubeola,  treatment,  581 
in  yellow  fever,  treatment,  653 
Cooking,  necessity  of  a  physician's  know- 

ledge of,"  196 
Corpuscles,  pus-,  43 
Corrosive  sublimate,  use  of,  as  antiseptic  in 

puerperal  fever,  1025,  1029 
Coryza,  chronic,  following  rubeola,  574 
complicating  scarlet  fever,  520 
of  scarlet  fever,  treatment,  546 
Cough,  in  rubeola,  treatment,  581 

significance  of,  in  general  diagnosis,  158 
Counterirritants,  use  of,  in  pertussis,  848 
Course  of  vaccinia,  458 
irregularities,  460 
Cow-pox,  456 

spontaneous,  456 
Cramps  in  beriberi,  1039. 
in  cholera,  740 
treatment,  769 
causes,  740 

Cretinism  and  goitre,  hereditary  nature,  128 
Croup,  respiration,  157 
Croupous  inflammation  distinguished  from 

croup,  49 
of  fauces,   complicating    scarlet  fever, 

516 

membrane,  685 
characters,  685 
mode  of  formation,  685 
metamorphosis,  80 
Crust  in  vaccinia,  composition,  4<M 
Crusts,  objections  to  use  of,  in  vaccination, 

476 

Cubebs,  use  of,  in  diphtheria,  709 
Cultivation  of  bacillus  tuberculosis,  100 
Curare,  use  of,  in  treatment  of  hydrophobia, 

907 
Cutaneous  deposits  in  glanders,  microscopic 

characters,  917 
diphtheria,  treatment,  713 
lesions  of  glanders  in  man,  922 
symptoms  of  glanders  in  man,  921 
Cysts,  definition,  1  15,  121 


Deaf-mntism  following  cerebro-spinal  men- 

ingitis, 819 

Deafness  in  cerebro-spinal  meningitis,  811 
Death,  causes  of,  in  cerebro-spinal   menin- 

gitis, 818 
in  glanders,  915 


Debility  in  cerebro-spinal  meningitis,  813 

in  influenza,  treatment,  876 

influence  of,  in  causation  of  glanders,  912 

in  relapsing  fever,  386 
Decline,  stage  of,  in  pertussis,  841 
Decubitus,  significance  of,  in  general  diag- 
nosis, 150 
Definition  of  anthrax,  926 

of  beriberi,  1038 

of  cerebro-spinal  meningitis,  795 

of  cholera,  715 

of  contagion,  200 

of  cysts,  115,  121 

of  dengue,  880 

of  diphtheria,  656 

of  erysipelas,  629 

of  glanders,  909 

of  idiopathic  parotitis,  620 

of  influenza,  851 

of  leprosy,  785 

of  pernicious  malarial  fever,  605 

of  pertussis,  836 

of  the  plague,  771 

of  puerperal  fever,  984 

of  pyaemia,  953 

of  rabies  and  hydrophobia,  886 

of  relapsing  fever,  3(59 

of  remittent  fever,  598 

of  rotheln,  582 

of  rubeola,  557 

of  •fceptitternia,  953 

of  simple  continued  fever,  231 

of  symptomatic  parotitis,  625 

of  term  "climate,"  185 

of  typhoid  fever,  237 

of  typho-malarial  fever,  614 

of  vaccinia,  455 

of  varicella,  481 

of  variola,  434 

of  yellow  fever,  640 
Degeneration,  72 

amyloid,  84 

cheesy,  79 

colloid,  83 

fibrinous,  80 

fatty,  74 

granular,  72 

hyaline,  80 

lardaceous,  84 

mucous,  82 

of  tubercle,  96 

parenchymatous,  73 

waxy,  84 
Deglutition,  difficult,  in  idiopathic  parotitis, 

treatment,  G24 
Delirium  in  cerebro-spinal  meningitis,  812 

in  erysipelas,  treatment,  637 

in  idiopathic  parotitis,  treatment,  624 

in  pyamiia,  971 

in  relapsing  fever,  384 

in  typhoid  fever,  278 
treatment,  334 

in  typhus  fever,  348 
treatment,  366 

in  yellow  fever,  treatment,  653 

significance  of,  in  general  diagnosis,  166 
Demonstration  of  bacillus  of  glanders,  914 


INDEX. 


1053 


DENGUE,  879 

Svnonyms,  879 
Jlistory,  879 
Definition,  880 
Etiology,  883 

Specific  origin,  884 

Contagiousness,  884 
Symptoms — prodromal  stage,  880 

Mode  of  onset,  880 

Temperature,  881 

Pulse,  881 

Delirium,  881 

Facies,  881 

State  of  gastro-intestinal  tract,  881 

State  of  tongue,  881 

Stomach  and  bowels,  881 

State  of  urine,  881 

Eruptions,  881 

Hemorrhages,  882 

Prostration,  882 

Convalescence,  882 
Duration  of,  882 
Morbid  anatomy,  882 

Specific  nature  of,  882 

Kelation  to  acute  articular  rheumatism, 
883 

Changes  in  abdominal  organs,  883 
Diagnosis,  884 

From  acute  articular  rheumatism,  884 

From  yellow  fever,  884 
Prognosis,  885  k 

Treatment,  885 

Use  of  colchicum,  8S5 
quinia,  885 
opium,  885 
Depletion,   local,  use  of,  in  cerebro-spinal 

meningitis,  830 
Depressing  emotions,  as  a  cause  of  typhoid 

fever,  245 
Dermatitis,  complicating  vaccination,  4G8 

vaccination,  treatment,  4G9 
Desquamation,  date  of,  in  mild  scarlet  fever, 

500 

in  erysipelas,  633 
in  relapsing  fever,  377 
Desiccation  in  varicella,  482 

in  variola,  440 
Diagnosis,  general,  148 

divisions  of,  148 

main  direction  of  inquiries,  148 

proper  method  of  procedure,  150 

significance  of  alteration  of  voice  in,  158 
of  anthrax  in  animals,  936 

in  man,  942 

of  cerebro-spmal  meningitis,  826 
•of  cholera,  750 
of  comatose  form  of  pernicious  malarial 

fever,  609 
of  dengue,  884 
of  diphtheria,  689 
of  erysipelas,  635 
of  idiopathic  parotitis,  624 
of  glanders  in  horse,  918 
of  glanders  in  man,  923 
of  influenza,  872 
of  intermittent  fever,  594 
of  leprosy,  792 


Diagnosis  of  the  plague,  782 

of  pyaemia  from  septiesemia,  978,  979 

of  remittent  fever,  GOO 

of  rabies  and  hydrophobia,  900 

of  relapsing  fever,  418-422 

of  rotheln,  587 

of  rubeola,  575 

of  scarlet  fever,  532 

of  simple  continued  fever,  234 

of  symptomatic  parotitis,  627 

of  typhoid  fever,  311-314 

of  typho-malarial  fever,  616 

of  typhus  fever,  358,  359 

of  vaccinia,  464 

of  varicella,  483 

of  variola,  447 

of  varioloid,  444 

of  yellow  fever,  648 

Diaphoretics,  use  of,  in  yellow  fever,  649 
Diarrhoea  in  cerebro-spinal  meningitis,  814 

in  cholera,  738 
results,  738 
treatment,  760 

in  mild  scarlet  fever,  503 

in  pyaemia,  975 

in  relapsing  fever,  405 

in  rubeola,  treatment,  581 

in  septicaemia,  977 
treatment,  983 

in  typhoid  fever,  287 

treatment,  331 

Diarrhceal  diseases  from  impure  water,  182 
Diathesis,  127 

hereditary,  transmission,  130 
Diet  in  anthrax,  944 

in  beriberi,  1042 

in  cerebro-spinal  meningitis,  834 

in  cholera,  763 

in  convalescence,  206 

in  erysipelas,  639 

in  glanders,  924 

in  influenza,  874 

in  relapsing  fever,  430 

in  pertussis,  848 

in  puerperal  fever,  1036 

in  pypemia,  982 

in  rubeola,  579 

in  typhoid  fever,  323 

in  typho-malarial  fever,  619 

in  typhus  fever,  362 

in  yellow  fever,  654 

of  convalescence,  206 
Digestion,   condition    of,   in   cerebro-spinal 

meningitis,  814 
Digestive  tract,  condition  of,  in  glanders,  921 

in  idiopathic  parotitis,  623 
Digitalis,  use  of,  in  puerperal  fever,  1033 
in  relapsing  fever,  428 
in  scarlet  fever,  543 
in  typhoid  fever,  330  . 

in  yellow  fever,  651 

DlPHTHKRIA,  656 

Synonyms,  656 
Definition,  656 
History,  656  et  seq. 

Panum's  view    regarding    relation  of 
bacteria  to,  667 


1054 


INDEX. 


DIPHTHERIA — Etiology :  Age,  influence  of, 

on  causation,  680 

Sex,  influence  of,  on  causation,  680 
Causes  of  frequency  of,  in   childhood. 

680 
Pharyngeal,  buccal,  and  nasal  catarrh  a 

cause  of,  in  children,  680 
Physiological  causes  of,  greater  frequen- 
cy in  childhood,  681 
Family  predisposition,  681 
Thermometric  and  barometric  changes 

a  cause,  682 
Season  as  a  cause,  682 
Filth  as  a  cause,  682 
Polluted  air  as  a  cause,  682 
water  as  a  cause,  683 
milk  as  a  cause,  683 
Contagiousness,  678 
Modes  of  transmission  of  poison,  678 
In  the  lower  animals,  683 
Traumission  of,  from  lower  animals  to 

man,  683 

Artificial  production  of  membrane,  684 
Invasion,  676 

duration  of  incubation  period,  679 
Symptoms — Prodromal  stage,  667 
duration,  667 

localized  redness    of   mucous   mem- 
branes, 667 
Different  manifestations  of  diphtheritic 

process,  668 
Severe  form,  668 

appearance  of  membrane  in   severe 

form,  668 

Gangrenous  condition  of  membrane,  669 
Swellings  of  glands  at  angle  of  jaw  as 
sign  of  invasion  of  nasal  cavities, 
66!),  670 

Mode  of  invasion  of  nasal  cavities,  669 
Mode  of  spread  to  nasal  cavities,  669 
Nasal  form,  669 
Conjunctival  form,  670 
Aural  form,  670 
Laryngeal  form,  671 
Formation  of  membrane  in  larynx,  671 
Tracheal  and  bronchial  forms,  671 

primary  form,  672 
Oral  form,  672,  673 
Intestinal  form,  673 
Of  wounds,  673 
Eruption  of,  G74 
Vulvar  and  vaginal  forms,  674 
In  puerperal  women,  674 
Vesical  form,  674 
Placental,  674 

Liability  of  open  wounds,  672,  679 
Tendency  to  second  attacks  from  cbronic 
nasal  and  pharyngeal  catarrh  fol- 
lowing, 670 
Complications  and  sequelae,  672 

complicated    by  fibrinous   pneumonia, 

672 

by  broncho-pneumonia,  672 
by  erysipelas,  673 
by  urticaria  and  purpura,  674 
by  kidney  affections,  674 
by  albumin  uria,  674 


DIPHTHERIA — complicated  by  granular  de- 
generation of  blood,  675 
by  cardiac  degeneration,  675 
by  symptoms  of  cardiac  degeneration, 

675 

by  embolism,  675 
by  acute  endocarditis,  671 
by  leucocythaemia  and  Hodgkin's  dis- 
ease, 675 

by  nervous  diseases,  675 
by  paralysis,  676 
seat  of,  676 

date  of  appearance,  676 
fatty  degeneration  and  atrophy  fol- 
lowing, 676 
sensory,  676 
Secondary  form,  671 

Morbid  anatomy — characters  of  the  mem- 
brane, 685 

Mode  of  formation  of  membrane,  6S5 
Varieties  of  membrane  in,  686 
Bindfleisch's  definition  of  diphtheritic 

inflammation,  686 
Changes  in  the  heart,  686 

fatty  and  granule  degeneration,  686 
endocarditis,  687 
cardiac  thrombi,  687 
Changes  in  lungs,  687 
Spleen,  687 
Liver,  687 
Kidneys,  687 
Muscles,  687 
Lymphatic  glands,  687 
Mucous  membranes.  688 
Influence  of   different    mucous    mem- 
branes   upon    characters    of   false 
membrane,  688 
epithelia  upon  growth  and  spread  of 

false  membrane,  688 
Changes  in  intestines,  689 

nervous  system,  689 

Diagnosis — significance  of  localized  pha- 
ryngeal injection,  689 
From  muguet  or  thrush,  690 

Follicular  stomatitis,  690 
Significance  of  glandular  swelling,  61)0 

lymphadenitis  in  nasal  form,  690 
Of  laryngeal  form,  691 
Significance  of  absence  of  fever,  691 
Of  paralysis,  691 

Prognosis — symptoms    indicating    favor- 
able, 692 
unfavorable,  692 

Significance  of  glandular  swelling,  692 
In  nasal,  692 

Of  fetid  and  putrid  discharges,  693 
Of  epistaxis,  693 
In  laryngeal,  692 
In  trachea),  692 
Of  tracheotomy,  692 

significance  of  state  of  pulse  after,  692 
of  dry  respiration  after,  692 
of  temperature-range  after,  692 
of  character  of  membrane,  692 
Influence  of  temperature,  693 
state  of  pulse,  693 
complications,  693 


IXDEX. 


1055 


DIPHTHERIA — Prognosis :      Influence     of 

bronchitis  and  pneumonia,  693 
endocarditis,  693 
albuminuria,  693 
affections  of  sensoriuin,  693 
purpura,  693 

icteric  discoloration  of  skin.  693 
Of  relapses,  694 
Treatment — hyperpyrexia,  694 
Reflex  symptoms,  694 
Vomiting,  694 
Futility  of  expectant,  694 
Use  of  stimulants,  694 
Amount  of  stimulants  necessary,  695 
Importance  of  general  treatment,  695 
Futility  of  venesection,  695 
Prophylactic,  696 
Danger  of  self-infection,  696 
Prevention  of  self-infection,  696 
Isolation,  696 
Closure  of  schools  and   public  places 

during  epidemics,  697 
Disinfection,  698 
Special,  701 
Local,  701,  709 

by  steam,  701 
Use  of  water,  702 

Ice  and  cold,  702 

Cold  baths,  702 
Mode  of  applying  cold,  702 
Centra-indications  to  use  of  cold,  703 
Solvents  of  pseudo-membrane,  703 
Use  of  lime-water,  703 

Slaking  lime,  703 

Lactic  acid,  703 

Pepsin,  neurin,  and  chinolin,  703 

Papayotin,  703 

Pilocarpine,  704 
objections  to,  704 

Turpentine  inhalations,  704 

Ammonium  chloride,  704 

Mercury,  705 

Tincture  of  chloride  of  iron,  70G 

Carbolic  acid,  707 

Salicylic  acid,  707 

Quinia,  708 

Bromine,  708 

Boric  acid,  709 

Sodium  salicylate,  709 

Ozone,  709 

Sulphur  and  cubebs,  709 

Chlorate  of  potassium,  699 
Dose  of  chlorate  of  potassium,  700 
Danger  in  large  doses  of  chlorate  of 

potassium,  701 

Mechanical  removal  of  membrane,  709 
Cauterization  of  membrane,  709 
Glandular  swellings,  710 
Abscess  of  glands,  710 
Of  nasal  form,  710 

danger  of  permitting  sleep  in,  712 

local  applications,  710 
Of  conjunctiva!  form,  712 
Of  laryngeal  form,  712 

use  of  emetics,  712 
Of  paralysis,  713 

by  strychnia,  713 


DIPHTHERIA— Treatment  of  paralysis   by 

electricity,  713 
artificial  alimentation,  713 
Of  cutaneous  form,  713 
Diphtheria,  complicating  rubeola,  573 
scarlet  fever,  514 

of  genitalia  in  puerperal  fever,  1002 
Diphtheritic  endometritis,  987 

exudations,  complicating  rubeola,  735 
membrane,  cauterization,  709 

mechanical  removal,  709 
conjunctivitis,  670 

treatment,  712 
inflammation,  causes,  51 

distinguished  from  diphtheria,  50 
paralysis,  treatment,  713 
pock  in  vaccinia,  463 
Disease,  35 
Causes,  125,  175 

arsenical  poisoning,  193 
climate,  185 
cold,  133 

contagion,  135,  200 
epidemic  influences,  135 
errors  of  diet,  135 
exciting,  125 
exercise,  abnormal,  134,  198 

deficient,  135 
functional,  134 
habitation,  186 
heat,  133 
hereditary,  132 
humidity  of  atmosphere,  133 
improper  clothing,  198 
impure  air,  177 
ice,  185 
water,  182 
ingestive,  135 
intemperance,  197 
mental,  204 
minute  organisms,  141 
predisposing,  125 
pre-natal,  126,  175 

poisons  and  misuse  of  medicines,  135 
soil,  condition  of,  187 
Definition  of,  1 35 
Elevation  of  site,  influence  of,  134 
Means  of  discovery,  175 
Abdominal,  hot  climate  as  a  cause,  133 
Respiratory,  cold  as  a  cause,  133 
Prevention,  175 
Respiration  in,  156 
Theory  of — bioplastic,  140 
chemical,  138,  140 
fermentation,  138 
germ,  138 

points  of  objection,  142 
undecided  state,  147 
Zymotic,  table  of,  136 
Disinfectants,  varieties,  202 
Disinfection  in  anthrax,  937,  943 
in  cholera,  758 
in  diphtheria,  G98 
of  glanders,  925 
in  the  plague,  784 
in  puerperal  fever,  1025,  1028 
in  pyaemia  and  septicamia,  980 


1056 


INDEX. 


Disinfection  in  scarlet  fever,  201,  538 
in  typhus  fever,  362 
methods,  201 
practical  difficulties,  201 
principles,  201 
Dissecting  poison,  relation  of,  to  causation 

of  puerperal  fever,  1018 
wounds,  relation  of,  to  causation  of  septi- 
caemia, 962 

Dissemination  of  influenza,  863 
in  typhoid  fever,  249 
of  puerperal  fever  by  physicians.  1018 
Diuretics,  use  of,  in  scarlet  fever,  555 

in  wet  beriberi,  1042 
DRAINAGE  AND  SEWERAGE,  213 
Back,  ventilation  of  traps,  221 
Disposal  of  liquid  wastes  by  irrigation,  225 
Frequency  of  leakage  in  waste-pipes,  222 
Necessity   of,   in   prevention   of  typhoid 

fever,  321 
Of  houses,  188 
Necessity   of  abundant   water-supply  in, 

220 

Of  soil,  226 

Perfect,  fundamental  requirements,  213 
Kemoval  of  human  excrement,  215 

of  liquid  household  wastes,  220 
Varieties  of  grease-traps,  221 
Ventilation  of  waste-pipes,  223 
Drainage-pipes,  effects  of  large  traps,  220 
of  too  large  bore,  220 
of  vertical  position,  220 
Drinking-water   as   a  medium   of  dissemi- 
nating typhoid  fever,  248 
propagation  of  cholera  by,  723 
Dropsies,  67-71 

Drugs,  use  of,  in  the  plague,  784 
Dry  form  of  beriberi,  symptoms,  1040 

treatment,  1043 

Duration  of  cerebro-spinal  meningitis,  818 
of  dengue,  882 
of  anthrax,  940,  941 
of  acute  form  of  glanders  in  horses,  915 
of  chronic  form  of  glanders  in  horses,  915 
of  acute  form  of  glanders  in  man,  921 
of  chronic  form  of  glanders  in  man,  922 
of  influenza,  865 
of  malignant  scarlet  fever,  508 
of  mild  scarlet  fever,  506 
of  prodromal  stage  of  rubeola,  565 
of  remittent  fever,  602 
of  rabies  and  hydrophobia,  900 
of  septicaemia  lymphatica,  1012 
Dysentery  complicating  relapsing  fever,  406 

t\  plius  fever,  355 

Dyfephagia,  significance  of,  in  general  diag- 
nosis, 162 
Dyspnoea,  causes,  157 

E. 

Ear,  affections  of,  in  rubeola,  treatment,  581 
diseases  of,  complicating  rubeola,  570 
displacement  of  lobe  in  idiopathic  paro- 
titis, 624 

internal,  lesions  of,  in  cerebro-spinal  men- 
ingitis, 824 


Ear,  lesions  of,  in  pyaemia,  967 

in  symptomatic  parotitis,  626 
middle,  suppuration  of,  in  cerebro-spinal 

meningitis,  811 
symptoms  of  diphtheria,  670 
Ears,  significance  of  appearance  of,   in  gen- 
eral diagnosis,  151 

Early  stages  of  yellow  fever,  treatment,  649 
Earth-closets,  218 

Effluvia,  offensive,  symptoms  due  to,  181 
Effusions,  67 
causes,  68-71 

distinguished  from  exudations,  67 
Elaterium,  use  of,  in  wet  beriberi,  1042 

in  dry  beriberi,  1013 
Electricity,  use  of,  in  diphtheritic  paralysis, 

713 
Elevated  temperature  as  a  cause  of  typhoid 

fever,  246 
Emaciation,  causes,  160 

significance  of,  in  diagnosis,  159 
Einboli,  action  of,   in  production  of  meta- 

static  abscesses  in  pyaemia,  967 
Embolism,  62 

complicating  diphtheria,  675 
from  septic  thrombus,  66 
hemorrhagic  results,  64,  65 
in  typhoid  fever,  treatment,  335 
mechanical  effects,  63 
necrosis  from,  64,  65 
results,  64 

softening,  cerebral,  from,  65 
symptoms,  66 
Embolus,  62 
arterial,  63 
venous,  63 
terminations,  65 
Emetics,  use  of,  in  cerebro-spinal  meningitis, 

830 

in  cholera,  765 
during  cold  stage  of  intermittent  fever, 

595 

in  influenza,  876 
in  laryngeal  diphtheria,  712 
in  pertussis,  845 
Emphysema,  aggravation  of,  by  influenza,  870 

significance  of,  in  general  diagnosis,  159 
Endocarditis,  acute,  complicating  diphthe- 
ria, 675 

in  diphtheria,  687 
in  puerperal  fever,  990 

Endo-  and  pericardium,  lesions  of,  in  septi- 
caemia, 972 

Endocolpitis  in  puerperal  fever,  986,  1005 
Endometritis  in  puerperal  fever,  986 
Enthetic  febrile  diseases,  hereditary  nature, 

130 

Epidemic  causation  of  disease,  135 
Epidemics  of  rubeola,  frequency,  560 

frequency  in  the  new-born,  563 
Epiglottis,  symptoms  of  diphtheria,  671 
Epistaxis  in  relapsing  fever,  393 
complicating  rubeola,  570 
in  remittent  fever,  602 
in  rubeola,  treatment,  580 
in  typhoid  fever,  273 
treatment,  3o5 


INDEX. 


1057 


Epithelia,  influence  of  different,  in  spread 

of  diphtheritic  membrane,  688 
Ergot,  use  of,  in  cerebro-spinal  meningitis, 

833 

Ergotine,  use  of,  in  pyaemia,  982 
Eruption,  absence  of,  in  rubeola,  568 
causes  of  absence  of,  in  mild  scarlet  fever, 

505 

in  cerebro-spinal  meningitis,  816,  817 
in  dengue,  881 
in  diphtheria,  674 
in  influenza,  866 
in  malignant  scarlet  fever,  507 
in  mild  scarlet  fever,  504 
in  pyaemia,  974 
in  relapsing  fever,  376 
in  rotheln,  585,  586 
in  rubeola,  566 

peculiarities  in  character,  569 

in  seat,  509 
relapses,  570 

retrocession  of,  in  rubeola,  treatment,  580 
in  tubercular  form  of  leprosy,  789 
in  typhoid  fever,  273 
in  typhus  fever,  351 
in  varicella,  487 
in  variola,  437 
characters,  438 
position,  438 
in  varioloid,  444 
Eruptive  stage  of  rubeola,  duration  of,  567 

symptoms  of,  565 
of  variola,  treatment,  452 
ERYSIPELAS,  629 
Definition,  629 
Synonyms,  629 
Classification,  629 
History,  629 
Etiology,  629 

Unity  of  the  origin,  629 
Age  and  sex  as  a  causa,  630 
Season  as  a  cause,  630 
Contagiousness,  630 
Nature  of  contagion,  630 
Manner  of  propagation,  630 
Relation  to  childbed  fever,  630 
Symptoms— initial,  631 

Characters  of  cutaneous  lesions,  631 
Course  of  cutaneous  lesions,  631 
Severe  varieties  of  cutaneous  lesions, 

632 

Migration  of  cutaneous  lesions,  632 
Swelling  of  integument,  632 
Starting-point  of  cutaneous  lesions,  632 
Physiognomy,  632 
Condition  of  tongue,  633 

of  fauces  and  buccal  membrane,  633 
General  symptoms  of  grave  form,  633 
pulse,  633 
temperature,  633 
Occurrence  of  gangrene,  233 
Resolution,  633 
Desquamation,  633 
Complications  and  sequelae,  633 
Complicated  by  lymphangitis  and  aden- 

opathy,  634 
By  pneumonia,  634 

VOL.  I.— 67 


ERYSIPELAS— complicated  by  plenritis,  634 
By  inflammation  of  joints,  634 
By   inflammations    of   serous   mem- 
branes, 634 

By  pyaemia  and  septicaemia,  634 
By  eye  diseases,  634 
Followed  by  seborrhoea  of  scalp,  633 

By  loss  of  hair,  633 
Modification  of  previous  skin  disorders. 

634 

Chronic  forms,  634 

Variety  and  nature  of  chronic  forms,  634 
Morbid  anatomy,  635 
Changes  in  skin,  635 
Viscera,  635 
Mucous  surfaces,  635 
Diagnosis,  635 

From  dermatitis,  636 
From  eczema,  636 
From  erythema,  636 
From  pemphigus,  636 
From  scarlet  fever,  636 
From  urticaria,  636 

Prognosis — symptoms  indicating  unfavor- 
able, 636 

Treatment — preventive,  636 
Hygienic,  637 
General,  637 
Hyperpyrexia,  637 
Delirium,  637 
Local,  637 

Value  of  abortive,  638 
Surgical,  638 

Mouth  complications,  638 
Nasal  complications,  638 
Abscesses,  638 
Value  of  expectant,  639 
Convalescence,  639 
Diet,  639 
Use  of  quinia,  637 

tincture  of  the  chloride  of  iron,  637 
Erysipelas,  complicating  diphtheria,  673 
typhus  fever,  355 
vaccination,  469 
variola,  445 

relation  of,  to  puerperal  fever,  1002 
Etiology,  general,  125 
of  anthrax  in  animals,  928 

in  man,  939 
of  beriberi,  1038 
of  cerebro-spinal  meningitis,  801 
of  cholera,  720 
of  dengue,  883 
of  diphtheria,  680 
of  erysipelas,  629 
of  glanders  in  horse,  911 

in  man,  919 

of  idiopathic  parotitis,  620 
of  influenza,  859 
of  leprosyj  787 
of  pertussis,  838 
of  the  plague,  774 
of  puerperal  fever,  1013 
of  pyaemia,  955 

of  rabies  and  hydrophobia,  887 
of  relapsing  fever,  370 
of  remittent  fever,  598 


1058 


INDEX. 


Etiology  of  rotheln,  583 
of  rubeola,  557 
of  scarlet  fever,  487 
of  septicaemia,  960 
of  septo-pyaemia,  963 
of  simple  continued  fever,  232 
of  symptomatic  parotitis,  625 
of  typhoid  fever,  242 
of  typhus  fever,  341 
of  varicella,  481 
of  variola,  435 
of  yellow  fever,  640 

Eucalyptus,  use  of,  in  typhoid  fever,  331 
Excision  of  cicatrix  for  prevention  of  hydro- 
phobia, 908 

of  primary  nucleus  in  anthrax,  943 
Exciting   cause,   mechanical   nature   of,  in 

symptomatic  parotitis,  626 
of  the  plague,  775 
of  typhoid  fever,  248 
of  typhus  fever,  343 

Excrement,  human,  disposal  of,  by  privy- 
vaults,  219 

dry  conservancy,  21 8  et  seq 
removal  of,  by  water-carriage,  215 
Exercise,  abnormal,  as  a  cause  of  disease,  134 
amount  necessary  for  health,  198 
as  a  part  of  a  systematic  education,  199 
deficiency  of,  a  cause  of  disease,  135 
Du  l>ois  Reyraond's  definition,  198 
importance  of,  in  preservation  of  health, 

198 

relation  of,  to  mental  work,  199 
Expectant  treatment  of  erysipelas,  value,  639 
Expectoration,  significance  of,  in  diagnosis, 

158 

External  anthrax,  localized,  935 
Exudation,  distinction  from  transudation,  42 
in  inflammation,  42 

in  peri-  and  parametritis  of  puerperal  fe- 
ver, 1007 

in  pelvic  peritonitis,  9S9 
Eye,  affections  of,  following  cerebro-spinal 

meningitis,  819 
in  rubeola,  treatment,  581 
condition  of,  in  cerebro-spinal  meningitis, 

810 

diseases  of,  complicating  erysipelas,  634 
rubeola,  571 
variola,  445 
lesions   of,   in   cerebro-spinal  meningitis, 

8-24 

in  pyaemia,  967 

Eyes,  appearance  of,   significance  in    gen- 
eral diagnosis,  151 

F. 

Face,  appearance  of,  in  typhus  fever,  348 
Family  predisposition  to  diphtheria,  681 
Faradization,  use  of,  in  rabies  and  hydro- 
phobia, 907 
Farcy,  909 

Fatigue  as  a  cause  of  typhus  fever,  342 
Fat,  sources  of,  in  the   body,  74 
Fatty  degeneration,  74 
causes.  78 


Fatty   degeneration,  following   diphtheritic 

paralysis,  676 
infiltration,  76 
metamorphosis,  74,  79 
Fauces,  condition  of,  in  cerebro-spinal  men 

ingitis,  814 
in  erysipelas,  633 
in  malignant  scarlet  fever,  508 
in  typhoid  fever,  286 
inflammation    of,   complicating    rubeola, 

571 
significance  of  appearance  of,  in  general 

diagnosis,  152 

Faucial  and  nasal  mucous  membrane,  con- 
dition of,  in  mild  scarlet  fever,  504 
Febrifuge,  use  of,  in  relapsing  fever,  428 
Febrile  stage  of  grave  form  of  the  plague, 

778 

Fermentation  theory  of  disease,  138 
Fever,  agents  producing  heat  in,  40,  41 
definition,  38 
inflammatory,  37 

distinguished  from  idiopathic,    37 
influence  of  vaso-motor  system  on  produc- 
tion of  heat  in,  39 
intermittent,  592 
malarial,  589 
pernicious  malarial,  605 
puerperal,  984 
relapsing,  369 
remittent,  598 
sanitary  effects,  41 
scarlet,"  486 

secondary,  in  variola,  439 
simple  continued,  231 
symptoms,  38 
temperature,  38-40 
traumatic,  37 
typlio-malarial,  614 
typhoid,  237 
typhus,  338 
yellow,  640 
Fibrinous  degeneration,  80 

inflammation,  49 
Filtering  power  of  soil,  187 
Filth  as  a  cause  of  cholera,  721 
diphtheria,  682 
the  plague,  774 
relapsing  fever,  370 
Foetus,  effects  of  maternal  impression  upon, 

131 
Fomites,  propagation  of  cholera  by,  721 

special,  of  cholera,  723 
Food,  adulterations,  197 

appetite  as  a  guide  to  necessary  amount, 

195 

as  a  cause  of  disease,  195 
infants,  196 
patient's  sensations  as  a  guide  to  choice 

of,  in  disease,  205 
popular  errors  in  regard  to,  195 

to  overeating,  195 
preparation  of,  necessity  of  a  physician's 

knowledge  of,  196 
proper,   necessity  of,    in    prevention    of 

pyaemia  and  septicaemia,  980 
transmission  of  anthrax  by,  929 


1050 


Formad  on  peculiarities  of  scrofulous  habit, 

101 

Forms  of  anthrax  in  animals  and  man,  934, 
940 

of  leprosy,  789 

of  the  plague,  777 

of  rabies,  895 

of  relapsing  fever,  395 

of  vaccine,  476 
Fourth    ventricle,   lesions    of,   in    cerebro- 

spinal  meningitis,  824 
Framum  lingua?,  ulceration  of,  in  pertussis, 

841 
Frequency  of  puerperal  fever,  984 

of  typho-malarial  fever,  616 
Frictions,  use  of,  in  dry  beriberi,  1043 
Frontal  pains  in  influenza,  867 
Fruit,  propagation  of  mahiria  by,  591 
Fulminant  form  of  the  plague,  779 
Furious  form  of  rabies,  896 
Furuncles,  complicating  variola,  445 

G. 

Gait,  peculiarity  of,  in  beriberi,  1039 
Gall-bladder,  lesions  of,  in  cholera,  746 

in  typhoid  fever,  266 
Gangrene,  56 

complicating  vaccination,  468 
following  typhoid  fever,  293 

typhus  fever,  355 
in  erysipelas,  633 
in   symptomatic    parotitis,   treatment  of, 

628 

of  neck,  complicating  scarlet  fever,  512 
pulmonary,  complicating  relapsing  fever, 

404 

Gangrenous  affections  following  rubeola,  574 
Gastro-intestinal     canal,    condition    of,    in 

dengue,  881 

condition  of,  in  yellow  fever,  644 
lesions  of,  in  anthrax,  936 
in  influenza,  872 
in  rabies  and  hydrophobia,  902 
in  relapsing  fever,  413 
symptoms  in  influenza,  866 
in  mild  scarlet  fever,  505 
in  malignant  scarlet  fever,  507 
of  septicaemia  lymphatica,  1011 
Gelsemium,  use  of,  in  yellow  fever,  651 
GENERAL  ETIOLOGY,  125 
General  dropsies,  71 

treatment  of  erysipelas,  639 

of  glanders  in  horse  and  man,  919,  920 
Genitalia,  gangrene  of,  complicating  variola, 

446 

Geographical  distribution  of  anthrax,  926 
of  beriberi,  1038 
of  glanders,  909 
of  rabies  and  hydrophobia,  886 
of  relapsing  fever,  3G9 
of  typhoid  fever,  241 
Germ,  specific,  of  glanders,  nature  of,  914 
of  rabies  and  hydrophobia,  892 

point  of  election  of,  892 
Germ-theory  of  disease,  138 
of  scarlet  fever,  488 


Giddiness,  significance  of,  in  general  diag- 
nosis, 166 

GLAKDERS  (FARCY),  909 
Synonyms,  909 
Definition,  909 
History,  909 

Geographical  distribution,  909 
Etiology — Contagiousness,  911 
Specific  nature,  911 
Predisposing  causes,  912 
Ill-health,  relation  of,  to  causation,  912 
Cold  and  damp  stables,  relation  of,  to 

causation,  912 
Debility  from  chronic  diseases,  relation 

of,  to  causation,  912 
Infection,  channels  of,  913 
Particular  nature  of  the  germ,  914 
Virulence  of  the  germ,  914 
Modes  of  culture  of  germ,  914 
Demonstration  of  bacillus  of,  914 
Symptoms — in  horses,  914 
Acute  form,  914 

Incubation  period,  914 
Mode  of  onset,  914 
Local  lesions,  915 
Appearance  of  nostrils,  915 

of  lymphatics,  915 
Enlargement  of  joints,  915 
Appearance  of  ulcers,  915 
Mode  of  death  in,  915 
Chronic  form,  915 

Premonitory  symptoms,  915 
Condition  of  general  health,  915 
Local  lesions,  915 
Lymphatics,  915 

Bronchial  and  pulmonary  form,  916 
Acute  cutaneous  form  (farcy),  916 

Local  lesions,  916 

Chronic    cutaneous     form     (chronic 
farcy),  916  < 

Local  lesions,  916 
Duration,  915 
Morbid  anatomy,  916 

Nasal  lesions,  characters  of,  917 
Pulmonary  lesions,  characters  of,  917 
,  Cutaneous  lesions,  characters  of,  917 
Diffuse  glanderous  swellings,  917 
of  nose,  918 
of  lungs,  918 
of  muscles,  918 
Diagnosis,  918 

Value  of  inoculation  in,  918 
Prognosis,  918 

Unfavorable  nature  of,  918 
Treatment — in  animals,  918 
Not  commendable,  918 
Local,  918 
General,  919 
Diet  in,  919 
Preventive,  919 
Extermination  of  disease  in  animals, 

919 

Glanders  in  Man,  919 
History  of,  919 
Etiology,  919 
Modes  of  infection,  919 
immediate,  919 


1060 


INDEX. 


Glanders  in  Man — Etiology:  Modes  of  in- 
fection, mediate,  920 
Influence  of  occupation,  920 
Influence  of  ill-health,  920 
Symptoms — incubation  period,  920 
Appearance  of  wound,  920 
General,  920 
Mode  of  onset,  920 

Character  and  seat  of  local  lesions,  921 
Appearance  of  sores,  921 
Condition  of  nasal  mucous  membrane, 

921 

of  submaxillary  glands,  921 
of  conjunctiva,  921 
Digestive  tract,  921 
Nervous  system,  921 
Temperature  in,  921 
Pulse  in,  921 
Chronic  form,  921 
General,  921 
Local,  921 

Cutaneous  lesion,  922 
Respiratory  lesions,  922 
Lymphatic  glands,  922 
Digestive  tract,  922 
Convalescence,  922 
Duration  of  acute  forms,  921 

of  chronic  forms,  922 
Morbid     anatomy — changes    in    mucous 

membranes,  922 
Lungs  and  pleurae,  922 
Gastro-intestinal  tract,  922 
Spleen  and  liver,  922 
Joints,  922 
Bones,  922 

Brain  and  membranes,  923 
Microscopy  of  lesions,  923 
Diagnosis,  923 

Pathognomonic  signs  in,  923 
From  "rheumatic  fever,  923 
Chronic  form,  from  pyaemia  and  septi- 
caemia, 923 
From  syphilis,  924 
From  miliary  tuberculosis,  924 
Presence  of  bacillus  not  conclusive,  924 
Value  of  inoculation  in,  924 
Prognosis — unfavorable  nature  of,  924 
Treatment — External  cases,  924 
Erysipelatoid  swellings,  924 
Abscesses  and  tumors,  924 
Nasal  ulcers,  924 

Importance  of  general  treatment,  924 
Use  of  antiseptics,  924 
Diet,  924 
Preventive,  925 

Extinction  of  affection  in  animals,  925 
Necessity  of  disinfection,  925 
Glanderous  swelling,  diffuse,  917 
Glands  at  angle  of  jaw,  swelling  of,  sympto- 
matic of  nasal  invasion,  in  diph- 
theria, 669,  670 
Glandular  abscesses  in  diphtheria,  treatment, 

710 

degenerations,  72 

swellings  in  diphtheria,  treatment,  709 
Glycosuria,   complicating    relapsing   fever, 
410 


Gout,  hereditary  nature,  127 
Granuloma,  120,  124 

Grave  forms  of  cholera,  physiognomy,  734 
stools,  733 
symptoms,  732 
of  the  plague,  777 
of  relapsing  fever,  395 
Grease-traps,  varieties,  221 
GROWTHS,  MORBID,  105 
Gums,  significance  of  state  of,  in  general  di- 
agnosis, 151 

H. 

Habits,   depressing,  as  a  cause  of  cerebro- 

spinal  meningitis,  802 
Hsematemesis,  significance  of,  in  general  di- 
agnosis, 163 
in  relapsing  fever,  390 
Haematoidin,  91 
Hsematoma,  115, 122 
Haematuria  in  relapsing  fever,  390 
Haemoglobin,  90 

Haemophilia,  hereditary  nature,  129 
Haemoptysis,  significance  of,  in  general  diag- 
nosis, 163 

Haemostatics,  use  of,  in  yellow  fever,  652 
Hair,  appearance  of,  in  typhoid  fever,  275 

loss  of,  following  erysipelas,  633 
Headache  in  cerebro-spinal  meningitis,  808 
in  idiopathic  parotitis,  624 
in  influenza,  867 
treatment,  874 
in  relapsing  fever,  383 
in  typhoid  fever,  277 

treatment,  334 
in  typhus  fever,  348 

treatment,  366 

Health,  importance  of  exercise  in  preserva- 
tion, 198 

Health-resorts,  disease  from,  185 
Hearing,  impairment  of,  following  cerebro- 
spinal  meningitis,  819 
disorders  of,  in  relapsing  fever,  400 
modifications  of,  in  typhoid  fever,  279 

significance  of,  in  general  diagnosis,  166 
Heart,  alterations  of,  in  beriberi,  1041 
condition  of,  in  beriberi,  1040 
in  cholera,  737 
in  pyaemia,  976 
in  typhus  fever,  351 
disease,  complicating  influenza,  870 
lesions  of,  in  cholera,  746 
in  diphtheria,  686 
in  relapsing  fever,  411 
in  septicaemia,  972 
in  typhoid  fever,  267 
in  typhus  fever,  357 
and  blood-vessels,  lesions  of,  in  rabies  and 

hydrophobia,  902 
palpitation  of,  in  beriberi,  1039 
Heart-clot,  complicating  relapsing  fever,  402 
rubeola,  672 
scarlet  fever,  523 
Heat  as  a  cause  of  disease,  133 

use  of,  in  cholera,  769 
Hemorrhages  in  dengue,  882 


INDEX. 


1061 


Hemorrhages  in  hemorrhagic  form  of  per- 
nicious malarial  fever,  treatment, 
612 

in  remittent  fever,  treatment,  605 
in  yellow  fever,  646 

treatment,  651 
intestinal,  in  typhoid  fever,  287,  288 

treatment,  332 
Hemorrhagic  form  of  pernicious  malarial 

fever,  609 
causes,  610 

seat  of  hemorrhages,  610 
symptoms,  611 
treatment,  612 
of  scarlet  fever,  509 
of  variola,  treatment,  454 
infarction,  64 
rubeola,  569 
small-pox,  442 

variola,  morbid  anatomy  of  pock  in,  447 
Hepatic  abscess  following  typhoid  fever,  295 
Heredity  as  a  cause  of  disease,  175 
influence  of,  on  marriage,  176 
relation  of,  to  life  insurance,  175 
as  a  cause  of  leprosy,  787 
Hereditary  diathesis,  transmutation,  130 
nature  of  syphilis,  127 

of  non-malignant  morbid  growths,  129 
of  nervous  diseases,  129 
of  organic  disease,  129 
of  rickets,  128 

predisposition  to  disease,  126 
Herpes  labialis,  complicating  influenza,  874 
Hiccough  in  cholera,  762 
in  relapsing  fever,  405 
significance  of,  in  general  diagnosis,  158 
Histoid  tumors,.  116 
History  of  anthrax  in   animals   and   man, 

926,  939 

of  beriberi,  1038 
of  cerebro-spinal  meningitis,  796 
of  cholera,  715 
of  dengue,  879 
of  diphtheria,  656 
of  erysipelas,  629 
of  glanders  in  horses,  909 

in  man,  919 
of  influenza,  852  ei  seq. 
of  pertussis,  836 
of  rabies  and  hydrophobia,  886 
of  relapsing  fever,  309 
of  rotheln,  582 
of  rubeola,  557 

of  pyaemia  and  septicaemia,  945-952 
of  scarlet  fever,  486 
of  simple  continued  fever,  231 
of  typhoid  fever,  238 
of  typhus  fever,  338 
of  vaccination,  465 
of  vaccinia,  456 
of  varicella,  481 
of  variola,  434 
Hodgkin's  disease,  complicating  diphtheria, 

675 

Horse-pock  vaccine,  473 
Hospitals  for  infectious  diseases,  necessity, 
203 


Hospital,  maternity,  advantages,  1021 

Hot  stage  of  intermittent  fever,  treatment,  595 

House-drainage,  188 

disconnection  of,  from  sewer,  190 
testing,  190 
House-plumbing,  190 
Houses,  sanitary  inspection,  187,  193 
House-sewerage,  188 

dangers  to  health  from,  189,  191 
examination  of  a  system,  188 
main  points  in  a  good  system,  191 
peppermint-test  for  defects,  190 
Human  excrement,  removal  of,  by  drainage, 

^  215 
Humanized   and  animal   vaccine,   relative 

merits,  473 

vaccine,  points  of  superiority,  473 
Humidity  of  air  as  a  cause  of  disease,  133 
Hunger,  influence  of,  on  causation  of  rabies 

and  hydrophobia,  888 
Hyaline  degeneration,  80 
Hydro-bilirubin,  91 
Hydrocephalus,     following     cerebro-spinal 

meningitis,  819 
Hydrochloric  acid,  local  use  of,  in  puerperal 

fever,  1028 
Hydrophobia,  886 
Hygiene,  173 

importance  of  perfect,  in  cholera  epidem- 
ics, 758 

in  pertussis,  848 

public,  relation  of  physicians  to,  207 
Hygienic  treatment  of  erysipelas,  637 
of  hydrophobia,  906 
of  scarlet  fever,  539 
of  typhoid  fever,  322 
of  yellow  fever,  654 
Hygroma,  116,  122 

Hyperpyrexia  in  diphtheria,  treatment,  694 
in  erysipelas,  treatment,  637 
in  puerperal  fever,  treatment,  1032 
in  relapsing  fever,  treatment,  426 
in  rubeola,  treatment,  579 
in  scarlet  fever,  treatment,  541 
in  typhoid  fever,  treatment,  327 
in  typhus  fever,  treatment,  364 
in  yellow  fever,  treatment,  651 
Hypodermatic   injection   of  anthrax  swell- 
ings, 938,  943 


Ice,  impure,  as  a  cause  of  disease,  185 
use  of,  in  diphtheria,  702 

in  scarlet  fever,  542 
Idiopathic  parotitis,  620 
Idiosyncrasy  as  a  cause  of  typhoid  fever, 

245 

influence  of,  in  causation  of  variola,  436 
Ill-health,  influence  of,  in  causation  of  glan- 
ders, 912,  920 
Impure  air  as  a  cause  of  disease,  177 

evil  effects  of,  181 
water,  as  a  cause  of  disease,  182 
Impurities  of  water,  from  living  organisms, 

184 
nature,  184 


1062 


IXDEX. 


Incubation  of  relapsing  fever,  376 
of  scarlet  fever,  492 
of  typhus  fever,  34.6 
of  varicella,  481 
of  variola,  436 
period  of  anthrax  in  animals,  934 

in  man,  940 

of  diphtheria,  duration  of,  679 
of  glanders  in  horse,  914 

in  man,  920 
of  influenza,  863 
of  intermittent  fever,  592 
of  the  plague,  777 
of  rabies  and  hydrophobia,  894 
of  rotheln,  585 
of  typhoid  fever,  259 
of  yellow  fever,  643 

stage. of  idiopathic  parotitis,  duration,  621 
of  idiopathic  parotitis,  621 
of  puerperal  fever,  1004 
of  pyaemia,  973 
of  rubeola,  563 
Indications  for  treatment  of  puerperal  fever, 

1028 

of  septicaemia,  982 
of  yellow  fever,  649 
Infants'"  food,  196 
Infarction,  hemorrhagic,  164 
Infection,  200 

channels  of,  in  glanders,  913 
modes  of,  in  human  anthrax,  939 
Infiltration,  albuminoid,  72 
amyloid,  84 
fatty,  76 

INFLAMMATION,  37 
Characteristics,  37 
Heal,  37 
Redness,  37 
causes,  37 
Pain,  41 

causes,  41 
Swelling,  41 
causes,  41 
Exudation,  42 
Keuss  on  distinction  of  exudation  from 

transudation,  42 

Migration  of  white  corpuscles,  42 
Coagulation  of  exudation,  43 
Changes  in  the  blood-vessels,  43 
Disturbance  of  functions,  44 
Varieties  of — hemorrhagic,  48 
Diphtheritic,  50 
Productive,  51 
Catarrhal,  52 
I'hlegmonous,  52 
Acute,  53 
Chronic,  53 
Interstitial,  53 
Parenchymatous,  53 
Termination,  54,  55,  56 
Resolution,  54 
New  formations,  54 
Cicatrization,  55 
Abscesses,  56 
Destruction  of  tissue,  56 
Causes,  toxic,  43 
traumatic,  44 


INFLAMMATION— Causes,  parasitic,  45 

infectious,  45 

constitutional,  46 

trophic,  46 
Course,  46 

Sthenic  and  astheuic,  46 
Serous,  47 
Typhoidal,  47 

symptoms,  47 
Purulent,  48 

Suppurative,  relation  of  microbia,  48 
Fibrinous,  49 

of  fauces,  catarrhal  and  diphtheritic,  com- 
plicating typhoid  fever,  295 
of  neck,  complicating  parotitis,  511 
simple,  complicating  vaccination,  468 
Inflammations,  serous,  complicating  typhus 

fever,  355 

Inflammatory  fevers,  37 
form  of  typhus  fever,  354 
rubeola,  568 

INFLUENZA — Definition,  Sol 
Synonyms,  851 
History,  852  el  seq. 
Etiology,  859 

Predisposing  causes,  859 

Age,  relation  of,  to  causation,  SCO 

Social  condition,  relation  of,  to  causa 
tion,  860 

Sex,  relation  of,  to  causation,  860 

Occupation,   relation  of,   to  causation, 
860 

Race,  relation  of,  to  causation,  860 

Over-crowding  and  filth,  relation  of,  to 
causation,  860 

Season,  relation  of,  to  causation,  860 

Climate,  relation  of,  to  causation,  860 

Air,  condition  of,  to  causation,  860 

Winds,  relation  of,  to  spread,  860 

Mode  of  onset  of  epidemics,  860,  861 

Duration  of  epidemics,  861 

Exciting  causes,  862 

Specific  poison,  863 

Contagiousness,  862 

Dissemination,  863 

Relation  of,  to  other  epidemic  diseases,  863 
Incubation  period,  863 
Clinical  history,  864 

Variations   in   intensity   of  symptoms, 
864 

Symptoms  of  mild  cases,  864 

of  severe  cases,  864 
Symptomatology,  865 

Analysis  of  symptoms,  865 

Fever,  865 

Temperature,  865 

Pulse,  866 

Urine,  866 

Skin,  866 

Eruptions,  866 

Gastro-intestinal  system,  866 

Nausea  and  vomiting,  866 

Physiognomy,  866 

Catarrhal  symptoms,  866 

Condition  of  mucous  membrane,  866 

Hoarseness,  867 
.  Cough  and  dyspnoea,  867 


IXDEX. 


1063 


INFLUENZA — Symptoinology :  Nervous  sys- 
tem, 867 
Headache,  867 
Frontal  pain,  867 
Pains  in  limbs,  868 
Pleurodynia,  868 
Delirium,  868 
Dizziness,  868 
Sleeplessness,  868 
Hebetude  and  torpor,  868 
Muscular  twitchings,  868 
Mental  condition,  868 
Duration,  865 

Complications  and  sequels,  868 
Inflammations  of  lungs,  868 

Bronchitis    and    capillary    bronchitis. 

868,  869 

Catarrhal  pneumonia,  869 
Lobar  pneumonia,  869 
Localized  pulmonary  collapse,  869 
Gangrene  of  lungs,  870 
Pleurisy,  870 
Pericarditis,  870 

Laryngitis  and  chronic  bronchitis,  870 
Inflammation  of  middle  ear,  870 
Parotitis,  870 
Herpes  labi;ilis,  870 
Phthisis,  870 

Emphysema,  aggravation,  870 
Old  neuralgias,  aggravation,  870 
Heart  disease,  aggravation,  870 
Bright's  disease,  aggravation,  870 
Pregnancy,  870 
Intermittent  fever,  870 
Morbid  anatomy,  871 
Essential  lesions,  871 
Appearance  of  respiratory  tract,  871 
Changes  in  gastro-intestinal  tract,  872 
Bronchial  glands,  872 
Lung  tissue,  872 

Pathology — Not  a  simple  acute  inflamma- 
tion, 871 

Specific  character,  871 
Diagnosis — From    non-specific    catarrhal 

affections,  872 
From  typhoid  fever,  872 
Prognosis — Influence  of  age,  872 

pre-existing  organic  disease,  872 
of  character  of  epidemic,  872 
Mortality,  872,  873 

Variability  in  different  epidemics,  873 
Rate  of,  873 
Cause  of  death,  873 
Treatment — preventive,  873 
Mild  forms,  874 
Catarrh,  874 
Headache,  874 
Cough,  875 
Use  of  quinine,  874 
Opium,  774 
Fat  inunctions,  874 
Diet,  874 
Severe  forms,  875 

Indications  for  treatment,  875 
High  temperature,  875 
Cough,  876 
Sub-sternal  and  chest  pains,  876 


INFLUENZA— Treatment :  Severe  forms,  use 

of  diaphoretics,  875 
Bloodletting,  875 
Emetics,  876 
Purgatives,  876 
Quinine,  876 
Mineral  acids,  876 
Expectorants,  877 
Opium,  876 
Alcohol,  877 
Chloral,  877 
Diarrhoea,  877 
Debility,  877 
Lung  complications,  877 
Diet  in,  875 
Convalescence,  878 
Danger  of  depressing  measures,  878 
Inhalations,  use  of,  in  pertussis,  844 
Initial  stage  of  pertussis,  840 

symptoms  of  yellow  fever,  644 
Injections,  intravenous,  use  of,  in  cholera,  768 
in  hydrophobia,  908 
in  puerperal  fever,  1029 
vaginal,  use  of,  in  prevention  of  puerperal 

fever,  1026 

Inoculation  as  a  means  of  diagnosis  in  glan- 
ders, 918 
as  a  means  of  diagnosis  in  hydrophobia, 

902 

as  a  prophylactic  in  anthrax,  937 
in  rabies  and  hydrophobia,  905 
in  scarlet  fever,  536 
of  leprosy,  788 
of  rubeola,  559 
of  small-pox,  465 

Insects,  propagation  of  anthrax  by,  929 
Insomnia  in  typhoid  fever,  treatment,  334 
in  typho-malarial  fever,  'treatment,  619 
in  typhus  fever,  treatment,  366 
Inspection  of  houses,  sanitary,  187 
Insusceptibility  to  rabies  and  hydrophobia, 

894 
Intellect,  impairment  of,  following  cerebro- 

spinal  meningitis,  819 
impairment  of,  following  typhoid  fever, 

292 

Intellectual  condition  in  typhus  fever,  348 
Intemperance  as  a  cause  of  cholera,  721 
of  disease,  197 
of  relapsing  fever,  370 
of  typhoid  fever,  245 
of  typhus  fever,  342 
Intermission  in  intermittent  fever,  594 

in  relapsing  fever,  381 
INTERMITTENT  FEVER,  592 
Incubation  period,  592 
Symptoms — prodromal  stage,  592 
Paroxysm,  592 
Cold  stage,  592 

theory  of  cause  of  cold  stage,  593 
Hot  stage,  593 

duration  of  hot  stage,  593 

relation   of  type  to  duration  of  hot 

stage,  593 
Sweating  stage,  593 

Nausea  and  vomiting  during  paroxysm, 
693 


J064 


INDEX. 


INTERMITTENT  FEVER— Symptoms :  Inter- 
mission, 594 

Duration  of  intermission,  594 
Relative    frequency    of   different    types, 

594 

Convertibility  of  different  types,  594 
Morbid  anatomy,  594 
Treatment — cold  stage,  594 
Use  of  quinia,  595 
Opium,  595 
Emetics,  595 
Hot  stage,  595 
Use  of  opium,  595 
Quinia,  596 
Purgatives,  596 
Of  convulsions,  597 
Sweating  stage,  597 

Use  of  quinia,  597 
Causes  of  failure  of  quinia,  597 
Adjuvants  to  quinia  in  preventing  re- 
turn of  paroxysms,  598 
Use  of  nitric  acid  to  prevent  return  of 

paroxysms,  598 

Internal  anthrax  in  animals,  934 
Interstitial  inflammation,  53 
Intestinal  anthrax  in  man,  941 
canal,  lesions  of,  in  cholera,  743 
catarrh,  chronic,  following  rubeola,  574 

complicating  rubeola,  572 
tract,  lesion  of,  in  typhus  fever,  357 
Intestines,  lesions  of,  in  diphtheria,  689 

symptoms  of  diphtheria  of,  673 
Intravenous  injection  of  warm  water  in  hy- 
drophobia, 908 

Inunction  in  scarlet  fever,  541 
Inunctions,  use  of,  in  rubeola,  580 
Invasion  of  cerebro-spinal  meningitis,  806 
of  diphtheria,  676 
of  variola,  438 

stage  of  grave  form  of  the  plague,  777 
of  idiopathic  parotitis,  duration,  621 

treatment,  624 
of  variola,  treatment,  452 
of  varioloid,  443 
Iodine  as  a  specific  in  typhoid  fever,  336, 

337 
lodoform,  intra-iiterine  use  of,  in  puerperal 

fever,  1025 
Iron,  persulphate,  local  use  of,  in  puerperal 

fever,  1028 

tincture  of  the  chloride,  use  of/ in  diph- 
theria, 706 
in  erysipelas,  637 
in  yellow  fever,  652 
Irregular  forms  of  scarlet  fever,  508 
Irrigation,   disposal   of   liquid    wastes  by, 

225 

Irritability  of  nervous  system  in  hydropho- 
bia, 899 

Irritants,  influence  of,  in  production  of  mor- 
bid growths,  108 

Isolated  glands,  lesions  of,  in  cholera,  745 
Isolation  in  anthrax,  937 
in  diphtheria,  696 
in  the  plague,  783 
in  rubeola,  578 
in  scarlet  fever,  536 


Isolation,  necessity  of,  in  typhus  fever,  361 
principles  of,  in  disease,  203 

J. 

Jaborandi,  use  of,  in  scarlet  fever,  552 

in  yellow  fever,  650 
Jaundice  in  relapsing  fever,  391 
in  septicaemia  venosa,  1012 
complicating  typhoid  fever,  295 

typhus  fever,  356 
in  remittent  fever,  600 
in  yellow  fever,  646 
Joints,  chronic  diseases  of,  following  rube- 

ola, 574 

condition  of,  in  glanders  in  man,  920 
inflammation  of,  complicating  erysipelas, 

634 

lesions  of,  in  pyaemia,  967 
purulent  inflammation   of,  in   puerperal 

fever,  990 

suppuration  of,  in  pyaemia,  976 
swelling  of,  in  cerebro-spinal  meningitis, 

814 

in  relapsing  fever,  400 
Jugular  veins,  pulsation  of,  significance  in 

general  diagnosis,  156 
Juniper  gin,  use  of,  in  wet  beriberi,  1042 

K. 

Kibble's  fever-cot,  use  of,  in  puerperal  fever, 

1034,  1035 
Kidney  affections,  complicating  diphtheria, 

676 

complications   in    hemorrhagic  form   of 
pernicious    malarial    fever,   treat- 
ment, 612 
Kidneys,  lesions  of,  in  anthrax  in  animals, 

937 

in  man,  942 
in  cholera,  746 
in  diphtheria,  687 
in  pyaemia,  969 

in  rabies  and  hydrophobia,  903 
in  relapsing  fever,  414 
in  scarlet  fever,  526 
in  septicaemia,  972 
in  typhoid  fever,  268 
in  typhus  fever,  357 
Koch's  investigation  of  bacillus  tuberculosis. 

99 

of  cholera  bacilli,  745-749 
of  bacteria  of  puerperal  fever,  997 


Lactic  acid,  use  of,  in  diphtheria,  703 

Lardaceous  degeneration,  84 

Laryngeal  diphtheria,  local  treatment,  712 

prognosis,  692 
Laryngitis,  complicating  rubeola,  571 

typhoid  fever,  294 
Larynx,  inflammation  of,  complicating  va- 

riola, 446 
lesions  of,  in  hydrophobia,  902 

in  relapsing  fever,  413 


INDEX. 


1065 


Larynx,  lesions  of,  in  typhoid  fever,  266 

symptoms  of  diphtheria,  671 
Latent  form  of  typhoid  fever,  300 
Leeches,  use  of,  in  puerperal  fever,  1031 
LEPROSY,  785 
Definition,  785 
Synonyms,  785 
History,  785 
Etiology,  787 

Heredity  as  a  cause,  787,  788 
Contagiousness,  788 
Transmission,  by  inoculation,  788,  789 
Sex  as  a  cause,  789 
Forms,  789 
Symptoms — prodromal  stage,  789 

Duration  of  prodromal  stage,  789 
Tubercular  form,  789 
Local,  789 
Eruptions,  789 
Earlier  eruptions,  790 
Characteristic  eruptions,  790 
General,  790 
Duration,  790 
Anaesthetic  form,  790 
Local,  790 
General,  791 
Duration,  791 
Morbid  anatomy,  791 
Changes  in  nerves,  791 

Skin,  791 
Bacteria,  792 
Seat  of  bacteria,  792 
Diagnosis,  792 
Prognosis,  793 
Treatment,  793 

Futility  of  specific,  in,  793 
Indications,  793 
Prophylaxis,  794 
Segregation  of  afilicted,  794 
Quarantine  in,  794 
Local,  794 

Lesions  characteristic  of  anthrax,  935 
Lethargic  form  of  rabies  in  dogs,  897 
Leucocytes,  death  of,  aa  a  cause  of  throm- 
bosis, 57 
migration,  42 
Leucocythsemia,    complicating    diphtheria, 

675 

Lime-water,  use  of,  in  diphtheria,  703 
Limbs,  significance  of  appearance  in  general 

diagnosis,  160 
Listerine  as  a  prophylactic  in  scarlet  fever, 

537 
Liver,  abscess   of,  following  typhoid  ferer, 

295 

enlargement  of,  in  pyaemia,  976 
lesions  of,  in  cholera,  745 

in  diphtheria,  687 
,  in  glanders,  918,  922 
in  pyaemia,  969 
in  remittent  fever,  602 
in  relapsing  fever,  414 
in  scarlet  fever,  531 
in  typhoid  fever,  265 
in  typhus  fever,  357 
in  yellow  fever,  649 
Local  dropsies,  71 


Local  lesions  of  glanders,  915,  921 
symptoms  of  glanders  in  animals,  914 

of  glanders  in  man,  921 
treatment  of  anthrax  in  animals,  938 
of  anthrax  in  man,  943 
of  diphtheria,  701,  709 
of  erysipelas,  637 
of  glanders  in  horse,  918 

in  man,  924 
of  pyaemia,  981 
of  septicaemia,  983 
Lochial  discharge,  influence  of,  on  causation 

of  puerperal  fever,  1015 
Lung  diseases,  complicating  influenza,  868 
complicating  influenza,  treatment,  877 
Lungs,  gangrene  of,  in  influenza,  870 

hypostatic  congestion  of,  in  typhus  fever, 

353 

lesions  of,  in  cholera,  746 
in  diphtheria,  687 
in  glanders,  917,  922 
in  influenza,  872 
in  pyaemia,  968 
in  relapsing  fever,  413 
in  septicaemia,  972 
in  typhoid  fever,  266 
Lymph,  dried,  use  of,  in  vaccination,  477 
of  vaccinia,  microscopical  characters,  463 
vaccine,  proper  time  for  collecting,  479 
Lymphangetis,  complicating  erysipelas,  634 

vaccination,  468 
Lymphatic  glands,  condition  of,  in  anthrax, 

940 
in  glanders  in  horses,  915 

in  man,  921 

in  malignant  scarlet  fever,  508 
in  rotheln,  586 

lesions  of,  in  human  anthrax,  942 
in  anthrax  of  lower  animals,  935 
in  diphtheria,  687 
in  relapsing  fever,  417 
pigmentation  of,  92 

Lymphatics,  as  channel  of  entrance  of  poi- 
son of  septicaemia,  963 
lesions  of,  in  symptomatic  parotitis,  626 
Lymphatic  swellings,  seat  of,  in  grave  form 

of  the  plague,  778 
system,  lesions  of,  in  the  plague,  781 
Lymphoma,  120,  124 

M. 

Magnesium  sulphate,  use  of,  in  wet  beriberi, 

1042 
Malaria,  89 

action  of  poison  on  system,  591 
entrance  into  system,  modes  of,  591 
communicability  by  drinking-water,  590 
by  fruit,  591 
by  milk,  590 
conditions  necessary  to  mature  the  poison, 

589 

duration  of  incubation  of  poison,  591 
from  impure  water,  182 
influence  of  moisture  in  production,  187 
means  of  access  of  the  poison,  590 
nature  of  the  poison,  589 


10GG 


IXDEX. 


Malaria,  non-interchangeableness  of  the  poi- 
son, 591 

ponderability  of  the  poison,  590 
production,  137 
specific  nature  of  poison,  591 
MALARIAL  FEVER,  PERNICIOUS,  605 
Definition,  605 
Varieties,  GOG 

Algid  or  congestive  form,  606 
Causes,  GOG 
Frequency,  607 

Cases  illustrating  clinical  history,  606 
Causes  of  death,  607 
Mortality-rate,  007 
Treatment,  607 

General  indications  for  treatment,  608 
Use  of  ice  and  cold  in  treatment,  608 
Opium,  608 
Alcohol,  608 
Comatose  form,  600 
Symptoms,  608 
Previous  condition  of  persons  attacked, 

609 

Diagnosis  from  congestive  form,  609 
Treatment,  609 
Hemorrhagic  form  of,  609 
Causes,  G10 

Seat  of  hemorrhages,  610 
Cases  illustrating  clinical  history,  611 
Treatment,  612 
Indications  for  treatment,  612 
Use  of  quinia,  612 
Hemorrhages,  612 
Renal  complications,  613 
Depurative,  613 

Use  of  calomel  and  purgatives,  613 
Malarial  fevers,  589 

definition,  589 

nature  of  remittent  fever,  598 
Malignant  anthrax  oedema,  940 
pustule,  926 
tumors,  114 
Mania  following  cerebro-spinal  meningitis, 

a  819 

Maternity  hospitals,  advantages  of,  1021 
Marriages,  influence  of,  hereditary,  176 
of  diseased  persons,  176 
transmission  of  hereditary  proclivities  by, 

131 

Marriages,  consanguineous,  131 
Marson's  theory  of  multiple  vaccination,  467 
Masked  forms  of  yellow  fever,  symptoms,  654 
Maturation  in  variola,  439 
Measles,  557 

relations  of,  to  idiopathic  parotitis,  620 
Mechanism  of  transudation,  68 
Medical  diagnosis,  general,  148 
Melanaemia,  92 
Melanin,  92 
Membrane,  appearance  of,  in  severe  form  of 

diphtheria,  668 

diphtheritic,  artificial  production,  684 
characters,  685 
mode  of  formation,  685 
varieties,  686 

gangrenous   condition   of,  in   diphtheria, 
669 


MENINGITIS,    EPIDEMIC   CER EEC-SPINAL, 

795 

Definition,  795 
Synonyms,  795 
History,  796 
Etiology,  801 

Seasons  as  a  cause,  802 
Meteorological  agencies,  802 
Localities,  802 
Age,  influence,  802 
Sex,  influence,  802 

Depressing  and  debilitating  habits  803 
Contagiousness,  803 
Morbific  principle,  803 
Pandemic  nature,  804 
In  the  lower  animals,  804 
Types,  804 
Forms,  805,  806 
Symptoms — summary  of,  806 
"Modes  of  onset,  806,  807 
Individual,  808 
Pain  in  the  head,  808 

spine,  808 
Hypenesthesia  and  anaesthesia  of  skin, 

808 
Spinal  rigidity  or  opisthotonos,  809 

duration  of,  809 
Convulsions,  809 
Paralysis,  810 
Aphasia,  810 
Condition  of  eyes,  810 
pupils,  in,  810 
strabismus,  810 
blindness,  811 
Deafness,  811 
Suppurative    inflammation   of    middle 

ear,  811 

Physiognomy,  812 
Delirium,  812 
Coma,  812 
Vertigo,  812 
Debility,  813 
Condition  of  tongue,  813 
Kausea  and  vomiting,  813 
Characters  of  matter  vomited,  813 
Appetite  and  digestion,  814 
Thirst,  814 

Constipation  and  diarrhoea,  814 
Condition  of  fauces,  814 
Urine,  814 

Swelling  of  joints  and  limbs,  814 
Respiration,  814 
Pulse,  815 
Temperature,  815 

fluctuations  of,  816 
Eruptions,  816 

irregularity  of,  816,  817 
petechiae  and  ecchymoses,  816,  817 
bullre  and  pemphigus,  817 
Cause  of  death,  818 
Duration,  818 
Convalescence,  819 
characters,  819 
cause  of  tardv,  819 
Relapses,  820 

frequency,  820 
Sequela?,  819 


INDEX. 


1067 


MENINGITIS,  EPIDEMIC  CEREBRO-SPIXAL — 
Sequelae:  Followed  by  eye  affec- 
tions, 819 

Impairment  of  hearing,  819 
Deaf-mutism,  819 
Impaired  intellect  and  mania,  819 
Hydrocephalus,  819 
Paresis  and  paralysis,  819 
Softening  of  bruin,  820 
Difficulty  of  speech,  820 
Severe  neuralgic  pains,  820 
Mortality  of,  820,  828 

variability  of  death-rate,  820,  828 
influence  of  age  upon,  828 
Morbid  anatomy,  820 

General  appearance  of  body  after  death, 

820  ^ 
Changes  in  the  muscles,  821 

in  brain  and  membranes,  821 
Changes  due  to  congestion  of  brain  and 

membranes,  821 

to  inflammation  of  meninges,  822 
to  softening  of  the  brain,  823 
Changes  in  pia  mater,  821 
in  brain-tissue,  823 
in  spinal  cord  and  membranes,  823 

position  of,  823 
in  internal  and  auditory  apparatus, 

824 

Softening  of  fourth  ventricle  and  audi- 
tory nerve,  824 
Changes  in  eye  and  optic  nerve,  824 

in  the  viscera,  824 

Absence  of  enlargement  of  spleen,  824 
Changes  in  blood,  824 
Amount  of  fibrine  in  blood  before  death, 

825 

after  death,  825 

Changes  in  blood-corpuscles,  825 
Summary  of  pathology,  826 
Diagnosis  of,  826 

From  sporadic  meningitis,  827 

Functional   and    hysterical    nervous 

affections,  827 
Typhoid  fever,  827 
Typhus  fever,  827 
Prognosis  of,  828 

Symptoms  indicating  unfavorable,  829 

favorable,  829 

Imprudence  of  absolute,  in,  829 
Treatment,  829 
Emetics,  830 
Purgatives,  830 
Futility  of  venesection,  830 
Local  depletion,  830 
Cold  applications,  830 
Blisters,  830 

Mode  of  using  blisters,  831 
Of  coldness  of  skin,  431 
Of  collapse,  831 
Use  of  alcohol,  831 

Opium,  832 
Value  of  opium,  833 
Use  of  quinia,  833 
Antipyretics,  833 
Mercury,  833 
Calabar  bean,  834 


MEXISGITIS,  EPIDEMIC  CEREBRO-SPINAL,— 
Treatment:  Use  of  belladonna,  833 
Ergot,  833 

Potassium  bromide,  834 
Hydrate  of  chloral,  834 
Potassium  iodide,  834 
Management  of  convalescence,  835 
Diet  in,  834 

Meningitis,  granular,  following  rubeola,  574 
Menstrual  disorders,  complicating  relapsing 

fever,  410 
typhoid  fever,  296 
Menstruation,  complicating   typhus    fever, 

356 

significance  of  abnormal,  in  general  diag- 
nosis, 165 

Mental  condition  in  hydrophobia,  899 
in  influenza,  868 
in  septicaemia  lymphatica  of  puerperal 

fever,  1012 
in  typhoid  fever,  277 
disorders  following  the  plague,  781 
impressions,  influence  of,  in  causation  of 

yellow  fever,  643 

overwork  as  a  cause  of  typhus  fever,  342 
strain,  symptoms  due  to,  205 
work,  relation  of,  to  exercise,  199 
Mercury,  use  of,  in  cerebro-spinal  meningitis, 

833 

in  diphtheria,  705 
Metamorphosis,  cheesy,  79 
colloid,  83 
croupous,  80 
fatty,  74,  79 
mucous,  82 
Metastasis  in  idiopathic  parotitis,  G23,  624 

treatment,  625 
in  pyaemia,  pathology,  964 
of  tumors,  110 
Methods  of  disinfection,  201 

of  vaccinating,  478 

Metritis  in  puerperal  fever,  lesions,  987 
Meteorism  in  typhoid  fever,  286 
Micro-organisms  of  puerperal  fever,  1015 
in  pyaemia,  blood-changes  effected,  970 
Microbes,  as  poison  producers  and  carriers, 

141 
difficulty  of  separation  of,  from  surround 

ing  material,  146 

liability  to  error  from  minuteness,  143 
Microbia  in  inflammation,  45,  48 
Micrococci,  141 

in  healthy  bodies,  144 
Microscopic  organisms,  classification,  141 
Microscopy  of  glanderous  lesions  in  man, 

923 

Migration  of  leucocytes,  42 
Mild  forms  of  cholera,  731 

character  of  stools,  732 
number  of  stools,  732 
of  influenza,  treatment,  874 
form  of  typhus  fever,  354 

of  yellow  fever,  symptoms,  644 
Milk,  adulteration,  197 
as  a  cause  of  disease,  197 
as  a  medium  of  dissemination  of  anthrax, 
929 


10G8 


INDEX. 


Milk  as  a  medium  of  dissemination  of  ma- 
laria. 590 

of  rabies  and  .hydrophobia,  891 
of  scarlet  fever,  491 
of  typhoid  fever,  252 
as  a  vehicle  of  bacillus  tuberculosis,  105 
polluted,  as  a  cause  of  diphtheria,  683 
Mind,  state  of,  in  relapsing  fever,  384 
Miscarriage,  complicating*  typhus  fever,  356 
Modern  conveniences  questionable  benefits, 

215 
Moral  sense,  perversion  of,  following  typhoid 

fever,  292 
Morbid   anatomy,   of  anthrax   in  animals, 

935 

in  man,  941 
of  beriberi,  1040 
of  cerebro-spinal  meningitis,  820 
of  cholera,  741 
of  dengue,  882 
of  diphtheria,  685 
of  erysipelas,  635 
of  glanders  in  horses,  916 

in  man,  922 

of  idiopathic  parotitis,  621 
of  influenza,  871 
of  intermittent  fever,  594 
of  leprosy,  791 
of  pertussis,  843 
of  the  plague,  781 
of  puerperal  fever,  985 
of  pyaemia,  966 
of  pyaemia  simplex,  970 
of  rabies  and  hydrophobia,  902 
of  relapsing  fever,  413-417 
of  remittent  fever,  602 
of  rubeola,  575 
of  scarlet  fever,  530 
of  septicaemia,  971 
of  septo- pyaemia,  972 
of  simple  continued  fever,  235 
of  symptomatic  parotitis,  626 
of  typhoid  fever,  260 
of  typhus  fever,  356 
of  vaccinal  pock,  463 
of  varicella,  483 
of  variola,  446 
of  yellow  fever,  649 
growths,  105 

classifications,  114,  122 
Cohnheim's  theory  of  origin,  106 
influence  of  an  irriiant  in  production, 

108 

method  of  origin,  106 
non-malignant,  hereditary  nature,  129 
processes,  35 

Morbific  principle  of  cerebro-spinal  menin- 
gitis, 803 
Morphia,  hypodermic   use   of,  in  beriberi, 

1043 

use  of,  in  rabies  and  hydrophobia,  907 
Mortality  of  anthrax  in  animals,  936 

in  man,  943 

of  cerebro-spinal  meningitis,  820,  828 
in  cholera,  754 
of  glanders  in  man,  924 
of  influenza,  872 


Mortality  of  pertussis,  841 
of  the  plague,  780 
of  puerperal  fever,  1020 
of  rabies  and  hydrophobia,  894 
in  relapsing  fever,  422 
of  remittent  fever,  599 
of  rubeola,  577 
of  scarlet  fever,  534 
of  typhoid  fever,  316-320 
of  typho-malarial  fever,  616 
of  typhus  fever,  360,  361 
of  yellow  fever,  647,  648 
Mouth,  condition  of,  in  idiopathic  parotitis, 

6-22 
of  mucous  membrane  of,  in  erysipelas, 

G33 
complications   in    erysipelas,    treatment, 

638 

symptoms  of  diphtheria,  672,  673 
Mucous  degeneration,  82 

membranes  of  palate  and  fauces,  appear- 
ance   of,    in    prodromal    stage  of 
rubeola,  564 
condition  of,  in  confluent  small-pox,  441 

in  rotheln,  586 
eruptions  of  varicella  on,  483 
influence  of  different,  upon  the  charac- 
ter of  diphtheritic  membrane,  688 
lesions  of,  in  diphtheria,  688 
in  glanders  in  man,  922 
in  rabies  and  hydrophobia,  902 
in  erysipelas,  635 

localized   redness   of,   symptomatic   of 
prodromal  stage  of  diphtheria,  667 
variolous  pustules  upon,  439 
metamorphosis,  82 
softening,  82 
Multiple  tumors,  110 
Mumps,  620 
Murmurs,  arterial,  in  beriberi,  1040 

cardiac,  in  beriberi,  1040 
Muscles,  alteration  of,  in  beriberi,  1041 
lesions   of,  in   cerebro-spinal   meningitis, 

821 

in  diphtheria,  687 
in  pyaemia,  966 
in  typhoid  fever,  267 
of  neck,  suppuration  of,  in  symptomatic 

parotitis,  626 
voluntary,  lesions  of,  in  relapsing   fever, 

410 

Muscular  pains  in  yellow  fever,  644 
paralysis  in  beriberi,  1039 
rigidity  after  cholera,  741 
spasm,  in  typhoid  fever,  279 
tenderness  in  beriberi,  1039 
tremor  in  typhoid  fever,  279 
in  typhus  fever,  349 


Naevi,  vaccination  as  a  means  of  destroying, 

468 

Nails,  appearance  of,  in  typhoid  fever,  275 
Nasal  cavities,  condition  of,   in   malignant 

scarlet  fever,  508,  520 
mode  of  invasion  of,  in  diphtheria,  669 


IXDEX. 


1069 


Nasal  complications  in  erysipelas,  treatment. 

638 
diphtheria,  local  treatment,  710 

prognosis,  692 

form  of  diphtheria,  symptoms,  669 
lesions  in  glanders,  917 
mucous  membrane,  condition  of,  in  influ- 
enza, 866 
Nationality  in  relation  to  relapsing  fever, 

371 

Nature  of  puerperal  fever,  views  concern- 
ing, 990-1004 
of  vaccinia,  455 
Nausea,  during  intermittent  fever  paroxvsm, 

593 

in  cerehro-spinal  meningitis,  813 
in  influenza,  866 
in  relapsing  fever,  390 
in  rubeola,  treatment,  581 
in  typhoid  fever,  285 
in  typhus  fever,  350 
in  yellow  fever,  treatment,  652 
significance    of,    in    general     treatment, 

162 
Negroes,  insusceptibility  of,  to  yellow  fever, 

644 
Neck,  significance  of  appearance  of,  in  djag- 

nosis,  152 

Necrosis  from  embolism,  64,  65 
Neoplasms,  105 
Nephritis,  complicating  scarlet  fever,  525 

in  scarlet  fever,  treatment,  550-555 
Nerves,  lesions  of,  in  leprosy,  791 
in  symptomatic  parotitis,  626 
Nervous  diseases,  complicating  diphtheria, 

675,  676 

hereditary  nature  of,  129 
influence  of,  upon  susceptibility  to  ru- 
beola, 561 

symptoms  in  relapsing  fever,  383-385 
complicating  scarlet  fever,  510 
of  dengue,  882 
of  influenza,  867 
of  malignant  scarlet  fever,  507 
Nervous  system,  chronic  diseases  of,  follow- 
ing rubeola,  574 
condition  of,  in  cholera,  741 

in  remittent  fever,  602 
lesion  of,  in  diphtheria,  689 

in  septicaemia,  972 

Neuralgia,  following  cerebro-spinal  menin- 
gitis, 820 

in  yellow  fever,  644 
Neuralgias,  old,  aggravation  of,  in  influenza, 

870 

Neurine,  use  of,  in  diphtheria,  703 
Nitric  acid,  use  of,  to  prevent  the  return  of 

intermittent  fever  paroxysm,  598 
Nitro-muriatic    acid,  use    of,    in    anthrax, 

938 

Nodule,  nasal,  in  glanders,  917 
Nomenclature  of  pyaemia,  953 

of  septicaemia,  953 
Nose,  inflammation  of,  complicating  variola, 

445 

Nostrils,  condition  of,  in  glanders  in  man, 
921 


Nourishment,  necessity  of,  in  typhus  fever, 

363 
Nuisance,  legal  views  as  to  what  constitutes. 

182 

O. 

Obesity,  tendency  to,  following  typhoid  fever, 

Obstetrical  scarlatina,  498 
Occupation,  influence  of,  in  causation  of  an- 
thrax, 939 
of  glanders,  920 
of  influenza,  860 
of  typhoid  fever,  244 
of  typhus  fever,  343 
relation  of,  to  relapsing  fever,  372 
Odor  of  body,  significance  of,  in  general  diag- 
nosis, 159 

of  relapsing  fever,  378 
OZdema,  69 

complicating  relapsing  fever,  400 
scarlet  fever,  529 
typhoid  fever,  297 
from  nervous  influence,  71 
of  glottis,  complicating  scarlet  fever,  512, 

529 

of  lungs,  Welch  on  cause  of,  72 
significance  of,  in  general  diagnosis,  159 
(Esophagus,  lesions  of,  in  typhoid  fever,  265 
Offensive  effluvia,  symptoms  due  to,  181 
Oil,  inunctions  of,  in  the  plague,  784 
Open  wounds,  liability  of,  to  diphtheria,  679 
Opisthotonos  in  cerebro-spinal  meningitis, 

809 

Opium,  use  of,  during  cold  stage  of  inter- 
mittent fever,  595 
during  hot  stage  of  intermittent  fever, 

595 

in  algid  form  of  pernicious  malarial  fe- 
ver, 608 

in  cerebro-spinal  meningitis,  832 
in  cholera,  767 
in  dengue,  885 
in  influenza,  874,  877 
in  puerperal  fever,  1031 
in  relapsing  fever,  429 
in  reraitttent  fever,  604 
in  typhus  fever,  366 

Ophthalmia,  chronic,  following  rubeola,  574 
Optic  nerve,   lesions  of,  in   cerebro-spinal 

meningitis,  824 

Organic  disease,  hereditary  nature  of,  129 
Organisms,  microscopic,  classification,  141 

minute,  convertibility,  145 
Organoid  tumors,  116 
Origin  of  vaccinia,  457 
Origins,  specific,  of  the  plague,  776 
Ossification,  87 

Otitis,  chronic,  following  rubeola,  574 
complicating  scarlet  fever,  520 
in  scarlet  fever,  results,  521 

treatment,  547 
Ovaries,  lesions  of,  in  septicaemia,  972 

in  pelvic  peritonitis  in  puerperal  fever, 

989 

Overcrowding  as  a  cause  of  cholera,  721 
of  typhus  fever,  341 


1070 


INDEX. 


Overwork  as  a  cause  of  disease,  204 

of  the  plague,  775 
Ozone,  use  of,  in  diphtheria,  709 

P. 

Pain,  in  idiopathic  parotitis,  623 
in  inflammation,  41 

significance  of,  in  general  diagnosis,  105 
Pains,  muscular  and  joint,  in  relapsing  fever, 

385 
of  general  peritonitis  in  puerperal  fever, 

1010 
peritoneal,  in   para-  and   perimetritis  of 

puerperal  fever,  1007 
rheumatic,  in  relapsing  fever,  399 
Palpitation  of  heart  in  beriberi,  1039 
Pancreas,  lesions  of,  in  relapsing  fever,  417 
Pandemic  nature    of   cerebro-spinal    men- 
ingitis, 804 

Panum's  view  of  bacteria  of  diphtheria,  667 
Papayotin.  use  of,  in  diphtheria,  703 
Papule  in  variola,  morbid  anatomy,  446 
Paralysis,  complicating  diphtheria,  676 

variola,  445 

diphtheritic,  date  of  appearance,  676 
seat,  676 
treatment,  713 
following  cerebro-spinal  meningitis,  819 

typhoid  fever,  293 
in  cerebro-spinal  meningitis,  810 
local,  in  relapsing  fever,  398 
motor,  in  relapsing  fever,  385 
muscular,  in  beriberi,  1039 
sensory,  in  diphtheria,  676 
Paralytic  form  of  rabies  in  dogs,  896 
stage  of  hydrophobia  in  man,  900 
Parenchymatous  inflammation,  53 
Para-  and  perimetritis   in  puerperal  fever, 

symptoms,  1005 

Parametritis  in  puerperal  fever,  lesions,  987 
Paresis  following  cerebro-spinal  meningitis, 

819 

Parotid  glands,  lesions  of,  in  idiopathic  paro- 
titis, 621 
gland,  lesions  of,  in  svmptomatic  parotitis, 

626 

in  pyaemia,  967 
swelling,   character    of,   in    symptomatic 

parotitis,  627 

complicating  typhoid  fever,  296 
PAROTITIS,  IDIOPATHIC,  620 
Definition,  620 
Nature,  620 

Etiology — predisposing  causes,  620 
Age,  influence,  620 
Sex, influence,  620 
Season,  influence,  620 
Relation  to  measles,  diphtheria,  and  scar- 
let fever,  620 

Peculiarities  in  mode  of  occurrence,  621 
Anatomical  appearance,  621 

Changes  in  parotid  gland,  621 
Symptoms,  621 

Duration  of  incubation  stage,  621 
Of  invasion  stage,  621 
Actual  attack,  621 


PAROTITIS,  iDiorATHic — Svrnptoms :  LocaL 

621 

Physiognomy,  622 
Mouth  and  tongue,  622 
Digestive  tract,  622 
Temperature  and  pulse,  623 
Respiration,  623 
Pain,  623 
General,  623 
Complications,  623 
Metastasis,  623 
Frequency,  823 
Date  of  appearance,  623 
Orchids,  623 

Symptoms,  624 
Diagnosis,  624 

Significance  of  outward  displacement  of 

lobe  of  ear,  624 
Prognosis,  624 

Result  of  inetastatic  orchitis,  624 
Treatment,  624 

Delirium  and  headache,  624 
Difficult  deglutition,  624 
Sleeplessness,  625 
Local,  625 

Suppuration  of  gland,  625 
Incomplete  resolution,  625 
*  Metastasis,  625 
in  females,  625 
with  depression,  625 
PAROTITIS,  SYMPTOMATIC  or  METASTATIC, 

625 

Definition,  625 
Etiology,  625 

Mechanical  nature  of  exciting  cause, 

626 

Altered  blood  as  a  cause,  626 
Morbid  anatomy,  626 

Changes  in  parotid  gland,  626 
Suppuration  of  muscles  of  neck,  626 
Changes    in    periosteum    and    cranial 

bones,  626 

lymphatics,  veins,  and  nerves,  626 
in  middle  ear,  626 
Thrombi  of  jugular  veins,  626 
Symptoms,  626 

Characters  of  swelling,  627 
Date  of  pointing  of  abscess,  627 
Physiognomy,  627 
Prognosis,  627 

Of  bilateral  form,  627 
Diagnosis — from  idiopathic  parotitis,  627 
Treatment  of,  627 
Local,  628 

Of  incomplete  resolution,  628 
Of  gangrene,  628 

Parotitis,  complicating  cholera,  735 
influenza,  870 
relapsing  fever,  404 
typhus  fever,  356 
"  treatment,  367 

Paroxysm  of  intermittent  fever,  592 
primary,  of  relapsing  fever,  375,  378 

of  remittent  fever,  599 
Paroxysms  of  hydrophobia  in  man,  899 
of  pertussis,  characters,  837 
duration,  840 


IXDEX. 


1071 


Paroxysms  of  pertussis,  frequency,  840 

of  rabies  in  dogs,  896 
Pasteur's  experiments  as  to  infectiveness  of 

rabies,  892,  893 

method  of  inoculation  in  anthrax,  937 
for  prevention  of  rabies  and  hydro- 
phobia, 905 

Pathognomonic  lesions  of  rabies  in  dogs,  903 
Pathology  of  glanders  in  man,  916,  918 
of  influenza,  871 
of  pyaemia,  963 
Pearly  distempejr,  relation  of,  to  tuberculosis. 

99 

Pelvic  abscesses  in  puerperal  fever,  treat- 
ment, 1036 

cellulitis  in  puerperal  fever,  lesions,  988 
exudations,  treatment  of,  in  puerperal  fe- 
ver, 1036 

peritonitis,  in  puerperal  fever,  lesions,  988 
Peppermint-test  for  defects  in  plumbing,  190 
Pepsin,  use  of,  in  diphtheria,  703 
Perforation,  intestinal,  in  typhoid  fever,  289, 

290  _ 

in  typhoid  fever,  treatment,  333 
Pericarditis  in  relapsing  fever,  402 

complicating  influenza,  870 
Pericardium,  lesions  of;  in  cholera,  747 

in  pysemia,  968 

Peri-glandular  lesions  in  the  plague,  782 
Periostitis,  complicating  typhoid  fever.  297 
Peritoneal  effusions,  encysted,  in  puerperal 

fever,  treatment,  1036 
Peritoneum,  lesions  of,  in  relapsing  fever, 

417 
Peritonitis,  complicating  relapsing  fever,  406 

typhoid  fever,  295 
general,  in  puerperal  fever  lesions,  989 

in  puerperal  fever,  symptoms,  1010 
pelvic  and  diffused,  of  puerperal  fever,  988 
Pernicious  malarial  fever,  605 
Perspiration  in  pyaemia,  974 

in  yellow  fever,  645 
PERTUSSIS,  836 
History,  836 
Definition,  836 
Etiology,  838 
Specific  poison,  838 
Seat,  838 

period  of  greatest  virulence,  838 
inoculation  of  animals  with,  839 
Childhood,  influence  of,  in  occurrence, 

839 

Age  at  which  most  prevalent,  839 
Sex,  influence  of,  in  causation,  839 
Catarrhal  affections  as  predisposing 

causes,  839 
Symptoms,  840,  841 
'  Initial  stajre,  840 
Second  stage,  840 
Stage  of  decline,  841 
Paroxysm,  characters  of,  837 
duration,  840 
frequency,  840 

Fra-num  linguae,  ulceration,  841 
Urine,  condition,  841 
Mortality,  841 
Morbid  anatomy,  843 


PERTUSSIS— Complications,  848 
Prophylaxis,  843 
Treatment,  844 
Inhalations,  844 
Emetics,  845 
Potassium  carbonate,  845 
Alum,  845 
Belladonna,  846 
Ammonium  bromide,  846 
Chloral  hydrate,  846 
Quinia,  847 

Pilocarpine  muriate,  847 
Sodium  benzoate,  847 
Caustic  irritation,  848 
Diet,  848 
Hygiene,  848 

Pertussis,  following  the  plague,  781 
Petechiae,  characters  of,  in  grave  form  of  the 

plague,  779 
Petrifaction,  87 
Peyer's  patches,  lesions  of,  in  tvphoid  fever. 

261 

Pharyngeal  spasm  in  rabies  and  hydropho- 
bia, 899 

Pharyngitis  in  scarlet  fever,  treatment,  545 
and  tonsillitis,  complicating  relapsing  fe- 
ver, 405 

Pharynx,  lesions  of,  in  rabies  and  hydropho- 
bia, 902 

in  relapsing  fever,  413 
in  typhoid  fover,  265 
Phlebitis  and  phlebo-thrombosis,  lesions  of, 

in  puerperal  fever,  989 
Phlegmonous  inflammation,  52 
Phthisis,  complicating  influenza,  870 
following  typhus  fever,  355 
from  damp  soil,  187 
pulmonary,  hereditary  nature  of,  128 
Physicians  as  carriers  of  contagion  in  puer- 
peral fever,  1017 
mortality  in,  207 
relation  of,  to  public  hygiene,  207 
Physiognomy  of  cerebro-spinal  meningitis, 

812 

of  dengue,  881 
of  erysipelas,  632 
of  hydrophobia,  899 
of  idiopathic  parotitis,  622 
of  influenza,  866 
of  symptomatic  parotitis,  627 
of  relating  fever,  376 
of  typhoid  fever,  272 
of  yellow  fever,  644 
significance  of,  in  general  diagnosis,  150, 

151 

Pigmentation,  90 
Pilocarpine,  use  of,  in  diphtheria,  704 

in  rabies  and  hydrophobia,  907 
muriate,  use  of,  in  pertussis,  847 
Pitting,  frequency  of,  in  varicella,  4S2 

prevention  of,  in  variola,  452 
Placenta,  symptoms  of  diphtheria,  674 
PLAGUE,  THE,  771 
Definition,  771 
Synonyms,  771 
Classification,  771 
History,  772 


1072 


INDEX. 


PLAGUE,    THE  —  Etiology  :    Predisposing 

causes  of,  774 
Poverty  and  filth,  774 
Bodily  and  mental  overwork,  775 
Sex  and  age,  influence,  775 
Season,  775 
Exciting  causes,  775 
Dissemination  by  bodies  dead  from,  775 
Specific  origin,  776 
Contagiousness,  776 
Nature  of  the  poison,  776 
Air  as  a  medium  of  transmission,  776 
Period  of  incubation,  777 
Forms  of,  777 

Grave  or  ordinary  form,  777 
Fulminant  form,  779 
Abortive  form,  780 
Symptoms,  777 

Grave  form,  different  modes  of  onset,  779 
Invasion  stage,  777 
Second  stage,  or  stage  of  fever,  778 
Stage  of  fully-developed  local  mani- 
festations, 778 
Seat  of  enlarged  lymphatics,  778 

of  buboes,  778 

Characters  of  bubonic  swellings,  778 
Date  of  appearance  of  buboes,  778 
Seat  and  character  of  carbuncles,  778 

of  petechise,   779 
Character  of  vomited  matter,  779 
Constipation,  779 
Condition  of  urine,  779 
Stage  of  convalescence,  779 
Fulminant  form,  779 

duration,  779 
Abortive  form,  780 
General  duration  of,  780 
Complications  and  sequelae,  780 

Followed  by  catarrhal  pneumonia,  781 
Pertussis,  781 
Mental  troubles,  781 
Ulcers  and  abscesses,  781 
Morbid  anatomy,  781 

Changes  in  lymphatic  system,  781 
Appearance  of  buboes,  781 
Peri-glandular  tissue,  782 
Abdominal  viscera,  781 
Diagnosis,  782 
Prognosis,  780 
Mortality,  780 
Treatment,  782 
Preventive,  782 
Isolation,  783 
Quarantine,  783 
Disinfection,  784 
Clinical,  784 
Inunction  of  oil,  784 
Buboes,  784 
Drugs  used,  784 

Pleura,  lesions  of,  in  pyaemia,  968 
in  relapsing  fever,  413 
in  septicaemia,  972 
Pleurisy,  complicating  typhoid  fever,  294 

typhus  fever,  355 

in  septicaemia  Ivmphatica  of  puerperal 
fever,  1012 


Pleuritis,  complicating  erysipelas,  634 
iniluenza,  870 
relapsing  fever,  404 
scarlet  fever,  523 
in  scarlet  fever,  treatment,  556 
Plumbing,  examination  of  defects,  190 

of  houses,  188 

Pneumonia,'  catarrhal,   complicating   influ- 
enza, 869 

following  the  plague,  781 
complicating  erysipelas,  634 
relapsing  fever,  404      , 
rubeola,  571 
typhoid  fever,  294 
typhus  fever,  355 

fibrinous,  complicating  diphtheria,  672 
in  rubeola,  treatment,  581 
in  typhoid  fever,  treatment,  335 
lobar,  complicating  influenza,  869 
Pneumonias,  nature  of,  complicating  influ- 
enza, 870 

Pock  of  vaccinia,  date  of  appearance,  459 
depression,  459 
desquamation,  460 
development,  459 
incrustation,  460 

in  variola,  characters  of  mature,  439 
Poison,  diphtheritic,  fixity,  678 

transmission,  678 
influence   of  intensity  of,  on  severity  of 

cholera,  730,  731 

of  anthrax,  modes  of  transmission,  929 
of  cholera,  nature,  749 
of  malaria,  nature,  589,  591 
of  the  plague,  nature,  776 
of  yellow  fever,  birthplace,  641 
characteristics,  641 

influence  of  heat  and  cold  on  develop- 
ment, 641 

transportability,  641 
specific,  of  beriberi,  1038 

of  pertussis,  838 
Polluted  soil  as  a  means  of  disseminating 

typhoid  fever,  253 
Potassium  bromide,  use  of,  in  cerebro-spinal 

meningitis,  834 

carbonate,  use  of,  in  pertussis,  845 
chlorate,  danger  of  large  doses,  701 

use  of,  in  diphtheria,  699,  700 
iodide,  use  of,  in  cerebro-spinal  meningi- 
tis, 834 

Poverty  as  a  cause  of  typhus  fever,  342 
Predisposing  causes  of  beriberi,  1042 
of  cholera,  720 
of  glanders  in  horse,  912 
of  idiopathic  parotitis,  620 
of  the  plague,  774 
of  typhoid  fever,  242 
of  typhus  fever,  341 
Predisposition  to  disease,  hereditary  nature, 

126 

Predispositions,  inherited,  evidence,  132 
Pregnancy,  complicating  influenza,  871 

typhoid  fever,  296 

Preliminary  papule  of  anthrax,  treatment, 
943 


INDEX. 


1073 


Premonitory  symptoms  of  rabies  and  hydro- 
phobia, 895 
of  scarlet  fever,  502 

Prevention  of  anthrax  by  inoculation,  937 
Preventive  treatment  of  anthrax  in  animals. 

936 

in  man,  943 
of  cholera,  755 
of  erysipelas,  636 
of  glanders  in  horses,  919 

in  man,  925 
of  influenza',  873 
of  the  plague,  782 
of  puerperal  fever,  1021 
of  pyaemia  and  septicaemia,  979,  980, 

983 

of  rabies  and  hydrophobia,  903 
of  scarlet  fever,  536 
of  typhoid  fever,  321 
of  typhus  fever,  361 
Previous  attacks  of  variola,  protection  from, 

436 

Primary  vaccine,  473 
Privy  vaults,  contamination  of  water-supply 

by,  192 

dangers  from,  192 
PROCESSES,  GENERAL  MORBID,  35 
Prodromal  stage  of  diphtheria,  667 
of  intermittent  fever,  592 
of  leprosy,  789 
of  remittent  fever,  599 
of  rotheln,  585 
of  rubeola,  564 
of  varicella,  482 
Prognosis,  general,  167 
of  anthrax  in  animals,  936 

in  man,  943 
of  beriberi,  1042 
of  cerebro-spina]  meningitis,  628 
of  cholera,  753 
of  dengue,  885 
of  diphtheria,  692-694 
of  erysipelas,  636 
of  idiopathic  parotitis,  624 
of  influenza,  872 
of  intermittent  fever,  594 
of  glanders  in  horse,  918 

in  man,  924 
of  leprosy,  793 
of  the  plague,  782 
of  relapsing  fever,  422-425 
of  remittent  fever,  602 
of  rotheln,  588 
of  scarlet  fever,  533 
of  simple  continued  fever,  235 
of  symptomatic  parotitis,  627 
of  typho-malarial  fever,  616 
of  typhoid  fever,  314-316 
of  typhus  fever,  359,  360 
of  vaccinia,  464 
of  varicella,  484 
of  variola,  450 
of  varioloid,  444 
in  yellow  fever,  646,  647 
effect  of  constitution,  168 
of  nature  of  malady,  169 
of  present  state  of  patient,  169 
VOL.  I.— 68 


Prognosis,  influence  of  nursing,  169 

modifying  effects  of  medicinal  agents,  169 
Prophylactic  treatment  of  diphtheria,  696 
Prophylaxis,  individual,  in  contagious  dis- 
eases, 206 
of  leprosy,  794 
of  pertussis,  843 
of  puerperal  fever,  1021 
Prostration  in  dengue,  882 
in  typhus  fever,  348 

treatment,  305 
Protective  power  of  vaccination,  466 

duration  of,  468 
against  pertussis,  468 
Pseudo-membrane,  solvents  of,  703 
Psoas  abscess  in  puerperal  fever,  1010 
Psychical  treatment  of  hydrophobia,  906 
Public  sewers,  224 
PUERPERAL  FEVER,  984 
Definition,  984 
Frequency,  S84 
Etiology, '1013 

Atmosphere,  impure,  influence  on  cau- 
sation, 1013,  1014 

Malaria,  nosocomial,  influence  on  cau- 
sation, 1013 
Micro-organisms,  influence  on  causation, 

1013-1015 

Lochial    discharge,    influence  on    cau- 
sation, 1015 

Atmosphere,  peculiar  states  of,  on  cau- 
sation, 1016 

Direct  inoculation,  1016 
Contagiousness  of,  1017 
Contagion,   physicians    as  carriers  of, 

1017 

Dissecting  poison,  1018 
Self-inoculation,  1019 
Morbid  anatomy,  985 

Spiegelberg's  classification  of  puerperal 

inflammations,  986 
Endocolpitis  and  endometritis,  986 
Diphtheritic  ulceration,  986 
Metritis  and  parametritis,  987 
Diphtheritic  endometritis,  987 
Pelvic  cellulitis,  988 
Cellulitis  from  specific  infection,  988 
Peritonitis,  pelvic  and  diffused,  988 
exudation  in,  989 
general,  989 

appearance  of  abdominal   cavity, 

989 

ovaries,  989 

Phlebitis  and  phlebo-thrombosis,  989 
Thrombi  in  uterine  and  pelvic  veins, 

989 
Abscesses,  989 

pulmonary,  989 
Veins,  inflammation,  989 
Thrombi,  growth,  990 
Septicaemia,  990 
Abscesses,  metustatic,  990 
Endocarditis,  ulcerative,  990 
Pleuritis,  990 

Joints,  purulent  inflammation,  990 
Earlier  views  concerning  nature,  990 
Modern  view  concerning  nature,  992 


1074 


INDEX. 


PUERPERAL  FEVER— Septic    origin,   993- 

1003 
Bacteria,  relation  to  causation,  994 

Koch's  investigations  of,  997 

Physical  characters,  999 

modes   of    entering   the    circulation, 
1000 

action  of,  upon  the  blood,  1000 
Diphtheria  of  genitalia,  characters,  1002 
Relation  of,  to  erysipelas,  1002 
Inflammatory  affections  of  non-specific 

origin,  1003 
Symptoms,  general,  1004 

Incubation  period,  1004 

Chill,  significance  of,  1005 
Of  endometritis  and  endocolpitis,  1005 

temperature,  1005 
Parametritis  and  perimetritis,  1005 

Incubation,  1006 

Temperature,  1006 

Pulse,  1006 

Eelapse,  1006 

Headache,  1007 

Pains,  1007 

Vomiting,  1007 

Duration,  1007 

Exudation,  1007 

Uterus  fixity  of,  1007 

Tumors  in  iliac  fossa,  1008 

Abscesses,  1008 
location,  1008 
pointing  of,  1008 

Local  peritonitis,  1009 
Of  psoas  abscess,  1010 
Of  peritonitis,  general,  1010 

Pains,  1010 

Abdomen,  state,  1010 

Respiration,  1010 

Vomiting,  1010 

Vomit,  characters,  1010 

Fever,  1010 

Skin,  1010 

Pulse,  _1 010 

Pysemic  form,  1011 
Of  septicaemia  lymphatica,  1011 

Mode  of  onset,  101 1 

Temperature  in,  1011 

Abdomen,  state,  1011 

Skin,  state,  1011 

Vomiting,  1011 

Tongue,  condition,  1011 

Pulse,  condition,  1011 

Respiration,  1012 

Pleurisy  in,  1012 

Endocarditis,  1012 

Mental  condition,  1012 

Joint  affections  in,  1012 

Duration,  1012 
Of  septica?mia  venosa,  1012 

Chills  in,  1012 

Fever  in,  1012 

Temperature  in,  1012 

Pulse  in,  1012 

Abdomen,  state  of,  1012 

Uterus  in,  1012 
Of  pure  septicaemia,  1013 
Mortality,  1020 


PUERPERAL  FEVER — Relation  of,  to  zymot- 
ic diseases,  1020 
Prophylaxis,  1021 

Maternity  hospitals,  advantages,  1021 
Necessity  of  light  and  air,  1024 
Antisepsis,  value,  1024 

methods,  1025 
Sulphurous  acid,  use,  1025 
Corrosive  sublimate,  use,  1025 
lodoform,  use  of,  intra-uterine,  1025 
Vaginal  injections,  carbolized,  use,  1025 
Tanner's  maternity  pavilions  for  pre- 
vention, 1027 

Treatment — indications,  1028 
Disinfection,  1028 
Local,  1028 
Use  of  hydrochloric  acid,  1028 

Persulphate  of  iron,  1028 
Intra-uterine  injections,  use,  1029 
dangers  of,  J  029 
methods,  1029 

Corrosive  sublimate,  use,  1025,  1029 
Pain,  peritoneal,  1031 
Use  of  opium,  1031 

in  pysemic  variety,  1031 
Leeches,  1031 
Turpentine  stupes,  1032 
Hyperpyrexia,  1032 
Use  of  purgatives,  1032 
Quinia,  1032 
Sodium  sal  icy  late,  1032 
Veratrum  viride,  1033 
Digitalis,  1033 
Alcohol,  1033 
Cold  in,  1033 

Cold,  method  of  applying,  1034 
Cold    water,    intra-uterine    injections. 

1034 

Baths,  cold,  use,  1034 
Kibbie's  fever-cot,  use,  1034,  1035 
Coil,  1036 
Diet,  1036 

Encysted  peritoneal  effusions,  1036 
Quinia,  use,  1036 
Pelvic  exudations,  1036 
Pelvic  abscesses,  1036 

Puerperal  septicaemia,  relations  of,  to  obstet- 
rical scarlatina,  499 
women,  general  sepsis  from  diphtheria  in, 

674 

symptoms  of  diphtheria  in,  674 
Pulmonary  abscess  in  puerperal  fever,  989 
collapse,  complicating  influenza,  869 
complications  of  typhus  fever,  treatment, 

367 

oedema,  complicating  rubeola,  572 
Pulsation  of  jugular  veins,  significance  of,  in 

general  diagnosis,  156 

Pulse  and  temperature,  relation  of,  in  yel- 
low fever,  644 
average  frequency  in  health  and  disease, 

154 

characters  of,  in  erysipelas,  633 
in  idiopathic  parotitis,  623 
in  general  peritonitis  of  puerperal  fever, 

1010 
in  septicaemia,  977 


INDEX. 


1075 


Pulse,  characters  of,  in  septicaemia  lymphat- 

ica  of  puerperal  fever,  1011 
venosa  of  puerperal  fever,  1012 
condition  of,  in  acute  glanders  in  man,  921 
in  beriberi,  1040 
in  cerebro-spinal  meningitis,  815 
in  cholera,  737 
in  dengue,  881 
in  influenza,  866 
in  pyaemia.  975 
in  relapsing  fever,  382 
in  typhus  fever,  351 
significance  of,  in  general  diagnosis,  152 
in  malignant  scarlet  fever,  507 
in  typhoid  fever,  275 
kinds  of,  154 

methods  of  examining,  153 
relation  to  respiration,  154 
temperature,  relation  of,  in  relapsing  fe- 
ver, 382 

Pupil,  signilicance  of  state  of,  in  general  di- 
agnosis, 151 

Pupils,  condition  of,  in  cerebro-spinal  men- 
ingitis, 810 

Pure  septicaemia  of  puerperal  fever,  1013 
Purgatives,  use  of,  during  hot  stage  of  inter- 
mittent fever,  596 
in  cerebro-spinal  meningitis,  830 
in  hemorrhagic  form  of  pernicious  ma- 
larial fever,  613 
in  puerperal  fever,  1032 
in  remittent  fever,  604 
Purity  of  water,  standards  of,  184 
Purpura,  complicating  diphtheria,  674 
Pus,  48 

influence  of,  in  production  of  pyaemia,  955 
in  stools,  significance  in  diagnosis,  164 
Pustule,  malignant,  926 
Putrefaction  of  cadaver,  rapidity  of,  in  puer- 
peral fever,  971 
Putrified  flesh  as  a  means  of  disseminating 

typhoid  fever,  257 

PY^MIA  AND  SEPTICAEMIA,  945-955 
History,  945-952 
Nomenclature,  952  | 

Pyaemia,  953 

Definition,  953 
Septicaemia,  953 
Definition,  954 
Etiology  of  pyaemia,  955 
Theories  concerning,  955 
Pus,  influence  of,  in  production,  955 

Character  of  production,  956 
Thrombosis,  relation  of,  to   causation, 

957,  958 

Contamination   of  blood,   influence  of, 
in  causation,  958 
sources,  958 

Germs,  disease-,  influence  of,  in  causa- 
tion, 958 
Wounds,   characters    of,   influence    on 

causation,  958 

Etiology  of  spontaneous  pyaemia,  959 
Wounds  of  alimentary  canal  and  genito- 
urinary apparatus  as  cause,  959 
Air,  vitiated,  influence  of,  on  causation, 
959 


PyjEiriA    AND    SEPTICAEMIA  —  Etiology : 

Spontaneous  origin,  959 
Contagiousness,  960 
Chemical  origin,  960 
Living  organisms,  influence  of,  on  causa- 
tion, 958-960 
Etiology  of  septicaemia,  960 

Septic  intoxication,  relation  of,  to,  961 
Traumatic  fever,  relation  of,  to,  962 
Dissecting  wounds,  relation  of,  to 

causation,  962 
Putrid  substances,   maximum   toxic 

action  of,  on  the  body,  962 
Lymphatics  as  channel  of  entrance 

of  poison,  963 

Etiology  of  septo-pyaemia,  963 
Pathology,  963 

Condition  of  blood,  963 
in  pyaemia  simplex,  963 

multiplex,  963 
Metastasis,  conditions,  964 
Pus,  mode  of  entering  the  circulation, 

964 

Metastatic  abscesses,  production,  964 
from  primary  infection,  964 
from  secondary  infection,  964 
Emboli,   action    of,   in   production   of 

metastatic  abscesses,  964 
Thrombi,  action   of,  in   production  of 

metastatic  abscesses,  965 
Seat  of  pathological  changes,  965 
Fat  emboli,  influence  of,  in  production, 

_966 

Morbid  anatomy,  966 
Of  pyaemia,  966 

Appearance  of  body,  966 
Rigor  mortis,  966 
Lesions  of  cellular  tissue,  966 
Muscles,  966 

Brain  and  membrane,  966 
Retina  and  choroid,  967 
Cornea,  967 
Ear,  967 
Bones,  967 
Joints,  967 
Parotid  gland,  967 
Arteries  and  veins,  967 
Blood,  968 
Pericardium,  968 
Pleurae,  968 
Lungs,  968 
Liver,  969 
Spleen,  969 
Kidneys,  969 
Micro-organism  in  blood,  changes 

effected  by,  970 
Pyaemia  simplex,  970 

"Absence  of  abscesses  in,  970 
Septicaemia,  971 

Putrefaction  of  bodies,   rapidity  of, 

971 

Blood,  lesions  of,  971 
Sepsin,  nature,  971 
Lesions,  nervous  system,  972 
Endo-  and  pericardium,  972 
Lungs,  972 
Pleurae,  972 


1076 


IXDEX. 


PYJEMIA  AXD  SEPTIC^.MIA — Morbid  anat- 
omy :  Septicaemia,  lesions  of,  kid- 
neys, 972 
Spleen,  972 
Uterus,  972 
Ovaries,  972 
Bladder,  972 
Of  septo-pyaemia,  972 
Symptoms,  972 
Of  pyaemia,  972 

Prodromal  stage,  973 

Chills,  date  of  appearance,  973 

frequency,  973 
Temperature,  974 
Perspiration,  974 
Eruptions,  974 
Pulse,  975 

Tongue,  condition  of,  975 
Vomiting,  975 
Singnltus,  975 
Diarrhoea,  975 
Stools,  character  of,  976 
Heart,  condition  of,  976 
Lungs,  condition  of,  976 
Liver  and  spleen,  enlargement,  976 
Urine,  976 

Joints,  suppuration,  976 
Abscesses,  frequency,  976 
Delirium,  976 
Breath,  odor  of,  976 
"Wound,  changes,  976 
Of  septicaemia,  976 
General,  976 
Wound,  condition  of,  977 
Temperature,  977 
Abdomen,  state  of,  977 
Pulse,  977 
Diarrhoea,  977 
Vomiting,  977 
Tongue,  977 
Singultus,  977 
Bronchitis  in,  977 
Of  gangrene  foudroyante,  977 

Skin,  condition,  977 
Diagnosis,  978 

Of  pyaemia  from  septicaemia,  table  show- 
ing, 978,  979 
Treatment,  979 

In  fully-developed  cases  unsuccess- 
ful, 980 

Preventive,  979,  980 
Cleanliness,  necessity  of,  in  preven- 
tion, 980 
Atmosphere,   pure,   necessity    of,   in 

prevention,  980 
Food  and  drink,  proper,  necessity  of, 

in  prevention,  980 
Cheerful   and  pleasant  surroundings 

in  prevention,  980 
Antiseptics,  use  of,  980 
Local,  981 
Of  wound,  981 
Metastatic  abscesses,  981 
Constitutional,  982 
Sulphites    of    magnesium,    sodium, 
potassium,  and  lime,  use  of,  982 
Use  of  alcohol,  982 


PYJEMIA  AND  SEPTIC^MIA  —  Treatment: 

Quinia,  982 
Ergotine,  982 
Diet,  982 
Stimulants,  982 
Of  septicaemia,  982 
Indications  for,  982 
Local,  983 
Preventive,  983 
Of  wound,  983 
Diarrhoea,  983 
Antisepsis,  983 
Sulphites  and  hyposulphites,  use  of, 

983 

Quinia,  use  of,  983 
Of  puerperal  septicaemia,  983 
complicating  erysipelas,  634 
typhoid  fever,  295 
typhus  fever,  356 

Pysemic  form  of  general  peritonitis  of  puer- 
peral fever,  1010 

Q. 

Quarantine  in  cholera,  204,  755 
in  leprosy,  794 
in  the  plagne,  783 
Quinia,  use  of,  in  cerebro-spinal  meningitis, 

833 

in  dengue,  885 
in  diphtheria,  708,  712 
in  erysipelas,  637 
in  influenza,  874-876 
during  cold  stage  of  intermittent  fever, 

595 

hot  stage  of  intermittent  fever,  596 
sweating  stage  of  intermittent  fever, 

597 
to  prevent   the  return   of  intermittent 

fever,  paroxysm,  598 
in  hemorrhagic  form  of  pernicious  ma- 
larial fever,  612 
in  pertussis,  847 
in  puerperal  fever,  1032, 1036 
in  pyaemia,  982 
in  relapsing  fever,  426 
in  remittent  fever,  603 
in  rubeola,  580 
in  scarlet  fever,  543 
in  septicremia,  983 
in  typhoid  fever,  330 
in  typho-malarial  fever,  618 
in  typhus  fever,  365 
in  yellow  fever,  651 
and  opium,  use  of,  in  yellow  fever,  651 

K. 

RABIES  AKD  HYDROPHOBIA,  886 

Synonyms,  886 

Definition,  886 

History,  886 

Geographical  distribution,  886 

Etiology,  887 

Climate,  relation  of,  to  causation,  SS7 
Season,  relation  of,  to  causation,  887 
Summer  heats,  relation  of,  to  causation, 
887 


INDEX. 


1077 


RABIES   AND   HYDROPHOBIA  —  Etioloj,    . 
Hunger  and  thirst,  relation  of'"to 
causation,  888 
Improper  food,  relation  of,  to  causation 

888 

Sex,  relation  of,  to  causation,  888 
Liability  of  special  breeds,  889 
From  skunk-bite,  889 
Spontaneous  origin,  890 
Contagion,  891 
Modes  of  dissemination,  891 
Milk,  propagation  by,  891 
Saliva,  propagation  by,  891 
Specific  germ,  892 

Pasteur's  experiments  as  to  infectious- 
ness,  892 

Point  of  election  of  germ,  892 
Antagonism  between  blood  and  germ, 

892,  893 
Localization  of  the  virus  in  the  wound. 

893 
Relation  of  successful   inoculation     to 

bites,  893 

Insusceptibility  to,  894 
Incubation,  894 

Duration  of,  in  lower  animals,  894 

in  man,  894 

Condition  of  cicatrix  during,  895 
Symptoms,  895 
In  dogs,  895 

Importance  of  recognizing  premon- 
itory, 895 

Of  prodromal  stage,  895 
Of  furious  form,  896 
During  paroxysms,  896 
Between  paroxysms,  896 
Of  paralytic  form,  896,  897 
Of  lethargic  form,  897 
Popular  fallacies  regarding,  897 
In  horse  and  other  animals,  897 
In  man,  898 
Symptoms,  898 

Prodromal  stage,  898 
A  ppearance  of  wound,  898,  899 
Of  paroxysms,  899 
Duration,  899 

Reflex  irritability  during,  899 
Facies  during,  899 
Mental  condition,  900 
Delirium  during,  900 
Relative  severity  in  men  and  wo- 
men, 900 
Paralytic  stage,  900 

duration,  900 
"Without  paroxysms,  900 
Diagnosis,  900 

Pathognomonic  features  in,  900 
From  tetanus,  900 
From  diphtheria,  900 
From  pharyngeal  anthrax,  900 
From  acute  mania,  900 
From  epilepsy,  901 
From  hysteria,  901 
From  pseudo-hvdropliobia,  901 
Inoculation  in  doubtful  cases,  902 
Morbid  anatomy,  902 

Post-mortem  appearance  of  body,  902 


RABIES  AND  HYDROPHOBIA— Morbid  anat- 
omy: Changes  in  mucous  mem- 
branes, 902 

Bronchi  and  pharynx,  902 
Lungs,  902 

Heart  and  blood-vessels,  902 
Gastro-intestinal  tract,  902 
Liver  and  spleen,  902 
Kidneys,  902 
Bladder,  902 

Brain  and  spinal  cord,  902 
Pathognomonic  changes  in  dogs,  903 
Treatment,  903 
Preventive,  903 

Registration  of  dogs,  904 
Modes  of  preventing  diffusion,  904 
Inoculation,  904 
Pasteur's  method,  905 
Of  bites,  905 
Use  of  caustics,  905 
Excision  of  cicatrix,  906,  908 
Futility  of  eliminating  measures,  906 
Hygienic,  906 

Psychical,  importance  of,  906 
Therapeutic,  907 
Use  of  chloroform,  907 
Chloral,  907 
Pilocarpine,  907 
Curare,  907 
Morphia,  907 
Atropia  and  datnria,  907 
Vaccine  virus,  907 
"Warm  baths,  907 
Faradization,  907 
Inhalation  of  oxygen,  907 
Importance  of  rest  and  quiet,  907 
Intravenous  injections,  908 
Venesection,  908 
Race,  influence  of,  in  causation  of  variola, 

436 
protection  as  a  preventive  of  small-pox, 

130 

relation  of,  as  causation  of  rubeola,  561 
Rachialgia  in  cerebro-spinal  meningitis,  808 
Rash  of  variola,  date  of  appearance  of,  437 

significance  of,  437 
variolous,  437 

Raspberry  excrescence  in  vaccinia,  461 
Reaction  in  cholera,  734 

treatment,  763 
Reflex  irritability  in  hydrophobia,  899 

symptoms  in  diphtheria,  treatment,  694 
Registration  of  dogs  for  prevention  of  ra- 
bies, 904 

Relapse,  in  relapsing  fever,  381 
Relapses,  cause  of,  in  typhoid  fever,  309 
duration  of,  in  typhoid  lever,  304 
frequency  of,  in  typhoid  fever,  302 
in  cerebro-spinal  meningitis,  820 
of  diphtheria,  prognosis  of,  694 
in  rubeola,  563 
RELAPSING  FEVER,  369 
Definition,  369 
Svnonyms,  369 

History  and  geographical  distribution,  369 
Etiology,  370 
Destitution  and  filth  as  causes,  370 


1078 


INDEX. 


RELAPSING  FEVER — Etiology;    Intemper- 
ance as  a  cause,  370 
Starvation  and  over-crowding  as  a  cause, 

371 

Age,  relation  of,  to  causation,  371 
Sex,  relation  of,  to  causation,  371 
Nationality,  relation  of,  to  causation, 

371 

Season,  relation  of,  to  causation,  371 
Occupation,   relation   of,   to   causation, 

372 

Specific  origin,  370,  372 
Contagious  nature,  372 
Transmission  of  contagion,  373 
Area  of  contagious  atmosphere,  373 
Spirillum,  373 

Mode  of  detecting,  373 
Inoculation,  374 
Incubation  period,  376 
General  clinical  description,  374 
Invasion,  376 
Special  symptoms,  376 
Odor,  378 
Physiognomy,  376 
Bronzing  of  face,  376 
Eruptions,  377 
Hepatic  eruptions,  377 
Sudamina,  377 
Desquarnation,  377 
Primary  paroxysms,  duration,  378 
Temperature,  378 

at  crisis,  378 

peculiarities,  382 
Kelapse,  381 
Duration,  381 
Absence,  380 
Frequency,  382 
Later  relnpses,  381 
Cases  illustrating  frequency  of  relapses, 

394 

Average  duration  of  paroxysms,  381 
Intermission,  duration,  381 
Pulse,  382 

Relation  of  pulse  to  temperature,  382 
Character  of  pulse   during  paroxysm, 

383 
Pulse  at  crisis,  382 

Duriug  intermission,  383 
Character  of  heart-sounds,  383 
Convulsions,  384 
Mental  condition,  384 
Headache,  383 
\Vakefulnes8,  384 
Vertigo,  384 
Delirium,  384 
General  tremor,  384 
Muscular  rigidity,  384 
Muscular  and  joint  pains,  385 
Cause  of   muscular   and   joint    pains, 

385 

Seat  of  muscular  and  joint  pains,  385 
Motor  paralysis,  385 
Debility,  386 

Perversion  of  special  senses,  386 
Respiration,  386 
Relation    of   respiration,   temperature, 

and  pulse,  386 


RELAPSING  FEVER  —  Special    symptoms : 
Bronchitis  and  pneumonia,  387 

Condition  of  urine,  387 

Urine  of  paroxysm,  388 
of  intermission,  388 

Thirst,  389 

Anorexia,  389 

Condition  of  tongue,  389 

Nausea  and  vomiting,  390 

Hsematemesis,  390 

Condition  of  bowels,  390 
of  abdomen,  390 

Spleen,  enlargement,  391 

Liver,  enlargement,  391 

Jaundice,  signiticance  of,  391 

Epistaxis,  393 

Hemorrhages,  393 

Convalescence,  393 
Varieties,  395 

Grave  form,  395 

Multiple  or  protracted  form,  395 

Abortive  form,  395 

Case  illustrating  subintrant  form,  396 
Complications,  396 

Peculiarities  of  temperature,  397 

Mental  hebetude,  398 

Local  palsies,  398 

Severe  rheumatic  pains,  399 

Disorders  of  vision,  399 

Ophthalmia,  399 

Disorders  of  hearing,  400 

Otorrhcea,  400 

Swellings  and  effusions  of  joints,  400 

Bed-sores,  400 

Gangrene,  400 

Abscesses,  400 

Anaemia,  400 

(Edema,  400 

Sudden  collapse  and  syncope,  401 

Hemorrhages    from    mucous'  surfaces, 
401 

Pericarditis,  402 

Heart-clot,  402 

Thrombosis  and  embolism,  402 

Laryngitis,  403 

Bronchitis,  403     . 

Splenic  enlargement,  403 

Rupture  of  spleen,  403 

Parotitis,  404 

Pleurisy,  404 

Pneumonia,  404 

Pulmonary  gangrene,  404 

Metastalic  abscesses  of  lungs,  404 

Pharyngitis  and  tonsillitis,  405 

Hiccough,  405 

Diarrhcea,  405 

Dysentery,  406 
stools,  406 

Suppuration  of  mesenteric  glands,  406 

General  and  local  peritonitis,  406 

Emaciation,  407 

Renal  disorders,  408 

Albuminuria,  407 

Suppression  of  urine,  407 

Incontinence  of  urine,  407 

Hicmaturia,  409 

Glycosuria,  410 


INDEX. 


1079 


RELAPSING  FEVER— Complications:  Metas- 
tatic  inflammation  of  kidneys,  410 
Disorders  of  menstruation,  410 
Pregnancy,  410 
Sequelae,  398 

Local  palsies,  398 
Acute  miliary  tuberculosis,  404 
Dyspepsia,  406 
Anaemia,  400 
Morbid  anatomy,  410 

Post-mortem  appearance  of  body,  410 
Changes  in  voluntary  muscles,  410 

Blood,  411 

Granule-cells  of  blood,  412 
Changes  in  pericardium,  411 

Heat,  411 

Gastro-intestinal  canal,  412 
Solitary  and  agminated  glands,  413 
Mpsenteric  glands,  413 

Larynx  and  pharynx,  413 

Pleura,  413 

Lungs,  413 

Brain  and  membranes,  413 

Liver,  414 

Bile-ducts  and  gall-bladder,  415 

Spleen  and  capsule,  416 

Pancreas,  417 

Peritoneum,  417 

Kidneys,  414 

Bladder,  414 

Lymphatic  glands,  417 
Marrow  of  bones,  417 
Diagnosis,  418 

Presence  of  spirillum  as  a  means,  418 
From  typhus  fever,  418 
From  typhoid  fever,  419 
Grave  form  of,  from  typhoid  fever,  420 
From  bilious  remittent  fever,  420 

Yellow  fever,  420 

Small-pox,  421 

Acute  gastro-hepatic  catarrh,  421 

Simple  febricula,  421 

Rheumatic  fever,  421 

Acute  yellow  atrophy  of  liver,  422 

Parotitis,  422 

Cerebral  diseases,  422 
Prognosis,  422 

Symptoms  indicating  unfavorable,  424 
influence  of  variations  of  temperature, 
424 

Cerebral  symptoms,  424 

Character  of  eruption,  425 

Hiccough  upon,  425 

Epistaxis,  425 

Cough  upon,  425 

Heart  complications  on,  425 

Hepatic  enlargement  upon,  425 

Splenic  enlargement  upon,  425 

Jaundice  upon,  425 

Albnininuria,  425 

Mortality — bilious  typhoid  form,  422 
Influence  of  type  of  disease,  423 

Stage  of  disease,  423 

Season,  423 

Habits  and  previous  health,  424 

Sex,  424 

Age,  424 


RELAPSING  FEVER— Mortality  :  Influence 

of  race,  424 
Cause  of  death  in,  426 
Treatment — indications  for  treatment  in 

regular  cases,  426 
Hyperpyrexia,  426 
Cause  of  failure  of  antipyretics,  429 
Insomnia,  429 
Headache,  429 
Nausea  and  vomiting,  430 
Constipation,  430 
Jaundice,  431 
Muscular  tremor,  432 

soreness  and  pains,  432 
At  critical  fall  of  temperature,  432 
Renal  complications,  432 
Epistaxis,  432 
Collapse,  433 

Necessity  of  absolute  rest  in,  432 
R&ume  of  treatment,  432 
Diet,  430 

Special  remedies,  431 
Use  of  nntiperiodics,  428 
Arsenic,  427 
Atropia,  429 

Bromide  and  chloral,  430 
Blisters,  431 
Chloroform,  431 
Cold  baths,  428 

Digitalis  and  other  antipyretics,  428 
Hyposulphite  of  sodium,  428 
Opium,  429 
Qtiinia,  426 

Salicylic  acid  and  salicylates,  428 
Simple  febrifuges,  428 
Stimulants,  430 
Venesection,  431 
REMITTENT  FEVER,  598 
Definition,  598 
Malarial  nature,  598 
Etiology,  598,  599 

Relation  of,  to  intermittent  fever,  599 
Symptoms,  599 

Prodromal  stage,  599 
Paroxysm,  599 
Temperature,  599 
Epistaxis,  602 
State  of  tongue,  600 
Stomach,  602 
Bowels,  602 
Urine,  602 
Jaundice,  600 

cause,  600 

Nervous  symptoms,  602 
Physiognomy,  600 
Pulse  in,  602 
Duration  of,  602 
Diagnosis,  600 

From  intermittent  fever,  600 
From  typhoid  fever,  600 
From  yellow  fever,  600 
Prognosis,  602 
Mortality,  599 
Morbid  anatomy,  602 
Changes  in  skin,  603 
Liver,  602 
Spleen,  602 


1080 


INDEX. 


REMITTENT  FEVER — Treatment,  603 
Main  indications,  603 
Use  of  quinia,  603 
Amount  of  quinia,  603 
Causes  of  failure  of  quinia,  604 
Adjuvants  to  quinia,  604 
Use  of  depuratives,  (504 
Purgative*,  604 
Opium,  604 
Of  hemorrhage,  605 
Of  tympanites,  605 
Of  vomiting,  605 
Renal  disease,  complicating  relapsing  fever, 

408 

scarlet  fever,  525 

Residence,  change  of,  in  treatment  of  beri- 
beri, 1042 

Resolution,  incomplete,  in  idiopathic  paro- 
titis, treatment,  625 

of  symptomatic  parotitis,  treatment,  628 
of  erysipelas,  633 
of  inflammation,  54 

Respiration  in  cerebro-spinal  meningitis,  814 
characters  of,  in  idiopathic  parotitis,  623 
in  general  peritonitis  of  puerperal  fever, 

1010 

in  mild  scarlet  fever,  504 
in  relapsing  fever,  386 
in  septicaemia  lymphatica,  1012 
in  typhoid  fever,  276 
in  typhus  fever,  352 
in  croup,  157 
in  disease,  156 
kinds  of,  156 

significance  of,  in  general  diagnosis,  156 
Respiratory  diseases,  relation  of,  to  rubeola, 

561 
organs,  lesions  of,  in  typhus  fever,  356 

spread  of  diphtheria  into,  671 
tract,  alterations  of,  in  scarlet  fever,  531 
Rest,  necessity  of,  in  cholera,  760 
in  rabies  and  hydrophobia,  907 
in  relapsing  fever,  432 
in  yellow  fever,  654 
Retention-cysts,  116,  122 
Retro-vaccine,  473 
Re- vaccination,  time  of,  467 
Rheumatic    and    cardiac   inflammation   in 

scarlet  fever,  treatment,  556 
Rheumatism,  complicating  scarlet  fever,  521 
Rickets,  hereditary  nature,  128 
Rigidity,  muscular,  in  relapsing  fever,  384 
Rindfleisch's  definition  of  diphtheritic  in- 
flammation, 686 
ROTHELN,  582 
Definition,  582 
Synonyms,  582 
History,  582 
Etiology,  583 

Age  as  a  cause,  583 
Sex  as  a  cause,  583 
Specific  origin,  583 
Nature  of  contagion,  583 
Modes  of  transmission,  583 
Period  of  greatest  contagiousness,  583 
Distinct  nature,  584 
Frequency  of  second  attacks,  584 


ROTHELN — Relapses,  584 
Symptoms,  585 

Incubation  period,  583,  585 
Duration  of  incubation  period,  583 
Prodromal  stage,  585 
Eruption,  585 
Duration  of  eruption,  585 
Characters  of  eruption,  586 
Types  of  eruption,  586 
Condition  of  mucous  membranes,  586 
Swelling  of  lymphatic  glands,  586 
Temperature,  587 
Complications  and  sequelae,  587 
Diagnosis,  587 
From  measles,  587 
From  scarlet  fever,  587 
From  symptomatic  skin  eruptions,  588 
Prognosis  of,  588 
Treatment  of,  588 
RUBEOLA,  557 
Definition,  557 
Synonyms,  557 
History,  557 
Etiology,  557 

Nature  of  contagion,  558 
Relation  of  straw  fungus,  558 
Mode  of  entrance  into  body,  558 
Modes  of  dissemination  of  contagion, 

559 

Inoculation,  559 

Stage  when  most  easily  propagated,  560 
Race,  influence  of,  561 
Age,  influence  of,  501 
Sex,  influence  of,  562 
Climate  as  a  cause,  560 
Pregnancy  and  parturition  as  a  cause, 

561 

Scrofula  as  a  cause,  561 
Diseases  of  respiratory  organs  as  a  cause, 

561 

Relation  of,  to  acute  diseases,  561 
to  chronic  diseases,  561 
to  whooping  cough,  561 
Influence  of  nervous  diseases  upon  sus- 
ceptibility, 561 
Frequency  of  epidemics,  560 
in  new-born,  562 
second  attacks,  563 
Relapses  in,  563 
Symptoms,  563 

Incubation  stage,  563 
Duration  of  incubation  stage,  560 
Prodromal  stage,  564 
Temperature,  564 
Catarrhal  symptoms,  564 
Punctated  appearance  of  palatal  and 

faucial  mucous  membrane,  564 
Convulsions,  565 
Duration  of.  565 
Eruptive  stage,  565 

Temperature  of,  566 
Character  and  seat  of  eruption,  566 
General  symptoms,  567 
Symptoms  at  decline,  567 
Temperature  at  decline,  567 
Duration  of  eruptive  stage,  567 
Varieties  of,  568 


INDEX. 


KUBEOIA — Varieties:  Inflammatory  or  sy- 

nochal,  568 

Hemorrhagic  (rubeola  nigra),  569 
Without  eruption,  568 

catarrh,  568 

Deviations  from  ordinary  course,  569 
Peculiarities  in  seat  of  eruption,  569 

in  character  of  eruption,  569 
Relapses  of  eruption,  570 
Complications,  570 
Causes,  570 

Complicated  with  epistaxis,  570 
Skin  disorders,  570 
Pemphigoid  eruptions,  571 
Ear  diseases,  570 
Eye  diseases,  571 
Faucial  inflammation,  571 
Laryngitis,  571 
Bronchitis  and  capillary  bronchitis, 

571 

Pneumonia,  571 
Pulmonary  oedema,  572 
Acute  miliary  tuberculosis,  572 
Heart-clot,  572 
Intestinal  catarrh,  572 
Convulsions,  572 
Diphtheria,  573 
Sequelae,  573 

followed  by  general  miliary  tubercu- 
losis, 574 

Chronic  pulmonary  tuberculosis,  573 
Coryza,  574 
Ophthalmia,  574 
Ootitis,  574 
Intestinal  catarrh,  574 
Cutaneous  diseases,  574 
Bone  and  joint  disease,  574 
Nervous  affections,  574 
Granular  meningitis,  574 
Albuminuria,  574 
Gangrenous  affections,  574 
Morbid  anatomy,  575 

Changes  in  skin,  575 
Diagnosis,  575 

Value  of  punctated  appearance  of  pal- 
atal and  faucial  mucous  membranes, 
575 

Salient  points  in  diagnosis,  575 
From  rotheln,  576 
Scarlet  fever,  576 
Variola,  576 

Roseola  and  erythema,  577 
Typhus,  577 
Roseola  syphilitica,  577 
Prognosis,  577 

Factors  to  be  considered  in  making,  577 
Influence  of  hygienic  surroundings,  577 
previous  health,  578 
complications,  578 
Mortality,  578 

Influence  of  stage  of  disease,  578 

of  age,  578 
Treatment,  578 
Preventive,  578 
Isolation,  578 
Hygienic,  579 
Diet,  579 


1081 
Uncomplicated 


RUBEOLA  —  Treatment : 

cases,  579 
Results,  579 
Hyperpyrexia,  580 
Retrocession  of  eruption,  580 
Epistaxis,  580 
Diarrhoea,  581 
Nausea  and  vomiting,  581 
Constipation,  581 
Cough,  581 

Eye  complications,  581 
Aural  complications,  581 
Bronchitis  and  pneumonia,  581 
Convulsions,  581 
Use  of  aconite,  580 

Inunctions,  580 

Quinia,  580 

Stimulants,  580 

S. 

Salicylic  acid,  use  of,  in  diphtheria,  707 

in  relapsing  fever,  428 
Saliva,  propagation  of  rabies  and  hydropho- 
bia by,  891 
Salivary  glands,  lesions  of,  in  typhoid  fever, 

268 

Sanitary  inspection  of  houses,  187 
Sarcoma,  118 
SCARLET  FEVEK,  486 
History,  486 

Etiology — Specific  origin,  487 
Germ  theory,  488 
Microbes,  488 

Modes  of  cultivation  of  microbes,  488 
Modes  of  entering  the  system,  490 
Modes  of  communication,  490 
Dissemination  of,  by  milk,  491 
Fixity  of  the  poison,  491 
Solid  nature  of  the  poison,  492 
Duration  of  incubation,  492,  493 
Contagiousness,  494 
Area  of  contagiousness,  494 
Age,  influence  of,  in  causation,  500 
Variations  in  type,  494 
Surgical,  495    . 

distinguished  from  septicsemic  efflores- 
cence, 497 
effect  of  poison  upon  inflammation  of 

wounds,  498 
Obstetrical,  498 

liability  of  parturient  women  to,  498 
relation  of,  to  puerperal  septicaemia,  499 
Immunity  of  infants,  500 
Clinical  facts  regarding,  501 
Relapses  in,  501 

Frequency  of  second  attacks,  501 
Sympathetic  sore  throat  in,  502 

albuminuria  in,  502 
Symptoms,  502 

Ordinary  form,  502 
Premonitory,  502 
Nervous  system,  503 
Vomiting  in,  significance,  503 
Diarrhoea,  503 
Condition  of  tongue,  504 
of  faucial  and  nasal  membranes,  504 


1082 


INDEX. 


SCARLET  FEVER — Symptoms :  Respiratory, 

504 
Efflorescence,  504 

Seat  of  greatest  intensity  of  eruption, 

504 

Cause  of  absence  of  eruption,  505 
Date  of  desquamation,  506 
Temperature,  505 
Digestive  system,  505 
Urine,  characters,  505 
Duration,  506 

Malignant  or  grave  form,  507 
Digestive  system,  507 
Pulse,  507 
Eruption,  507 
Temperature,  507 
Nervous  symptoms,  507 
Condition  of  fauces,  508 
Of  throat,  503 
Nasal  cavities,  508 
Lymphatic  glands,  508 
Duration,  508 
Irregular  form,  508 
Causes,  508 

Absence  of  eruption,  508 
Hemorrhngic  form,  509 
Anginose  form,  510 
Complications  and  sequelae,  510 

Complicated  by  severe  nervous  symp- 
toms 510 

Throat  symptoms,  511 
Adenitis,  511 

Inflammation  of  neck,  511 
Gangrene  of  neck,  512 
CEdema  of  glottis,  512 
Diphtheria,  514 

course  of  diphtheria,  complicating, 

516 

Croupous  inflammation  of  fauces,  516 
Coryza,  520 
Otitis,  520 

course  of  otitis,  complicating,  520 
results  of  otitis,  complicating,  521 
By  rheumatism,  521 
By  cardiac  inflammations,  522 
By  dilatation  of  heart,  523 
By  heart-clot,  523 
By  pleuritis,  523 
By  nephritis,  525 
By  glomernlo-nephritis,  527 
By  albuminuria,  525 
By  anasarca  and  oedema,  529 

Order  and  date  of  appearance  of 

anasarca,  529 

By  head  symptoms  due  to  uraemia,  530 
Morbid  anatomy,  530 

Changes  in  the  blood,  530 
Respiratory  tract,  531 
Abdominal  organs,  531 
Post-mortem  appearance   of   eruption, 

532 
Changes  in  the  kidneys,  526 

hvaline  degeneration  of  kidneys, 

"527 

intestinal  nephritis,  528 
parenchymatous  nephritis,  526 
Changes  in  the  liver,  531 


SCART-ET  FEVER — Diagnosis,  532 
From  measles,  532 
From  erythema,  533 
From  rotheln,  533 
From  diphtheria,  533 
Prognosis,  533 

liiiluenceof  complications  upon,  533, 535 
type  upon,  534 
age  upon,  534 
Of  grave  cases,  535 
Mortality,  534 
Treatment,  536 
Preventive,  536 
Isolation  in,  537 

Inoculation  as  a  prophylactic,  536 
Belladonna  as  a  prophylactic,  536 
Sodium  sulpho-carbolate    as   a    pro- 
phylactic, 537 

Listerine  as  a  prophylactic,  537 
Boric  acid  as  a  prophylactic,  537 
Disinfection  in,  201,  538 
Hygienic,  539 
Therapeutic,  539 
Mild  cases,  540 
Inunction  in,  541 
Hyperpyrexia,  541 

by  cold,  541 

Mode  of  applying  cold,  542 
Antiseptic,  545 

Complications  and  sequelae,  545 
Pharyngitis,  545 

local,  546 

Coryza,  546 

local,  547 

Otitis,  547 

local,  549 

parucentesis  of  tympanum,  548 
Nephritis  and  albuminuria,  550 

modes  of  producing  diaphoresis,  551 
local,  555 
Convulsions,  556 
Rheumatic  and  cardiac  inflammation, 

556 

Pleuritis,  556 
Convalescence,  544 

Use  of  aconite  and  veratrum  viride,  543 
Alcohol,  544 

Ammonium  carbonate,  544 
Carbolic  acid,  545 
Cathartics,  554 
Diuretics,  555 
Digitalis,  543,  555 
Ice,  542 

Jaborandi  and  pilocarpine,  552 
Sodium  salicylate,  543 
Quinia,  543 

Scarlet  fever,  relation  of,  to  idiopathic  paro- 
titis, 620 

Scarlatina,  disinfection  in,  201,  538 
Schools,  closure  of,  for  prevention  of  disease, 

203 
Scrofula,  relation  of,  to  causation  of  rubeola, 

561 

relation  to  tuberculosis,  96,  101 
Scrofulosis,  hereditary  disposition  to,  127 
Scrofulous  habit,  peculiarities  of  tissue,  101 
Scurvy,  complicating  typhus  fever,  355 


INDEX. 


1083 


Season,  influence  of,  on  causation  of  anthrax. 

931,  940 

of  cerebro-spinal  meningitis,  802 
of  diphtheria,  682 
of  typhoid  fever,  245 
of  erysipelas,  630 
of  idiopathic  parotitis,  620 
of  influenza,  860 
of  the  plague,  775 
of  rabies  and  hydrophobia,  887 
of  relapsing  fever,  371 
of  typhus  fever,  343 
of  variola,  435 
on  cholera,  720 
proper,  for  vaccination,  477 
Seborrhcea,  following  erysipelas,  633 
Second  attack  of  rubeola,  frequency  of,  563 

stage  of  pertussis,  840 
Secondary  form  of  diphtheria,  671 
Segregation  of  lepers,  794 
Self-infection,  danger  of,  in  treating  diph- 
theria, 696 

prevention  of,  in  treating  diphtheria,  696 
Sensibility,  altered,  significance  of,  in  gen- 
eral diagnosis,  161 

modifications  of,  in  typhoid  fever,  279 
Sepsin,  971 
Septicaemia,  945 

complicating  erysipelas,  634 
distinguished  from  pyaemia,  978,  979 
lymphatics  of  puerperal  fever,  1011 
venosa,  1012 

Sequelae  of  cerebro-spinal  meningitis,  819 
of  cholera,  735 
of  erysipelas,  633 

of  grave  form  of  the  plague,  780,  781 
of  influenza,  868 
of  relapsing  fever,  396 
of  roiheln,  587 
of  rubeola,  573 

treatment,  580 
of  scarlet  fever,  510 
of  vaccinia,  464 
of  variola,  445 
Serous  inflammation,  47 

inflammations  complicating  erysipelas,  634 
Severe  form  of  diphtheria,  symptoms,  668 
of  influenza,  treatment,  875 
of  typhus  lever,  354 
Sewerage,  213 

Sewer-  and  soil-pipes,  importance  of  posi- 
tion, 188 
Sewer-gas,  189 

diseases  produced  by,  190 
symptoms  due  to,  189 
Sewers,  characters  of  efficient,  224 
public,  224 
ventilation  of,  224 
Sewer-traps,  test  as  to  their  efficiency,  190 

varieties,  191 

Sex,  influence  of,  on  causation  of  cerebro- 
spinal  meningitis,  802 
of  diphtheria,  680 
of  erysipelas,  630 
of  idiopathic  parotitis,  620 
of  influenza,  860 
of  leprosy,  789 


Sex,  influence  of,  on  causation  of  pertussis, 

839 

of  the  plague,  775 
of  rabies  and  hydrophobia,  880 
of  relapsing  fever,  371 
of  rotlieln,  583 
of  variola,  436 
typhoid  fever,  243 

_  relation  of,  to  causation  of  rubeola,  563 
Silver  nitrate,  use  of,  in  typhoid  fever,  332 
Simon's  triangles,  437 
SIMPLE  CONTINUED  FEVER,  231 
Definition,  231 
Synonyms,  231 
History,  231 
Etiology,  232 
Symptoms,  233 
Asthenic  form,  233 
Morbid  anatomy,  235 
Diagnosis,  234 

From  typhoid  fever,  234 
From  typhus  fever,  234 
From  relapsing  fever,  235 
From  tubercular  meningitis,  235 
Prognosis,  235 
Treatment,  236 

Simple  form  of  yellow  fever,  treatment,  649 
Singultus  in  pyaemia,  975 
in  septicaemia,  977 

significance  of,  in  general  diagnosis,  158 
Skin,  alterations  in  sensibility  of,  in  cere- 
bro-spinal meningitis,  808 
anaesthesia  of,  in  beriberi,  1039 
appearance  of,  in  typhoid  fever,  273 
character  of  lesions  in  erysipelas,  631 
chronic  diseases  of,  following  rubeola,  574 
color  of,  in  cholera,  737 
condition  of,  in  cholera,  736 
in  influenza,  866 
in  septicaemia,  97f 
coolness  of,  in  cerebro-spinal  meningitis, 

treatment,  831 

diseases  of,  complicating  vaccination,  471 
effects  on  course  of  erysipelas,  634 
following  vaccination,  471 
disorders  of,  complicating  rubeola,  570 
eruptions  of,  complicating  cholera,  735 

in  pyrcmia,  974 
erysipelas  of,  migration,  632 
hypenesthesia  of,  in  typhus  fever,  352 
lesions  of,  in  erysipelas,  635 

course  of,  631 
in  leprosy,  791 
in  remittent  fever,  603 
in  rubeola,  575 
morbid  anatomy  of  lesions  of,  in  variola, 

446 
odor  of,  in  typhoid  fever,  273 

in  typhus  fever,  352 

significance  of  color  of,  in  general  diag- 
nosis, 159 

swelling  of,  in  erysipelas,  632 
Skunk-bites  as  cause  of  rabies  and  hydro- 
phobia, 889 

Slaking  lime,  use  of,  in  diphtheria,  703  _ 
Sleep,  danger  of  prolonged,  in  nasal  diph- 
theria, 712 


1084 


INDEX. 


Sleeplessness  in   idiopathic  parotitis,  treat- 
ment, 625 
Small-pox,  434 
black,  442 

freedom  of  liability  to,  from  race-protec- 
tion, 130 

Sodium  benzoate,  use  of,  in  pertussis,  847 
chloride,  venous  injection  of,  in  cholera, 

762,  768 
hyposulphite,  use  of,  in  relapsing  fever, 

428 

salicylate,  use  of,  in  diphtheria,  707 
in  puerperal  fever,  1032 
in  scarlet  fever,  543 
in  typhoid  fever,  330 
sulpho-carbolate  as  a  prophylactic  in  scar- 
let fever,  537 
Softening,  cerebral,  from  embolism,  65 

mucous,  82 

Soil,  character  of,  as  cause  of  disease,  187 
composition  of,  187 
diminished  dryness  of,  a  cause  of  phthisis, 

187 
drainage  of,  for  prevention   of  anthrax, 

937 

of  disease,  226 
examination,  188 
filtering  power,  187 
humidity  of,  as  a  cause  of  cholera,  722 
Soils,  alkaline,  relation  of,  to  causation  of 

anthrax,  930 

Soil-pipes,  importance  of  position  of,  188 
tests  as  to  their  efficiency,  190 
ventilation  of,  189 
Solitary  glands,  lesions  of,  in  typhoid  fever, 

261 

Spasm  of  phaiyngeal  and  respiratory  mus- 
cles in  hydrophobia,  809 
Special  senses,  perversion  of,  in  relapsing 

fever,  386     • 
in  typhus  fever,  349 
Specific  origin  of  anthrax,  720,  726 
of  cholera,  727 
of  glanders,  911 
of  rotheln,  583 
of  yellow  fever,  640 
Speech,  impairment  of,  following  cerebro- 

spinal  meningitis,  820 
Spinal   cord,   lesions   of,   in    cerebro-spinal 

meningitis,  823 

marrow,  lesions  of,  in  cholera,  746 
rigidity  in  cerebro-spinal  meningitis,  809 
Spirillum,  142 

of  relapsing  fever,  373 
Spleen,  condition  of,  in  relapsing  fever,  391 
enlargement  of,  in  pyaemia,  976 
lesions  of,  in  anthrax  in  animals,  935 

in  man,  942 
in  cholera,  746 
in  diphtheria,  687 
in  glanders,  922 
in  hydrophobia,  903 
in  pyasmia,  969 
in  relapsing  fever,  416 
in  remittent  fever,  602 
in  septicaemia,  972 
in  typhoid  fever,  264 


Spleen,  lesions  of,  in  typhus  fever,  357 

rupture  of,  in  relapsing  fever,  403 
Spontaneous  cow-pox,  456 
origin  of  pyaemia,  959 

of  typhoid  fever,  254 
Stages  of  yellow  fever,  615 
Standards  of  purity  of  water,  184 
Starvation  and  over-crowding  as  causes  of 

relapsing  fever,  370 
Pteam,  use  of,  in  diphtheria,  701 
Sthenic  inflammation,  46 
Stimulants,  use  of,  in  diphtheria,  695 
in  relapsing  fever,  431 
in  rubeola,  580 
in  variola,  4-33 
Stomach,  lesions  of,  in  cholera,  743 

state  of,  in  remittent  fever,  602 
Stools,  as  a  medium  of  disseminating  typhoid 

fever,  249 

character  of,  in  cholera,  739 
in  pyaemia,  976 
in  typhoid  fever,  287 
in  typho-malarial  fever,  necessity  of  dis- 
infecting, 619 
necessity  of  disinfection  in  prevention  of 

typhoid  fever,  321 

significance  of,  in  general  diagnosis,  163 
Strabismus  in  cerebro-spinal  meningitis,  810 
Straw-fungus,  relation  of,  to  rubeola,  558 
Strychnia,  use  of,  in  diphtheritic  paralvsis, 

713 

in  dry  beriberi,  1043 
Stupor  in  typhoid  fever,  treatment,  334 

in  typhus  fever,  treatment,  366 
Subsoil-water,  level  of,  188 
Sudamina  in  typhoid  lever,  274 

in  typhus  fever,  352 
Sulphites  and  hyposulphites,  use  of,  in  py- 

remia,  982 
in  septicaemia,  983 
Sulphur,  use  of,  in  diphtheria,  709 
Summer  heats,  relation  of,  to  causation  of 

rabies  and  hydrophobia,  887 
Suppuration   in   idiopathic  parotitis,  treat- 
ment, 625 

influence  of  minute  organisms  in  produc- 
tion of,  144 

Suppurative  stage  of  variola,  439 
Surgical  scarlatina,  495 

treatment  of  erysipelas,  638 
Swelling  of  parotid  glands  in  cerebro-spinal 

meningitis,  814 

Swellings,  significance  of,  in  diagnosis,  159 
Sweating  stage  of  intermittent  fever,  593 
of  intermittent  fever,  treatment,  597 
Symptomatic  parotitis,  625 
Symptomatology,  general,  148 
Symptoms  at  decline  of  eruptive  stage  of 

rubeola,  567 

constitutional,  of  vaccinia,  459 
due  to  sewer-gas,  ]  89 
general,  of  idiopathic  parotitis,  623 
of  anaesthetic  form  of  leprosy,  791 
of  tubercular  form  of  leprosy,  7(JO 
of  confluent  small-pox,  441 
local,  of  anthrax,  935,  940 
of  idiopathic  parotitis,  621 


INDEX. 


1085 


Symptoms,  local,  of  anaesthetic  form  of  lep- 
rosy, 790 

of  glanders,  914,  915,  921 

of  tubercular  form  of  leprosy,  789 
nervous,  in  mild  scarlet  fever,  503 

in  typhus  fever,  348 
special,  in  typhus  fever,  347 
of  anthrax  in  animals,  934 

in  man,  940 

angina,  941 

intestinalis,  941 
of  malignant  anthrax,  940 
of  beriberi,  1039 
of  cerebro-spinal  meningitis,  806 
of  cholera,  731 
of  comatose  form  of  pernicious  malarial 

fever,  608 
of  dengue,  884 
of  diphtheria,  667 

of  endometritis  and  endocolpitis  of  puer- 
peral fever,  1005 
of  erysipelas,  631 
of  glanders  in  horses,  914 

in  man,  920 

of  hydrophobia,  in  man,  898 
of  influenza,  865 
of  idiopathic  parotitis,  621 
of  intermittent  fever,  592 
of  gangrene  foudroyante,  977 
of  general  peritonitis  of  puerperal  fever, 

1010 

of  leprosy,  789 

of  malignant  scarlet  fever,  507 
of  para-  and  perimetritis  in  puerperal  fe- 
ver, 1005 
of  pertussis,  840 
of  the  plague,  777 
of  puerperal  fever,  1004 
of  pyaemia,  972 

of  rabies  and  hydrophobia  in  dogs,  895 
of  relapsing  fever,  374 
of  remittent  fever,  599 
of  rotheln,  585 
of  rubeola,  563 
of  scarlet  fever,  502 
of  septicaemia,  976 

lymphatica  of  puerperal  fever,  1011 

venosa  of  puerperal  fever,  1012 
of  simple  continued  fever,  233 
of  symptomatic  parotitis,  626 
of  typho-malarial  fever,  615  . 
of  typhoid  fever,  268 
of  typhus  fever,  346 
of  vaccinia,  458 
of  varicella,  481 
of  variola,  436 
of  varioloid,  443 
of  yellow  fever,  644 
Synonyms  of  anthrax,  926 

of  cerebro-spinal  meningitis,  795 

of  cholera,  715 

of  dengue,  879 

of  diphtheria,  656 

of  erysipelas,  629 

of  glanders,  909 

of  influenza,  851 

of  leprosy,  785 


Synonyms  of  the  plague,  771 
of  rabies  and  hydrophobia,  886 
of  relapsing  fever,  369 
of  rotheln,  582 
of  rubeola,  557 

of  simple  continued  fever,  231 
of  typhoid  fever,  237 
of  typhus  fever,  338 
of  vaccinia,  455 
of  vaccination,  465 
of  varicella,  481 
of -variola,  434 
of  yellow  fever,  640 
Syphilis,  complicating  vaccination,  469 

modes  of  preventing,  470 

treatment  of,  471 
constitutional,  hereditary  nature  of,  127 

T. 

Taches  bleuatres  in  typhoid  fever,  275 

in  typhus  fever,  352 
Tarnier's  maternity  pavilions  for  prevention 

of  puerperal  fever,  1028 
Taste,  modifications  of,  in  typhoid  fever,  280 
significance  of  modification,  in  general  di- 
agnosis, 162 

Technics  of  vaccination,  472 
Teeth,  significance  of  condition,  in  diagno- 
sis, 152 
Temperature  in  anthrax  in  man,  940 

at  decline  of  eruptive  stage  of  rubeola,  567 
elevated,  influence  of,  in  origin  and  spread 

of  cholera,  720 

in  cerebro-spinal  meningitis,  815 
in  cholera,  736 
in  dengue,  881 

in  eruptive  stage  of  rubeola,  565 
in  erysipelas,  633 
in  fevers,  38-40 
in  general  peritonitis  of  puerperal  fever, 

1010 

in  idiopathic  parotitis,  623 
in  influenza,  864 
in  malignant  scarlet  fever,  507 
in  mild  scarlet  fever,  505 
in   para-  and  perimetritis  in   puerperal 

fever,  1006 

in  prodromal  stage  of  rubeola,  564 
in  pyaemia,  974 
in  relapsing  fever,  378,  382 
in  remittent  fever,  599 
in  rotheln,  587 
in  septicaemia,  977 

venosa  of  puerperal  fever,  1012 
in  typhoid  fever,  280 
in  typhus  fever,  349 

significance  of,  in  general  diagnosis,  158 
respiration  and  pnlse,  relations  of,  in  re- 
lapsing fever,  386 

Tenderness,  muscular,  in  beriberi,  1039 
Teratoid  tumors,  124 
Test,  peppermint,  for  defects  in  plumbing, 

198 

Tests  as  to  efficiency  of  soil-pipes,  190 
The  plague,  771 
Thermometer,  use  of,  in  typhoid  fever,  284 


1086 


INDEX. 


Thirst  in  cerebro-spinal  meningitis,  814 
in  rabies  and  hydrophobia,  899 
in  relapsing  fever,  389 
in  typhoid  fever,  285 
in  typhus  fever,  350 

treatment,  367 

significance  of,  in  general  diagnosis,  162 
treatment  of,  in  cholera,  770 
Throat     symptoms,    complicating      scarlet 

fever,  511 
Thoracic  duct,  obstruction  of,  as  cause  of 

dropsy,  69. 
Thrombi,  action  of,  in  production  of  meta- 

static  abscesses  in  pyaemia,  965 
calcification  of,  60,  89 
in  uterine  pelvic  veins,  989 
growth  of,  in  puerperal  fever,  989 
Thrombosis,  56 

relation  of,  to  causation  of  pyaemia,  957 
and  embolism,  56 
causes,  57 
symptoms,  66 
in  relapsing  fever,  402 
in  typhoid  fever,  treatment,  335 
THROMBUS,  56 

Calcification,  60,  88 
Characteristics,  59 
Changes,  60 
Composition,  56 

Distinguished  from  thrombosis,  56 
From  compression,  58 
From  death  of  leucocytes,  57 
From  dilatation,  58 
From  marasmus,  59 
From  traumatism,  58 
•Mechanical  effects,  62 
Organization,  60 
Softening,  61 
Varieties,  57,  58 

Tongue,  condition  of,  in  cerebro-spinal  men- 
ingitis, 813 
in  dengue,  881 
in  erysipelas,  633 
in  idiopathic  parotitis,  622 
in  mild  scarlet  fever,  504 
in  typhus  fever,  350 
in  yellow  fever,  644 
state  of,  in  pyaemia,  975 
in  relapsing  fever,  389 
in  remittent  fever,  600 
in  septicaemia,  977 
in  typhoid  fever,  285 
signification  of  state  of,  in  diagnosis,  152 
Tracheal  diphtheria,  prognosis  of,  692 
Trachea,   formation   of   diphtheritic  mem- 
brane in,  671 
Tracheotomy   in    diphtheria,   prognosis   of, 

.  6.92 
Transmission  of  cholera,  721,  723 

of  variola,  435 
Transudation,  68 

causes,  69 

mechanism,  68 
Traps,  ventilation,  221 
Traumatic  fever,  relation  of,  to  septicaemia, 
961 

fevers,  37 


Treatment  of  anthrax  in  animals,  938 
in  man,  943 

preventive,  of  anthrax,  936,  943 

of  beriberi,  1042 

of  cerebro-spinal  meningitis,  829 

of  cholera,  759 

of  dengue,  885 

of  diphtheria,  694 

general,  importance  of,  in  diphtheria,  695 

of  erysipelas,  636 

of  idiopathic  parotitis,  624 

local,  of  idiopathic  parotitis,  625 

of  intermittent  fever,  594 

of  leprosy,  793 

local,  of  leprosy,  794 

of  comatose  form  of  pernicious  malarial 
fever,  609 

of  glanders  in  horse,  918 
in  man,  924 

preventive,  in  horse,  919 
in  man,  925 

of  influenza,  873 

of  pertussis,  844 

of  the  plague,  782 

of  puerperal  fever,  1028 

of  septioemia.  983 

of  pya-mia,  979 

of  rabies  and  hydrophobia,  903 
preventive,  903 

of  relapsing  fever,  426-433 

of  remittent  fever,  603 

of  rotheln,  587 

of  rubeola,  578 

hygienic,  of  rubeola,  579 

preventive,  of  rubeola,  578 

of  scarlet  fever,  536 

of  septicaemia,  982 

of  simple  continued  fever,  236 

of  symptomatic  parotitis,  627 

local,  of  symptomatic  parotitis,  628 

of  typhoid  fever,  320 

of  typho-malarial  fever,  618 

of  typhus  fever,  361 

of  variola,  451 

hygienic,  of  variola,  451 

of  variola,  preventive,  451 

of  varioloid,  451 

of  yellow  fever,  649 

Treeak  farook,  use  of,  in  wet  beriberi,  1042 
TUBERCLE,  94 

Calcification,  96 

Cheesy  degeneration,  96 

Fibrous  transformation,  96 

Histology,  95 

Horn-like  change,  96 

Infectious  origin,  97 

Inoculability,  97 

Miliary   and    gray,   cause    of   infectious 
qualities,  99 

Origin  of,  from  absorption  of  cheesy  prod- 
ucts, 97 

Tubercular  form  of  leprosy,  789 
TUBERCULOSIS,  94 

Bacilli  of,  99,  100  et  seq. 

Dissemination,  103 

Hereditary  nature,  101 

Primary  seat,  104 


INDEX. 


1087 


TUBERCULOSIS — Eelation  of,  to  pearly  dis- 
temper, 99 
to  scrofula,  101 
Tuberculosis,   acute    miliary,   complicating 

rubeola,  572 

chronic  pulmonary,  following  rubeola,  573 
general  miliary,  folio  wing  relapsing  fever, 

404 

following  rubeola,  574 
relation  of,  to  pearly  distemper,  99 

to  scrofula,  96,  101 
TUMORS,  105 

Method  of  origin,  106 
Cohnheim's  theory  of  origin,  106 
Influence  of  irritants  in  producing,  108 
Growth,  109 
concentric,  109 
continuous,  109 
eccentric,  109 
influence  of  seat,  109 
rapidity,  109 
Primary,  110,  111 
Secondary,  110,  112 
Metastasis,  110 
Multiple,  110 
Recurrence,  110 
Transplantation,  110 
Embolic  nature,  112 
Changes  occurring,  113 

inflammatory,  113 

Analogy  of  structure  in  primary  and  sec- 
ondary, 113 
Benignant,  114 
Cachexia,  114 
Malignant,  114 
Resemblance  of,  to  normal  tissue  of  body, 

115 

Histoid,  116 
Organoid,  116 

Relation  of,  to  each  other,  117 
Connective  tissue,  118,  122 
Cystic,  115,  116,  121 
Influence  of  age  upon  development,  119 
Classification,  114,  121 
Infective  group,  120,  124 
Epithelial  group,  123 
Congenital,  124 

Turpentine  inhalations  in  diphtheria,  704 
stupes,  use  of,  in  puerperal  fever,  1032 
use  of,  in  typhoid  fever,  326 
Tympanites  "in  remittent  fever,  treatment, 

605 
in  typhoid  fever,  286 

treatment  of,  332 

in  typho-malarial  fever,  treatment,  619 
in  typhus  fever,  350 
Tympanum,  paracentesis  of,  in  scarlet  fever, 

548 

Types  of  cerebro-spinal  meningitis,  804 
of  intermittent  fever,  594 
of  scarlet  fever,  494 
of  varioloid,  444 
TYPHOID  FEVER,  237 
Synonyms,  2H7 
Definitions,  237 
History,  238 
Geographical  distribution,  241 


TYPHOID  FEVER — Etiology,  242 
Predisposing  causes,  242 
Age,  influence  of,  2-12 
Sex,  influence  of,  243 
Occupation,  influence  of,  244 
Change  of  residence,  influence  of,  244 
Idiosyncrasy,  influence  of,  245 
Depressing  emotions,  influence  of,  245 
Intemperance,  influence  of,  245 
Previous  ill-health,  influence  of,  245 
Season,  influence  of,  245 
Elevated  temperature,  influence  of,  246 
Rise  and  fall  of  subsoil-water,  influence 

of,  247 

Exciting  causes,  248 
Contagiousness,  248 
Dissemination,  249 

Cases  illustrating  modes  of  dissemina- 
tion, 250 

Dissemination    of,    by  drinking-water, 
248 

By  stools,  249 

By  milk,  252 

By  atmosphere,  252 

By  bed-linen,  etc.,  253 

By  polluted  soil,  253 

By  putrefied  flesh,  257 
Spontaneous  origin,  254 
Duration  of  virulence  of  germs,  256 
Bacillus  typhosus,  258 
Incubation  period,  259 
Morbid  anatomy,  260 
Lesions  peculiar  to,  261 
Changes  in  Peyer's  patches,  261 

Solitary  glands,  261 
Softening  of  Peyer's  patches  and  soli- 
tary glands,  263 
Cicatrization   of    Peyer's   patches    and 

solitary  glands,  263 
Changes  in  crecum  and  colon,  263 

Spleen,  264 

Abdominal  glands,  264 
Lesions  not  peculiar  to,  265 
Changes  in  liver  and  gall-bladder,  265 

Pharynx  and  oesophagus,  265 

Larynx  and  lungs,  266 

Brain  and  membranes,  266 

Muscles,  267 

Heart  and  blood-vessels,  267 

Blood,  268 

Salivary  glands,  268 

Kidneys,  268 
Symptoms,  268 

Clinical  description,  268 
Physiognomy,  272 
Epistaxis,  273 
Condition  of  skin,  273 

Odor,  273 

Eruption,  273 

Sudamina,  274 

Tilches  bleuatres,  275 
Condition  of  hair  and  nails,  275 

Pulse,  275 
Heart-sounds,  276 
Respiration,  276 
Frequency  of  bronchitis,  277 
Mental  condition,  277 


1088 


INDEX. 


TYPHOID  FEVER — Symptoms:   Headache, 

277 

Delirium,  278 
Muscular  spasm,  279 

tremor,  279 
Modifications  of  sensibility,  279 

Hearing,  280 

Vision,  280 

Taste,  280 
Temperature,  280 
State  of  tongue,  285 

Fauces,  286 

Nausea  and  vomiting,  285 
Anorexia,  285 
Thirst,  285 
-      Gurgling,  286 

Meteorism  or  tympanites,  286 
Diarrhoea,  287 
Character  of  stools,  287 
Intestinal  hemorrhage,  287 

frequency,  288 

causes,  288 

importance,  288 
Intestinal  perforation,  289 

frequency,  290 

causes,  290 

date  of  appearance,  290 

importance,  289 
Condition  of  urine,  291 

amount  of  solids,  291 

presence  of  albumen,  292 
Complications  and  sequelae,  292 
Complicated  by  pyaemia,  294 

Laryngitis,  294 
Bronchitis  and  pneumonia,  294 

Pleurisy,  294 

Jaundice,  295 

Peritonitis,  295 

Catarrhal  and  diphtheritic  inflamma- 
tion of  fauces,  295 

Parotid  swelling,  296 

Menstrual  disorders,  296 

Pregnancy,  296 

Suppuration  of  BartholSni's  glands, 
296 

Periostitis,  297 

CEdema,  297 

Bed-sores,  297 
Followed  by  impaired  intellect,  292 

Perversion  of  the  moral  sense,  292 

Paralysis  and  chorea,  293 

Cardiac  degeneration,  293 

Arterial  thrombosis,  293 

Venous  thrombosis,  294 

Gangrene  of  vulva  and  vagina,  293 

Hepatic  abscess,  295 

Tendency  to  stoutness,  298 
Varieties  of,  298 
Abortive  form,  298 
Latent  form,  300 
In  children,  301 
In  aged  persons,  302 
Eelapses  in,  302 
frequency,  302 
course,  303 
cases  illustrating,  304 
causes,  308 


TYPHOID  FEVER — Duration,  310 
Diagnosis,  311 
From  typhus,  311 
From  influenza,  312 
From  relapsing  fever,  312 
From   epidemic  cerebro-spinal  menin- 
gitis, 313 

From  simple  continued  fever,  313 
From  remittent  fever,  312 
From  the  eruptive  fevers,  313 
From  acute  tuberculosis,  313 
From  trichinosis,  314 
From  the  specific  inflammations,  314 
From  acute  tubercular  meningitis,  314 
Prognosis,  314     « 

Symptoms  indicating  unfavorable,  314 

favorable,  316 
Influence  of  hyperpyrexia  upon,  314 

Nervous  symptoms,  315 

Heart  symptoms,  316 

Condition  of  pulse,  316 

Abdominal  symptoms  upon,  316 
Mortality,  316 

Tables"  showing,  317,  318 
Influence  of  season,  318 

Sex,  319 

Age,  319 

Treatment,  319 

Habits,  320 

Social  condition,  320 

Recent  residence,  320 

Corpulence,  320 

Organic  disease,  320 

Childhood,  320 
Treatment,  320 
Preventive,  321 

Necessity  of  proper  drainage  in  preven- 
tion, 321 

Disinfection  of  stools,  321 
Hygienic,  322 
Irn  portance  of  ventilation,  323 

administering  water,  325 
Diet,  323 
Mild  cases,  326 
Hyperpyrexia,  327 

by  cold  baths,  327-329 
Typho-malarial  form,  331 
Vomiting,  331 
Diarrhoea,  331 
Tympanites,  332 
Intestinal  hemorrhage,  332 

perforation,  333 
Constipation,  333 
Headache,  334 
Insomnia,  334 
Stupor,  334 
Delirium,  334 
Albuminuria,  334 
Complications,  335 
Epistaxis,  335 
Pneumonia,  335 

Hypostatic  congestion  of  lungs,  335 
Thrombosis  and  embolism,  335 
Bed-sores,  335 
Convalescence,  335 
Use  of  alcohol,  324 

Digitalis,  330 


INDEX. 


1089 


TYPHOID  FEVER — Treatment :  Use  of  euca- 
lyptus, 331 
Qu'inia,  330 
Silver  nitrate,  332 
Sodium  salicylate,  330 
Turpentine,  326 
Specific,  336 
By  calomel,  336 
By  iodine,  336,  337 
Use  of  thermometer,  284 
Typhoidal  inflammation,  47 
Typhoid  state  of  cholera,  734 

following  variola,  445 
TYPHO-MAJ,ARIAL  FEVERS,  614 
Definition,  614 
Frequency,  616 
Symptoms,  615 
Diagnosis,  616 
Prognosis,  616 
Mortality,  616 
relative  mortality  of  white  and  black 

races,  616 
Treatment,  618 

Of  typhoidal  element,  618 
Of  malarial  element,  618 
Use  of  quinia,  618 
Depurative  treatment,  618 
Necessity  of  disinfection  of  stools,  619 
Of  tympanites,  619 
Of  insomnia,  619 
Diet,  619 

Typho-malarial  form  of  typhoid  fever,  treat- 
ment, 331 

TYPHUS  FEVER,  338 
Synonyms,  338 
History,  338 

Etiology — Predisposing  causes,  341 
Over-crowding  as  a  cause,  341 
Age,  influence  of,  342 
Debility  and  fatigue,  influence  of,  342 
Mental  and  physical  overwork,  342 
Intemperance,  342 
Poverty,  342 

Barometric    and    thermometric   varia- 
tions, 343 
Season,  343 
Occupation,  343 

Individual  susceptibility  to,  343 
Exciting  causes,  343 
Contagiousness,  343 
Nature  of  contagion,  343 
Modes  of  transmission  of  contagion,  344 
Communication  of,  by  fomites,  345 
Period  of  contagiousness,  345 
Spontaneous  origin,  345 
Period  of  incubation,  346 
Symptoms — Clinical  description,  346 
Special  symptoms,  347 
Prostration,  348 
Nervous  symptoms,  348 
Appearance  of  face,  348 
Intellectual  condition,  348 
Headache,  348 
Delirium,  348 
Wakefulness,  349 
Coma  vigil,  349 
Perversion  of  special  senses,  349 

VOL.  I.— 69 


TYPHUS    FEVER  —  Symptoms  :    Muscular 

tremor,  349 
Temperature,  349 
Condition  of  tongue,  350 
Anorexia,  350 
Thirst,  350 

Nausea  and  vomiting,  350 
Condition  of  bowels,  350 
Tympanites,  350 
Gurgling,  350 
Eruption,  351 
Duration  of  eruption,  351 
Taches  bleuatres,  352 
Sudamina,  352 
Hyperaesthesia  of  skin,  352 
Odor,  352 
Condition  of  pulse,  351 

of  heart,  351 
Respiration,  352 
Pneumonia,  353,  355 
Bronchitis,  353,  355 
Odor  of  breath,  353 
Hypostatic  congestion  of  lungs,  363 
Changes  in  urine,  353 
Varieties  of,  353 
Mild  form,  354 
Severe  form,  354 
Ataxic  form,  354 
Adynamic  form,  354 
Ataxo-adynamic  form,  354 
Inflammatory  form,  354 
Walking  form,  354 
Abortive  form,  354 
Complications  and  sequelae,  354 
Complicated  by  erysipelas,  355 

Cardiac  degeneration,  355 

Bronchitis  and  pneumonia,  353,  S-W 

Pleurisy,  355 

Albuminuria,  355 

Bed-sores,  355 

Scurvy,  355 

Dvsentery,  355 

Jaundice",  356 

Parotitis,  356 

Serous  inflammations,  356 

Pyaemia,  356 

Disorders  of  menstruation,  356 

Miscarriage,  356 
Followed  by  pulmonary  gangrene  und 

phthisis,  355 
Morbid  anatomy,  356 
Alteration  of  blood,  356 
Changes  in  respiratory  organs,  356 

Heart  and  membranes,  357 

Liver  and  kidneys,  357 

Spleen,  357 

Intestinal  tract,  357 

Brain  and  membranes,  358 
Diagnosis,  358 

From  typhoid  fever,  358 
From  meningitis,  358 
From  measles,  358 
From  typhoid  pneumonia,  359 
From  delirium  treinens,  359 
From  pnrpura,  359 
Prognosis  of,  359 
Svinptoms  indicating  favorable,  360 


1090 


INDEX. 


TYPHUS    FEVER  —  Prognosis:    Symptoms 

indicating  unfavorable,  360 
Influence  of  age,  859 

Sex,  359 

Former  habits,  359 

Convalescence  from  previous  illness, 
359 

Obesity,  359 

Mental  and  physical  overwork,  360 

Social  condition,  360 

Kace,  360 
Mortality,  360 

Difference  of,  in  hospital  and  private 

cases,  361 
Treatment,  361 
Preventive,  361 
Necessity  of  isolation,  361 
Disinfection,  362 
Diet,  362 
Quantity    of    nourishment    necessary, 

363 

Futility  of  abortive  treatment,  363 
General  treatment,  364 
Mild  cases,  364 
Hyperpyrexia,  364 
By  cold  water,  364 
By  cold  baths,  364 
Mode  of  using  cold  bath,  364 
Prostration,  365 
Headache,  366 
Delirium,  366 
Insomnia,  366 
Stupor,  366 

Urinary  complications,  366 
Thirst,  367 
Vomiting,  367 
Constipation,  367 
Parotitis,  367 

Pulmonary  complications,  367 
Use  of  alcohol  in,  366 

Opium  in,  366 

Quinia  in,  365 
Of  convalescence,  368 
Necessity  of  continuing  stimulants  dur- 
ing convalescence,  368 
Tyrosis,  79 

U. 

Ulceration,  complicating  vaccination,  468 
Ulcers,  complicating  cholera,  735 

following  the  plague,  781 
Umbilication   in   vaccinia,   mechanism    of, 

464 

in  varicella,  482 
in  variola,  438 
cause  of,  447 

Unemia  in  scarlet  fever,  530 
Urinary    complications     in    typhus    fever, 

treatment,  366 
Urine,  analysis  of,  importance    in    general 

diagnosis,  165 
condition  of,  in  cerebro-spinal  meningitis, 

814 

in  cholera,  739 
in  dengue,  881 
in  influenza,  866 


Urine,  condition  of,  in  mild  scarlet   fever, 

506 

in  grave  form  of  the  plague,  779 
in  pertussis,  841 
in  pyaemia,  976 
in  relapsing  fever,  387 
in  remittent  fever,  602 
in  typhoid  fever,  291,  292 
in  yellow  fever,  644 

suppression  of,  complicating  relapsing  fe- 
ver, 407 

in  cholera,  treatment,  764 
in  yellow  fever,  treatment,  653 
Urination,  difficult,  significance  of,  in  diag- 
nosis, 164 
Urobilin,  91 

Urticaria,  complicating  diphtheria,  674 
Uterus,  fixity  of,  in  para-  and  perimetritia 

of  puerperal  fever,  1007 
lesions  of,  in  septicaemia,  972 

V. 

VACCINIA,  455 
Definition,  455 
Synonyms,  455 
History,  458 
Etiology,  458 
K attire,  455 
Variolous  origin,  457 
Meteorological   conditions  as  a  cause, 

458 

Symptoms,  458 
General  course,  458 
Constitutional,  459 
Development  of  pock,  459 
Date  of  appearance  of  pock,  459 
incrustation  of  pock,  460 
falling  off  of  crust,  460 
Description  of  cicatrix,  460 
Irregularities  in  course,  460 
Raspberry  excrescence  of  pock,  461 
Lack  of  elevation  in  pock,  461 
Absence  of  a  constitutional    infection, 

460 

Bryce's  test  for  determining  constitu- 
tional infection,  461 
Diphtheritic  pock,  463 
Catarrhal  pock,  463 
Morbid  anatomv,  462 
Pock,  463 
Microspheres  and  vaccinals  of  lymph, 

463 
Microscopical  characters  of  the  lymph, 

463 

Mechanism  of  umbilication,  464 
Composition  of  crust,  464 
Complications  and  sequelae,  464 
VACCINATION,  465 
Synonyms,  465 
History  of,  465 
Protective  power  of,  461 
theories  regarding,  461 
duration  of,  468 
against  pertussis,  468 
Marson's  theory  of  multiple   insertions, 
467 


INDEX. 


1091 


VACCINATION — Time  of  revaccination,  467 
As  a  means  of  destroying  naevi,  468 
Complications,  468 

Simple  inflammatory,  468 
Complicated  by  dermatitis,  468 
Treatment  of  dermatitis,  469 
Complicated  by  lymphangitis  and  ade- 
nitis, 468 

By  ulceration  and  gangrene,  468 
Erysipelas,  469 

treatment,  469 
Complicated  by  syphilis,  469 

treatment,  471 
Modes  of  preventing  transmission  of 

syphilis,  470 
Complicated  by  skin  diseases,  471 

by  eczema,  472 
Impetigo    contagiosa,  its    relations  to, 

472 
Followed  by  cutaneous  affections,  471 

by  eczema,  472 
Conveyance  of  constitutional  taints  in, 

471 

Technics  of,  472 
Varieties  of  virus,  472 
Primary  vaccine,  473 
Horse-pox  vaccine,  473 
Retro-vaccine,  473 
Bovine  vaccine,  470 
Variola  vaccine,  473 
So-called  points  of  superiority  .  of  hu- 
manized vaccine,  473 
Kelative  merits  of  animal  and  human- 
ized vaccine,  473 
Advantages  of  animal  over  humanized 

virus,  475 

Forms  of  vaccine,  476 
Objections  to  use  of  crust,  476 
Use  of  dried  lymph,  477 

liquid  or  tube  lymph,  476 
Proper  season,  477 

Age,  477 

Part  of  body  most  suitable  for,  477 
Modes  of  operating,  478 

applying  the  virus,  478 
Storage  and  preservation  of  virus,  479 
Proper  time  of  collecting  lymph  for  stor- 
age, 479 

Proper  manner  of  transporting,  480 
Vaccination,  neglect  of,  as  a  cause  of  vari- 
ola, 436 
Vaccine  virus,  varieties  of,  472 

use  of,  in  treatment  of  rabies  and  hy- 
drophobia, 907 

Vagina,  symptoms  of  diphtheria  of,  674 
Vaginal  injections,  use  of,  for  prevention  of 

puerperal  fever,  1025 
Variations,  barometric,  influence  of,  upon 

course  of  diseases,  134 
VARICKLLA,  481 
Definition,  481 
Synonyms,  481 
History,  481 
Etiology,  481 
Contagiousness,  481 
Symptoms,  481 

Period  of  incubation,  482 


VARICELLA— Symptoms:  General,  482 
Prodromal'stage,  482 
Eruption,  482 

Umbilicatioa  of  eruption,  482 
Date  of  appearance  of  desiccation,  482 
Frequency  of  scarring,  482 
Appearance  of  vesicles  on  mucous  mem- 
brane, 483 

Morbid  anatomy,  483 
Complications,  483 
Diagnosis,  483 

From  variola  and  varioloid,  484 
From  vaccinia,  484 
From  impetigo,  483 
contagiosum,  483 
From  eczema  pustulosum,  483 
Prognosis,  484 
Treatment,  485 
Varicella  Prurigo,  nature,  484 
Varieties  of  beriberi,  1039 
of  grease-traps,  221 
of  pernicious  malarial  fever,  606 
of  rubeola,  568 
of  sewer-traps,  191 
of  typhoid  fever,  298 
VARIOLA,  434 
Definition,  434 
Svnonyms,  434 
History,  434 
Etiology,  435 

Contagiousness,  435 

Nature  of  contagium,  435 

Mode  of  entrance  of  contagium,  435 

Duration  of  activity  of  contagiurn,  435 

Period  of  greatest  activity  of  contagium, 

435 

Mode*  of  transmission,  435 
Race,  influence  of,  436 
Season,  influence  of,  436 
Sex,  influence  of,  436 
Neglect  of  vaccination  as  a  cause,  436 
Individual  idiosyncrasy,  436 
Protection  from,  by  previous  attacks,  436 
Effect  of  pre-existing  skin  disorders,  436 
Symptoms,  436 

Stage  of  incubation,  436 
Invasion,  436 
Variolous  rash,  437 
date  of  appearance,  437 
significance,  437 
Simon's  triangle,  437 
Stage  of  invasion,  438 
Eruptive  stage,  438 
Characters  of  eruption,  438 
Position  of  eruption,  438 
Stage  of  vesication,  438 
Umbilication,  438 
Maturation,  439 
Characters  of  mature  pock,  439 
Condition   of    patient    in    suppuration 

stage,  439 

Pustules  on  mucous  surfaces,  439 
Stage  of  desiccation,  439 
General,  during  desiccation,  440 
Secondary  fever,  439 
Dale  of  appearance  of  secondary  fever, 
4?9 


1092 


VAKIOLA  —  Symptoms:   Confluent  variety, 

440 

Seat  of  lesion,  441 

Condition  of  mucous  surfaces  in  con- 
fluent, 441 

General  condition  in  confluent,  441 
Ilemorrhagic  variety,  442 
First  form,  442 
Second  form,  443 
Lesions  of,  443 
Variolic  purpura,  442 
Complications  and  sequelae,  445 
Complicated  by  eye  diseases,  445 
Erysipelas,  445 
Nasal  inflammation,  445 
Furuncles  and  abscesses,  445 
Muscular  paralysis  and   hemiplegic 

attacks,  445 
Laryngitis,  446 
Gangrene  of  genitalia,  446 
Followed  by  a  typhoid  state,  445 
Pathology  and  morbid  anatomy,  446 

Cutaneous  lesions,  446 
Formation  of  papule,  446 

Vesicle,  446 

Cause  of  umbilication,  447 
Repair  of  pock,  447 
Hemorrhagic  variety,  447 
Changes  of  viscera,  447 
Diagnosis,  447 
From  measles,  448 
From  scarlatina,  449 
From  pustular  skin  diseases,  449 
From  dermatitis  medk-ameutosa,  449 
From  syphilodefm,  449 
From  acneform  disease,  449 
From  typhoid  fever,  450 
From  typhus  fever,  450 
Prognosis,  450 

Symptoms  indicating  unfavorable,  450 
Influence  of  sudden    defervescence  of 

eruption,  450 

Pregnancy  and  childbed,  450 
Fatality  of,  in  the  unvaccinated.  450 
Influence  of  vaccination  after  develop- 
ment, 451 
Treatment,  451 
Preventive,  451 
Hygienic,  451 

Necessity  of  cleanliness,  454 
Invasion  stage,  452 
Eruption,  452 
Exclusion  of  sunlight  for  prevention  of 

pitting,  452 

Use  of  warm  baths,  453 
Hot  water  compresses,  453 
Stimulants,  454 
Hemorrhagic  form,  454 
Disposition    of   clothes    and    body  after 

death,  454 

Variola  of  vaccine,  473 
Variolic  purpura,  442 
VARIOLOID,  443 
Symptoms,  443 

Invasion  stage,  443 
Eruption,  444 


VARIOLOID— -Symptoms :  Types  of,  444 
Identity  witli  variola,  444 
Treatment,  451 

Veins,  condition  of,  in  cholera,  737 
intestinal,  lesions  of,  in  cholera,  745 
jugular,  thrombi  of,  in  symptomatic  paro- 
titis, 626 
lesions  of,  in  pyamia,  967 

in  symptomatic  parotitis,  626 
Venesection  in  cholera,  764 
in  rabies  and  hydrophobia,  908 
in  relapsing  fever,  431 
futility  of,   iu  cerebro-spinal   meningitis, 

830 

VENTILATION,  177  el  seq. 
Defects,  179 
Distribution  of  air,  180 
Estimation  of  carbonic  acid  in  air,  178 
Insufficient,  evil  effects,  181 
Importance  of,  in  treatment  of  typhoid 

fever,  323 

Methods   of  calculating  amount   of  air- 
supply,  179 
Modes  of  investigating  merits  of  a  plan, 

179 

Of  waste-pipes  in  drainage,  223 
Of  soil-pipes,  189 

Proper  size  of  flues  and  registers,  179 
Relation  of,  to  heating  apparatus,  180 
Varieties  of  ventilators,  180 
Velocity  of  air,  180 
Ventilators,  varieties,  180 
Venous  emboli.  63 

thrombosis,  following  typhoid  fever,  294 
Veratrum  viride,  use  of,  in  puerperal  fever, 

1033 

in  scarlet  fever,  543 
in  yellow  fever,  651 

Vertigo  in  cerebro-spinal  meningitis,  812 
in  relapsing  fever,  384 
significance  of,  in  general  diagnosis,  158 
Vesi  cation  in  variola,  438 
Vesicle  in  variola,  morbid  anatomy  of,  446 
Views,  earlier,  concerning  nature  of  puer- 
peral fever,  990 
modern,  concerning  nature  of  puerperal 

fever,  992 

Virus  of  anthrax,  period  of  greatest  viru- 
lence, 928 

of  rabies,  localization  of,  in  wound,  893 
of  vaccination,  varieties  of,  472 
vaccine,  manner  of  transporting,  480 

storage,  479 
Viscera,  lesions  of  abdominal,  in  the  plague, 

781 

in  cerebro-spinal  meningitis,  824 
in  erysipelas,  635 
in  variola,  447 
Vision,  modifications  of,  in  relapsing  fever, 

399 

in  typhoid  fever,  280 
Vital  statistics,  registration,  208 
Voice,  alteration  of,  in  diagnosis,  158 
Vomit,  character  of,  in  cerebro-spinal  men 

ingitis,  813 
in  cholera,  738 


INDEX. 


1093 


Vomit,  character  of,  in  grave  form  of  the 

plague,  779 

Vomiting  during  intermitent  fever    parox- 
ysm, 593 

in  cerebro-spinal  meningitis,  813 
in  cliolera,  738 

treatment,  761 

in  diphtheria,  treatment,  694 
in  general  peritonitis  of  puerperal  fever. 

1010 

in  mild  scarlet  fever,  503 
in   para-  and   perimetritis    of    puerperal 

fever,  1007 
in  pyaemia,  975 

in  remittent  fever,  treatment,  605 
in  ruheola,  treatment,  581 
in  septicaemia,  977 
in  typhoid  fever,  285 

treatment,  331 
in  typhus  lever,  350 

treatment,  367 
in  yellow  fever,  644 

treatment,  652 

significance  of,  in  general  diagnosis,  162 
Vulva,  symptoms  of  diphtheria,  674 

W. 

Wakefulness  in  relapsing  fever,  384 

in  typhus  fever,  349 
Walk,  significance  of,  in  diagnosis,  161 
Walking  form  of  typhus  fever,  354 

of  yellow  fever,  symptoms,  654 
Washstands,  stationary,  dangers  from,  216 
Waste-pipes,  effects  of  large  bore  in,  220 
leakage  in,  222 
tests  for,  222 
ventilation,  223 
Water,   collections  of,   effect    upon    public 

health,  187 

fear  of,  in  rabies  and  hydrophobia,  899 
height  of  subsoil,  influence  of,  on  preva- 
lence of  cholera,  722 
importance  of,  in  treatment  of  typhoid 

fever,  325 

impure,  microscopic  characters  of,  184 
diarrhceal  aflections  from,  182 
disease  from,  182 
chemical  examination  of,  183,  184 
value  of  chemical  examination  of,  183, 

184 
impurity  of,  from  metallic  salts,  182        . 

from  organisms,  184 
nature  of  impurities,  182 
polluted,  as  a  cause  of  diphtheria,  683 
stagnant,  production  of  malaria  by,  187 
standards  of  purity,  184 
subsoil,  level  of,  188 

supply,    contamination    of,    from   privy- 
vaults,  192 
cess-pools,  192 
chloride  test  for  detecting  impurities  in, 

192 

tables  of  analyses,  184 
use  of,  in  diphtheria,  702 
Water-closets,  defects  of,  217 
location,  218 


Water-closets,  varieties,  191 

ventilation,  192,  217 
Waxy  degeneration,  84 
Welch  on  cause  of  oedema  of  lungs,  72 
Wet  form  of  beriberi,  symptoms,  1040 

treatment,  1042 
Whooping  cough,  836 

relation  of,  to  rubeola,  561 
Winds,  influence  of,  on  spread  of  influenza, 

860 
Wound,  appearance  of,  in  rabies  and  hydro 

phobia,  895,  899 
changes  in,  in  pyaemia,  976 
condition  of,  in  "septicaemia,  977 
influence  of  characters  of,  in  causation  of 

pyaemia,  958 
treatment  of,  in  pyaemia,  981 

in  septicjemia,  983 
Wounds,  diphtheria  of,  673 

Y. 

YELLOW  FEVER,  640 
Svnonyms,  640 
Definition,  640 
Etiology,  640 
Specific  origin,  640 
Poison  of,  inconvertibility,  840 
Birthplace,  641 
Characteristics,  641 
Ponderability,  641 
Vitality,  641 

Influence  of  heat  and  cold  on  devel- 
opment, 641 
Impossibility  of-  transportation  of,  by 

air,  641 
Transportability  of,  by  fomites,  etc., 

641 

Nature  of  fomites,  641,  642 
Fixity  of,  643 
Slowness  of  extension,  643 
Medium  of  admission  to  system,  642 
Localization    of   epidemics    by    atmo- 
spheric impregnation,  642 
Anxiety,  grief,  and  fatigue  as  causes, 

643 
Insusceptibility,  in  negroes,  644 

from  idiosyncrasy,  643 
Protective  power  of  previous  attacks, 

643 

Duration  of  incubation  period,  643 
Symptoms,  644 
Mild  cases,  644 
Initial,  644 
Physiognomy,  644 
Neuralgia  and  muscular  pains,  644 
Cerebral,  644 
Condition  of  tongue,  644 

Grastro-intestinal  canal,  644 
Vomiting,  644 

Character  of  matters  vomited,  644 
Condition  of  urine,  644 

Pulse,  644 

Relation  of  pulse  to  temperature,  646 
Perspiration,  645 
Stages,  645 
Masked  forms,  653 


1094 


TNDEX. 


YELLOTV    FEVER  —  Symptoms:    Walking: 

forms,  654 

Paroxysmal  stage,  645 
Calm  stage,  645 

Hemorrhages  and  jaundice,  646 
Prognosis,  646 

Symptoms  indicating  unfavorable,  646 
Influence  of  crowding  the  sick,  646 
Pregnancy  and  parturition,  647 
Condition  of  patient  at  time  of  at- 
tack, 647 

Temperature,  647 
In  hospital  cases,  647 
Mortality,  647 
Variableness,  647 
Difference  in  hospital  and  private  cases, 

(148 

Diagnosis,  648 

Significance  of  physiognomy,  648 
State  of  pulse,  648 
Albuminous  urine,  648 
Hemorrhagic  tendency,  648 
Yellow  discoloration  of  skin,  648 
Morbid  anatomy,  649 

Changes  in  liver,  649 
Treatment,  649 

Futility  of  abortive,  649 
Importance  of  early,  649 
Indications  for,  649 
Simple  form,  649 
Early  stages,  649 
Diaphoresis,  650 


YELLOW  FEVER  —  Treatment:  Jaborandi 

650 

Neumlgias  and  muscular  pains,  651 
Hyperpyrexia,  651 

by  cold,  651 
Hemorrhages,  651 

by  tincture  of  iron,  652 
Nausea  and  vomiting,  652 
Urinary  suppression,  652 
Failure  of  reaction  from  cold  stage,  65- 
Convulsions  and  delirium,  653 
Use  of  digitalis,  651 

Aconite,  651 

Veratrum  viride,  651 

Gelsemium,  651 

Haemostatics,  (!52 

Quinia,  650,  651 

Quinia  and  opium   in   combination, 

651 

Hygienic,  654 

Necessity  of  absolute  rest,  654 
Diet.  654 

Children,  655 

Typhoid  cases,  655 

Time  of  return  to  solid  food,  666 

Z. 

Zymosis,  meaning  of  term,  137 

Zymotic  diseases,  relation  of,  to  puerperal 

fever,  1020 
table,  136 


END   OF   VOL.  I. 


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Datr   Dur 


,N,NTIO  IN  »...».  CAT.   NO.   24    161 


****. 


1885-86 
Pepper,  William. 

A  system  of  practical  medicine 


WB100 


1885-86 
v.  1 
Pepper,  William. 

A  system  of  practical  medicine 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


